Adjunctive Use of WATS-3D in Symptomatic GERD Patients Increases Detection of Barrett's Esophagus and Dysplasia.

BACKGROUND: Patients with gastroesophageal reflux (GERD) symptoms undergoing screening upper endoscopy for Barrett's esophagus (BE) frequently demonstrate columnar-lined epithelium (CLE), with forceps biopsies (FB) failing to yield intestinal metaplasia (IM). Repeat endoscopy is often necessary. AIM: Assess the yield of IM leading to a diagnosis of BE by the addition of Wide-Area Trans-epithelial Sampling (WATS-3D) to FB in the screening of GERD patients. METHODS: We performed a prospective registry study of GERD patients undergoing screening upper endoscopy. Patients had both WATS-3D and FB. Patients were classified by their Z line appearance: regular, irregular (<1 cm CLE), possible short-segment BE (1-<3cm), and possible long-segment BE (≥3cm). Demographics, IM yield, and dysplasia yield were calculated. Adjunctive yield was defined as cases identified by WATS-3D not detected by FB, divided by cases detected by FB. Clinicians were asked if WATS-3D results impacted patient management. RESULTS: Of 23,933 patients, 6,829(28.5%) met endoscopic criteria for BE. Of these, 2,878(42.1%) had IM identified by either FB or WATS-3D. Among patients fulfilling endoscopic criteria for BE, the adjunctive yield of WATS-3D was 76.5%, and absolute yield was 18.1%. 1,317 patients (19.3%) who fulfilled endoscopic BE criteria had IM detected solely by WATS-3D. Of 240 patients with dysplasia, 107(44.6%) were found solely by WATS-3D. Among patients with positive WATS-3D but negative FB, the care plan changed in 90.7%. CONCLUSION: The addition of WATS-3D to FB in GERD patients being screened for BE resulted in confirmation of BE in an additional 1/5 th of patients. Furthermore, dysplasia diagnoses approximately doubled.

Malignant Melanoma of the Stomach.

Malignant melanoma with metastasis to the stomach is rare and seldom diagnosed before death. The most common gastrointestinal (GI) metastatic site is the small intestine, followed by the colon, rectum and stomach. We present the case of a 55-year-old woman with a history of melanoma who presented with melena and syncope, and was found to have metastatic gastric melanoma. LEARNING POINTS: It is important to consider gastric metastasis in patients with a history of melanoma who present with non-specific abdominal symptoms such as abdominal pain, nausea, vomiting, melena/haematochezia, weight loss and anaemia.It is crucial to keep gastric melanoma metastasis as a differential diagnosis in a patient with melanoma due to its aggressive nature and poor prognosis if diagnosis is delayed.Appearances can vary greatly at endoscopy, and so immunohistochemistry is vital at histological work-up for the identification of gastric melanoma.

Gastrointestinal Stromal Tumor and Ki-67 as a Prognostic Indicator.

Gastrointestinal stromal tumors (GISTs) albeit rare, are the most common mesenchymal neoplasms of our gastrointestinal (GI) tract. GISTs present with nonspecific symptoms and are found incidentally on endoscopy or imaging. A significant portion of GIST diagnoses expresses KIT/CD117 and DOG-1 tissue markers which are pathognomonic for GIST. More recently, Ki-67 was found to be a significant prognostic marker for determining the risk of recurrence. We present a patient with a mesenchymal mass in the small intestine with pathognomonic features of GIST and expression of Ki-67, an important immunocytochemical marker of proliferation. The patient was a 71-year-old male with a history of hyperlipidemia and hypertension. He presented to the emergency department complaining of bloody diarrhea for two days, with associated nausea, vomiting, and abdominal cramping. Initial blood pressure on presentation was 77/52 mm Hg. Computed tomography (CT) of the abdomen and pelvis revealed a large solid mass with cystic components. The mass was not visualized with esophagogastroduodenoscopy or colonoscopy, and surgical intervention was warranted. A 14 cm x 11.5 cm x 10 cm tumor was found in the ileum. The tumor was excised with small bowel segmental resection and the specimen was sent for pathological evaluation. Immunohistochemical analysis confirmed the diagnosis of GIST with diffuse CD117/c-Kit protein expression. The tumor was high grade with a high mitotic rate at 30 mitoses/50 high-power fields (HPF) and had spindle cell morphology. Of note, 10% of the tumor cells were positive for Ki-67. GISTs have a high risk of recurrence and a more favorable prognosis with advancements in management. Prior to imatinib therapy in the early 2000s, GISTs prognosis was very poor, as they are resistant to most conventional chemotherapeutic agents and radiation. While the prognosis is fair, surgical resection and imatinib therapy have improved outcomes and risk of recurrence. Prognosis and risk of recurrence can be determined by assessing the mitotic rate, tumor size, and recently, expression of Ki-67. Ki-67 provides a reliable and reproducible approach to assess the prognosis of GIST.

