Evolution of Antenatally Diagnosed Bronchogenic Cyst in an Infant.

Bronchogenic cyst is one of the rare developmental lung conditions. Depending on the location, it can cause significant compression of the mediastinal structures, especially airways leading to atelectasis, emphysema, wheezing, and stridor. Computerized tomography helps in the confirmation of diagnosis. Surgery is definitive management. We present a case of bronchogenic cyst which presented as emphysema leading to respiratory emergency in an infant.

Fetal Klippel-Trenaunay-Weber Syndrome: Antenatal Diagnosis and Postnatal Management.

Context: Klippel-Trenaunay-Weber syndrome (KTWS) is a rare disease characterized by a triad of venous malformations, vascular skin nevus and asymmetric hypertrophy of bone and soft tissue. The spectrum of disease in utero varies from asymptomatic nevus flammeus to life threatening complications like Kasabach-Merritt phenomena. Aim: The aim of this study was to review our experience of antenatal diagnosis of KTWS and it's postnatal management. Settings and Design: This was a retrospective observational study of all pregnant women who were antenatally diagnosed with KTWS and postnatally confirmed at a tertiary care center in north India between 2012 and 2021. Subjects and Methods: The electronic medical records were reviewed and data were collected regarding demographic information, obstetric history, clinical presentation, sonographic findings, mode of delivery, fetal outcome, and follow-up. Results: During the study period, four fetuses were diagnosed with KTWS on sonography. Three women were multigravida whereas one was a primigravida. Two women opted for medical termination of pregnancy and one each had liveborn child and an intra-uterine fetal death. KTWS was confirmed in all cases. The liveborn child underwent treatment for the vascular malformation and is alive at 4 years of age. Conclusions: This study attempts to add onto the available literature regarding the spectrum of prenatal presentations of KTWS. It emphasizes the importance of prenatal diagnosis and follow-up of the fetus/neonate.

Bronchial Carcinoid Tumor in an Adolescent Female: Diagnosis and Management by a Multi-Disciplinary Team.

Bronchial carcinoid is the most common primary malignant lung tumor in children; however, it remains a very rare diagnosis due to the overall low incidence of childhood lung malignancies. We report a case of a 17-year-old girl with respiratory symptoms who was initially misdiagnosed as a case of COVID pneumonia. She was later detected to have a right mainstem bronchial carcinoid which was managed successfully by a multi-disciplinary team.

Early Colonoscopy for Diverticular Bleeding Does Not Reduce Risk of Postdischarge Recurrent Bleeding: A Propensity Score Matching Analysis.

BACKGROUND & AIMS: Colonoscopy within 24 hours (early colonoscopy) is recommended for patients with colonic diverticular bleeding, but it is unclear if this strategy improves postdischarge outcomes. We aimed to determine whether early colonoscopy is associated with decreased risk of rebleeding and hospital re-admission within 30 days. METHODS: We performed a retrospective cohort study using Marketscan (Truven Health Analytics, Inc, Ann Arbor, MI), a nationwide insurance claims database. From January 2004 through September 2015, patients with a primary diagnosis of diverticular bleeding who underwent inpatient colonoscopy were included. We used propensity score matching to account for differences between recipients of early vs delayed colonoscopy. Multivariable logistic regression was performed to determine the association between early colonoscopy and rebleeding or hospital re-admission within 30 days of discharge. RESULTS: In total, 20,010 patients underwent colonoscopy for diverticular bleeding; 11,690 underwent early colonoscopy. After propensity matching, 8320 pairs of patients were analyzed. In the matched analysis, higher proportions of patients who received early colonoscopy underwent additional colonoscopies (73%), compared with patients who did not receive early colonoscopy (4%) (P < .0001), but lower proportions received endoscopic interventions (3% vs 8%; P < .0001). On multivariable analysis, early colonoscopy (odds ratio [OR], 1.34; 95% CI, 1.08-1.66; P = .007), transfusion requirement (OR, 2.31; 95% CI, 1.88-2.83; P < .0001), and baseline chronic kidney disease (OR, 2.13; 95% CI, 1.49-3.04; P < .0001) were associated with increased risk of rebleeding within 30 days. Early colonoscopy (OR, 1.18; 95% CI, 1.02-1.36; P = .03), endoscopic intervention (OR, 1.37; 95% CI, 1.03-1.81; P = .03), transfusion requirement (OR, 2.17; 95% CI, 1.88-2.51; P < .0001), coronary artery disease (OR, 1.27; 95% CI, 1.06-1.51; P = .009), and chronic kidney disease (OR, 1.98; 95% CI, 1.54-2.54; P < .0001) were associated with increased re-admission to the hospital within 30 days. CONCLUSIONS: In a propensity-matched analysis, we associated early colonoscopy with increased risk of rebleeding events and hospital re-admissions. However, these observations might be due to confounding factors.

Donor CD163 and nestin-positive cells predict graft function in living donor liver transplant.

AIMS: To evaluate the effect of donor liver resident mesenchymal cells, M2 macrophages on liver graft outcome after living donor liver transplantation. MATERIALS AND METHODS: Seventy donor biopsies were included in the study. Outcomes at day 3, 7, 30, and 180 postliver transplantation were assessed. Mesenchymal stem cells and M2 macrophages in donor liver biopsies were evaluated. RESULTS: Mean age of recipients was 40.9 ± 13.6 years. Sex mismatched transplants were 44 (M→F = 9; F→M = 35). On area under receiver operative curve analysis, donor biopsy (DB) nestin ≥3 and CD 163 ≥ 32/200x at day 3; CD163 ≥ 32 at day 7; CD 163 > 32, pRBC of <6.5 units at day 30, and DB nestin ≥3, CD 163 ≥ 32 and pRBC<6.5 units at day 180 predicted adequate graft functions. On multivariate analysis, higher DB nestin (P = .009) and lower cryoprecipitate (P = .009) usage at day 3, higher DB CD163 (P = .006) at day 7, higher DB CD163 (P = .018) and reduced transfusion of packed cell (pRBC) (P = .014) at day 30 and higher DB nestin (P = .011), higher CD163 (P = .009), and reduced pRBC (P = .045) at day 180 were the predictors of better outcome. CONCLUSIONS: Donor liver biopsy nestin+ and CD163+ can predict early graft outcome in living donor liver transplantation.

Outcomes of Early Versus Delayed Colonoscopy in Lower Gastrointestinal Bleeding Using a Hospital Administrative Database.

BACKGROUND: Limited data exist on whether early colonoscopy for lower gastrointestinal bleeding (LGIB) alters 30-day mortality, performance of endoscopic intervention, or need for blood transfusion. Our primary objective was to determine whether early colonoscopy in LGIB is associated with decreased 30-day mortality using a large hospital administrative database. METHODS: Patients hospitalized between January 2008 and September 2015 were identified using a validated, machine learning algorithm for identifying patients with LGIB. "Early" colonoscopy occurred by day 2 of admission and "late" colonoscopy between days 3 and 5. A propensity score for early colonoscopy was constructed using plausible confounders. Univariable and multivariable logistic regression were used to determine factors associated with 30-day mortality, endoscopic intervention, and transfusion need. The propensity score was included as a confounding factor for mortality analysis in the multivariable model. RESULTS: In total, 1204 patients underwent colonoscopy for LGIB. Of these, 295 patients (25%) underwent early colonoscopy, and these patients had a lower Charlson Comorbidity Index (P=0.001) and shorter length of stay (3 vs. 5 d, P=0.0001). Early colonoscopy was not associated with decreased 30-day mortality [odds ratio (OR), 0.73; confidence interval (CI), 0.27-1.69], but was associated with increased endoscopic intervention (OR, 2.62; CI, 1.37-4.95) and decreased need for transfusion (OR, 0.65; CI, 0.49-0.87). On multivariable analysis adjusting for timing of colonoscopy, age, and propensity score for early colonoscopy, early colonoscopy was not associated with a decrease in 30-day mortality (OR, 1.37; CI, 0.50-3.79). CONCLUSIONS: Early colonoscopy does not affect 30-day mortality but may allow for earlier endoscopic intervention and decreased transfusion need.

Resumption of Warfarin After Hospitalization for Lower Gastrointestinal Bleeding and Mortality Benefits.