Spontaneous Bacterial Peritonitis Secondary to Salmonella spp. in a Patient With Decompensated Liver Cirrhosis.

Spontaneous bacterial peritonitis (SBP) is a common and serious complication of cirrhosis, with gram-negative bacteria being the culprit in most cases. SBP secondary to Salmonella spp. is rare. Here, we report a case of Salmonella enterica SBP in a patient with decompensated cirrhosis, diagnosed via paracentesis coupled with ascitic fluid analysis and culture. A high index of suspicion must be maintained for atypical causes of SBP, with prompt initiation of treatment.

Under-diagnosing and under-treating iron deficiency in hospitalized patients with gastrointestinal bleeding.

AIM: To determine whether patients hospitalized with gastrointestinal (GI) blood loss anemia are being checked and treated for iron deficiency. METHODS: Retrospective chart review was conducted for all patients admitted to a single tertiary care hospital between 11/1/2011 and 1/31/2012 for any type of GI bleeding. The primary endpoint was the percentage of patients who had their iron studies checked during a hospitalization for GI blood loss anemia. Secondary outcomes included percentage of anemic GI bleeders who had adequate documentation of anemia and iron deficiency, and those who were treated for their iron deficiency. Then we tried to identify possible predictors of checking iron studies in an attempt to understand the thought process that physicians go through when managing these patients. Iron deficiency was defined as Iron saturation less than 15% or ferritin level less than 45 µg/L. Anemia was defined as hemoglobin level less than 13 g/dL for males and 12 g/dL for females. RESULTS: Three hundred and seven GI bleeders were hospitalized during the study period, and 282 of those (91.9%) had anemia during their hospital stay. Ninety-five patients (30.9%) had iron studies performed during hospitalization, and 45 of those (47.4%) were actually found to be iron deficient. Only 29 of those 45 iron deficient patients were discharged home on iron supplements. Of the 282 patients that had anemia during hospitalization, 50 (17.7%) had no documentation of the anemia in their hospital chart. Of the 45 patients that had lab proven iron deficiency anemia (IDA), only 22 (48.5%) had documentation of IDA in at least one note in their chart. Predictors of checking iron studies in anemic GI bleeders were lower mean corpuscular volume, documentation of anemia, having fecal occult blood testing, not having hematemesis or past history of GI bleeding. There were no significant differences between the teaching and non-teaching services in any patient characteristics or outcomes. CONCLUSION: Iron deficiency is under-diagnosed, under-recognized even when iron studies were checked, and under-treated in hospitalized patients with GI bleeding.

Colon cancer metastasis to mediastinal lymph nodes without liver or lung involvement: A case report.

Colon cancer is the second most common type of cancer in females and the third in males, worldwide. The most common sites of colon cancer metastasis are the regional lymph nodes, liver, lung, bone and brain. In this study, an extremely rare case of colon adenocarcinoma with extensive metastasis to the mediastinal lymph nodes without any other organ involvement is presented. A 44-year-old Caucasian male presented with abdominal pain, a change in bowel habits, melena and weight loss. Colonoscopy revealed a large friable, ulcerated, circumferential mass in the ascending colon. Biopsies were consistent with the diagnosis of invasive moderately differentiated adenocarcinoma. Subsequently, right colon resection was performed, and pathological analysis revealed moderately differentiated adenocarcinoma of the right colon with extensive regional lymph node involvement. Computed tomography (CT) scans of the chest, abdomen and pelvis were performed preoperatively as part of routine staging for colon cancer. No liver or lung pathology was identified; however, multiple pathologically enlarged mediastinal lymph nodes were observed. Endoscopic ultrasound with fine needle aspiration of the largest mediastinal lymph node, which measured 5.2×3.5 cm on CT scans, was performed. The pathology was again consistent with the diagnosis of metastatic colorectal primary adenocarcinoma. At present, no optimum treatment has been identified for metastatic colon cancer to the mediastinal lymph nodes. The patient in the current case received chemotherapy with folinic acid, fluorouracil and oxaliplatin (FOLFOX), as well as with bevacizumab. Initial follow-up CT scans of the chest revealed a positive response to treatment. Physicians, in particular, radiologists, must consider the mediastinum during the first evaluation and further follow-up of patients with colorectal carcinoma even in the absence of metastasis.

Neuroendocrine tumors of the gastrointestinal tract: Case reports and literature review.

Neuroendocrine tumors (NET) previously called carcinoid tumors are neoplasms of enterochromaffin/neuroendocrine cell origin which display neurosecretory capacity that may result in the carcinoid syndrome. The annual incidence of patients with NET is 8.4 per 100000; yet many NET remain asymptomatic and clinically undetected. A majority of NET follows a benign course; however, some will display malignant characteristics. NET most commonly occur in the gastrointestinal tract (67%) and bronchopulmonary system (25%). Gastrointestinal NET occur within the stomach, small intestine, liver, and rectum. We report a retrospective study of 11 subjects: Eight with benign carcinoid tumors: duodenal bulb (n = 2), terminal ileum (n = 1), sigmoid colon (n = 2), and rectum (n = 3); three with malignant carcinoid: liver (n = 1) and intra-abdominal site (n = 2). The diagnosis, endoscopic images, outcome, treatment and review of the literature are presented.

Recurrence of a pancreatic cystic lymphangioma after diagnosis and complete drainage by endoscopic ultrasound with fine-needle aspiration.

CONTEXT: Lymphangiomas are uncommon benign neoplasms that result from a blockage of the lymphatic system. Pancreatic cystic lymphangiomas are extremely rare. Pancreatic cystic lymphangiomas have been classically diagnosed on histopathologic examination following surgical excision, but recent reports have demonstrated successful diagnosis using endoscopic ultrasound with fine-needle aspiration (EUS-FNA). Data on the natural history of these lesions following drainage via EUS-FNA are lacking. We present a case of successful initial diagnosis and drainage of a pancreatic cystic lymphangioma using EUS-FNA, with unfortunate recurrence of the lesion four months later. CASE REPORT: A 50-year-old female was evaluated for epigastric abdominal pain and nausea. CT scan revealed a 4 cm retroperitoneal cystic lesion. EUS-FNA was performed with complete drainage of the lesion using a 22-gauge needle. Twenty-five mL of chylous white fluid was obtained with laboratory analysis consistent with a pancreatic cystic lymphangioma. The patient was symptom-free for 4 months following drainage, but eventually had symptoms again with a CT scan confirming recurrence. CONCLUSIONS: While EUS-FNA is effective for the diagnosis of pancreatic cystic lymphangiomas, its role in the management of these lesions is questionable. Temporary relief of symptoms can be achieved after EUS-guided drainage, but recurrence is a concern. Definitive cure likely requires complete surgical excision.

Lifestyle modification counseling in patients with gastroesophageal reflux disease.

The purpose of this study was to determine the rate of documented counseling on lifestyle modifications in patients presenting to the primary care setting with a diagnosis of gastroesophageal reflux disease. Retrospective chart review was conducted for 502 active patients with a primary or secondary diagnosis of gastroesophageal reflux disease from two internal medicine clinics at the University of Kansas School of Medicine-Wichita. Charts were reviewed for documented counseling on four specific lifestyle modifications: (a) smoking and alcohol cessation, (b) dietary changes, (c) head of bed elevation, and (e) postprandial avoidance of recumbency. Only 12% of patients in this sample received documented counseling on lifestyle modifications. Of those patients receiving documented counseling, 71% were counseled on dietary changes, 41% smoking or alcohol cessation, 28% head of bed elevation, and 21% postprandial avoidance of recumbency. Documentation indicated that patients with gastroesophageal reflux disease are not adequately counseled regarding recommended lifestyle modifications.