GOALS: To evaluate whether resumption of warfarin after hospitalization for lower gastrointestinal bleeding (LGIB) is associated with improved 90-day and 6-month survival. BACKGROUND: LGIB is a common complication for patients on warfarin. There is limited data to guide clinicians on the optimal management of warfarin following hospitalization for LGIB. STUDY: We identified patients hospitalized with LGIB while on warfarin using a validated, machine-learning algorithm. Patients were classified as those who had warfarin resumed at discharge and those who did not. Univariate and multivariate Cox proportional hazards were used to determine whether resuming warfarin was associated with improved 90-day and 6-month mortality. RESULTS: In total, 607 patients were admitted with warfarin-associated LGIB. A total of 403 (66.4%) patients had warfarin held at discharge. Discontinuation of warfarin was associated with an increased 90-day and 6-month mortality on univariate analysis [hazard ratio (HR), 2.07, 95% confidence interval (CI), 1.04-4.58, P=0.04; HR, 1.78, 95% CI, 1.02-3.27, P=0.04]. On multivariate regression adjusting for age, comorbidities, and transfusion requirement, only a higher Charlson Index was associated with increased 90-day mortality (HR, 1.18, 95% CI, 1.07-1.29, P=<0.001). At 6 months, only older age was associated with an increased mortality on multivariate regression (HR, 1.02, 95% CI, 1.00-1.05, P=0.02), with no significantly increased mortality risk with holding warfarin (HR, 1.48, 95% CI, 0.84-2.78, P=0.18) CONCLUSIONS:: There was no association between resumption of warfarin at discharge following hospitalization for LGIB and either 90-day or 6-month mortality on multivariate analysis. Mortality in LGIB was largely driven by age and comorbidities.

Lower gastrointestinal bleeding in patients with coronary artery disease on antithrombotics and subsequent mortality risk.

BACKGROUND: Lower gastrointestinal bleeding (LGIB) is a common complication for patients with coronary artery disease (CAD) due to the use of antithrombotic medications. Limited data exist describing which patients are at increased risk for mortality. AIM: This study aims to (i) determine whether patients on dual antiplatelet therapy (DAPT) or triple therapy are at higher risk of 90-day and 6-month mortality compared with patients on aspirin alone and (ii) evaluate risk factors for mortality in patients with CAD on antithrombotics hospitalized with LGIB. METHODS: We conducted a retrospective cohort study of patients hospitalized with LGIB and CAD while on aspirin at a single academic medical center from 2007 to 2015. Patients were identified using a validated, machine-learning algorithm and classified by use of aspirin, DAPT, or triple therapy. Univariate and multivariate Cox proportional hazards were used to determine mortality associated risk factors. RESULTS: Seven hundred sixteen patients were identified with LGIB and CAD. Four hundred seventy-two (65.9%) patients were on aspirin monotherapy, 179 (25%) on aspirin and thienopyridine (DAPT), and 65 (9.1%) on aspirin, thienopyridine, and systemic anticoagulant (triple therapy). On univariate analysis, triple therapy use was associated with increased risk of 90-day (hazard ratio [HR] 3.12, 95% confidence interval [CI] 1.52-5.92, P = 0.003) and 6-month (HR 2.46, 95%CI 1.29-4.35, P = 0.008) mortality. Holding anticoagulation was associated with higher mortality at 90 days (HR 2.30, 95%CI 1.27-4.07, P = 0.007). On multivariate analysis, after adjusting for confounding variables, the use of triple therapy remained associated with higher 90-day mortality (HR 3.23, 95%CI 1.56-6.16, P = 0.003). CONCLUSION: Triple therapy is associated with mortality at 90 days and at 6 months post discharge.

Topographic Distribution Pattern in Hepatic Amyloidosis Presenting with Portal Hypertension.

Background/aims: The liver is often involved in both primary and secondary forms of amyloidosis. Significant clinical evidence of portal hypertension is relatively uncommon and seems to be related to the reduced sinusoidal lumen and increased resistance to blood flow due to massive perisinusoidal amyloid deposits. The relationships between the pattern and extent of amyloid deposition in patients presenting with portal hypertension have not yet been clearly demonstrated. This study is focusing on the topographic distribution of amyloidosis in patients presenting with portal hypertension. Methods: The study included biopsy-proven cases of hepatic amyloidosis. The clinical, biochemical, and serological data, involvement of the extrahepatic organs, and HVPG values were recorded. Tissue sections were re-evaluated for the distribution patterns of amyloid deposits. Results: We had 41 patients with hepatic amyloidosis, of which, 32 were male. A mixed pattern (sinusoidal and vascular) was the most common (32/41; 78%). Hepatic venous pressure gradient was available in 21 cases. Portal hypertension was found in 14 patients (14/21; 67%). Cases of portal hypertension were found to have a sinusoidal pattern (3/14; 21.4%), vascular pattern (1/14; 7.1%), or a mixed sinusoidal and vascular pattern (10/14; 71.4%). Those not having portal hypertension showed hepatic artery (HA) involvement in 6/7 (85.7%) cases. A comparative analysis between portal hypertension (PTH) and non-PTH groups showed that HA amyloid deposition was dominant in the non-PTH group (6/7; 85.7%) and sinusoidal deposition in the PTH group (13/14; 92.8%). The difference was found to be significant (P < 0.05). Conclusion: We found that portal hypertension was noted in cases with diffuse sinusoidal deposition or mixed sinusoidal with portal vein deposition. In the non-PHT group, the deposition was mainly in HA alone.

Retroperitoneal yolk sac tumour encroaching the liver and adrenal gland with tumour thrombus in cavo-atrial region and hepatic veins.

Paediatric germ cell tumours (GCT) are rare tumours and are unique because of varied clinical presentation and locations. Yolk sac tumour is the predominant malignant histology and a serum marker; alpha fetoprotein is used to see treatment response and recurrent disease. It is extremely rare to find a retroperitoneal GCT with tumour thrombus extending up to the cavo-atrial region with involvement of the hepatic veins. We report a case of retroperitoneal yolk sac tumour (RPYST) with extension to the liver and right adrenal gland along with tumour thrombus in the inferior vena cava and in the right and middle hepatic veins. The child was operated after satisfactory response to chemotherapy. Excision of the tumour along with the right adrenal gland and around 5 cm of retro-hepatic caval resection was done. Inferior vena cava resection was tolerated without reconstruction. Currently child is disease-free and symptom-free at 22 months of follow-up with normal serum marker.

Cytological evaluation of thyroid nodules in children and young adults: a multi-institutional experience.

PURPOSE: The utility of the Bethesda system for reporting thyroid cytopathology is debatable in determining the risk of malignancy in pediatric patients. Moreover, the upper age limit for defining the pediatric group has varied across different studies. The aim of this study is to compare the risk of malignancy (ROM) and risk of neoplasia (RON) across different Bethesda categories between the pediatric, young adult, and adult patients. METHODS: This is a retrospective multi-institutional study performed in three Indian hospitals. ROM was calculated and compared across Bethesda categories in adult (>18 years) and pediatric age groups (≤18 years), with a subgroup analysis in young adults (19-21 years). RESULTS: Thyroid nodules from a total of 5958 patients were subjected to fine needle aspiration. Of these 199 were pediatric (3.3%) and follow-up histology was available in 2276. The ROM and RON rates, including overall ROM/RON, were significantly higher in pediatric age group as compared to adults. Overall ROM of suspicious for malignancy and malignant categories was higher in children as compared to adults. The overall surgical resection rates were also higher in pediatric patients (45.2% vs. 35.7%; p < 0.01). The similar trend of increased ROM, RON and resection rates was seen among young adults as compared to adult age group. CONCLUSION: Thyroid nodules presenting in children are more likely to be malignant than those in adults. Importantly, the young adult group behaved in a similar manner with regard to surgical resection rates, ROM and RON to pediatric.

UV-B signaling pathways and fluence rate dependent transcriptional regulation of ARIADNE12.

ARI12 belongs to a family of 'RING between RING fingers' (RBR) domain proteins with E3 ligase activity (Eisenhaber et al. 2007). The Arabidopsis genome codes for 14 ARI genes and two pseudogenes (Mladek et al. 2003). Under standard growth conditions ARI12 is predominantly expressed in roots. In addition, ARI12 is strongly induced in leaves following exposure to ultraviolet (UV)-B radiation at dosages similar to those in areas under a reduced ozone layer. With quantitative reverse transcription polymerase chain reaction analyses and promoter:reporter constructs we show that the expression of ARI12 peaks 2-4 h after UV-B radiation exposure. To test if ARI12's transcriptional activation depends on key players of the UV-B signaling pathway, ARI12 expression was quantified in mutants of the ELONGATED HYPOCOTYL5 (HY5), HY5 HOMOLOG (HYH) and the UV RESISTANCE LOCUS8 (UVR8) genes. ARI12 transcription was reduced by 50-70% in hy5, hyh and hy5/hyh double mutants, but not in uvr8 mutants. However, under low fluence rate UV-B conditions ARI12 is not induced in these mutants. Our results show that ARI12 represents a downstream target of the low fluence rate UVR8/HY5/HYH UV-B signaling pathway while under high fluence rates its expression is regulated by the two bZIP transcription factors HY5 and HYH in an UVR8-independent manner.

Biliary Epithelial Senescence in Cellular Rejection Following Live Donor Liver Transplantation.

Background: As with the hepatocytes, cholangiocyte senescence can also easily be detected in damaged small bile ducts and bile ductules during liver disease affecting the biliary system and cholangiocytes. Despite cellular senescence being a feature of chronic progressive cholangiopathies in adults, only a few studies have investigated its role in liver transplant rejection. Method: Transplant biopsies displaying features of rejection were reviewed and classified based on the type of rejection and the time since transplantation. An immunohistochemistry panel has been applied for 3 senescent cell markers (p53, p21, p16). Results: Immunohistochemical expression analysis for the biliary senescence markers (53 biopsies) was done in the post-transplantation periods (Group 1-4) for the cases with the histologically proven diagnosis of rejection. In post-transplant group 1 (<3 months), group 2 (3-6 months), group 3 (6-12 months) and group 4 (>12 months), any 2 senescent markers' positivity was noted in 5/14 (35.7%), 8/13 (61.5%), 16/17 (94.1%) and 9/9 (100%) biopsies respectively and were comparable in all four groups (P = 0.001). A comparison of early biopsies (Group1; 3 months) and late biopsies (Group 2,3&4; >3 months) revealed significantly higher expression in late biopsies (>3 months) (P = 0.001 for any two markers). In ACR, LAR, ECR, and CR/DR any two senescent markers were positive in 14/28 (50%), 12/13 (92.3%) cases, 9/9 (100%), and 3/3cases (100%). Senescent markers (any two) were comparable in all four histological groups (P < 0.001).LAR group had increased expression (P = 0.009 for any two markers and 0.001 for all three markers) and has increased progression to CR (P = 0.019) as compared to ACR. Conclusion: This study on a large number of LDLT allograft biopsies demonstrates the role of biliary senescence in rejection and suggests a pathobiological role for senescence in the poor prognosis seen in late acute cellular rejection and chronic rejection.

EUS-guided FNA in Diagnosing Pancreatic Lesions: Strength and Cytological Spectrum.

INTRODUCTION: Early and accurate diagnosis is paramount for improving the therapeutic efficacy of pancreatic cancers. Endoscopic ultrasonography-fine needle aspiration (EUS-FNA) cytology has come up with the advantage of an early and accurate diagnosis of pancreatic cancers. This study was conducted to analyze the spectrum of pancreatic lesions cytology, and appraise the diagnostic accuracy of EUS-FNA cytology for pancreatic solid and cystic lesions. MATERIALS AND METHODS: This retrospective study includes 288 EUS-guided pancreatic FNA cases. Clinical data, laboratory tests, cytopathology, histopathology, and imaging reports were retrieved. The final diagnosis was based on EUS-FNA cell block and/or pathology in surgical specimens, with immunohistochemistry support. The results of EUS-guided FNA were compared with the final diagnoses to calculate the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). RESULTS: Among 288 EUS-guided pancreatic FNA cases, 175 (62.0%) were malignant. The mean age was 57.8 ± 13.5 years and 50.1 ± 13.7 years, and the mean size of the lesion was 4.1 ± 1.8 cm and 2.2 ± 1.1 cm in malignant and benign groups, respectively. Sensitivity, specificity, PPV, and NPV of EUS-FNA cytology for solid malignant lesions were 98.3%, 95.1%, 98.3%, and 95.1%, and those for cystic lesions were 88%, 92.3%, 100%, and 100%. Diagnostic accuracy of EUS-FNA cytology for solid and cystic pancreatic lesions is 97.4% and 95.0%, respectively. In conclusion of the above; diagnosis of pancreatic solid and cystic malignancy can be assigned from a composite of the EUS-FNA cytology, cell block preparation and immunohistochemistry Diagnosis of pancreatic solid and cystic malignancy can be assigned from a composite of the EUS-FNA cytology, cell block preparation, and immunohistochemistry.

Inflammatory pseudotumors of the liver: Importance of a multimodal approach with the insistance of needle biopsy.

CONTEXT: Inflammatory pseudotumor (IPT) of the liver is a rare, tumor-like lesion that is considered to be biologically benign but often mimics malignancy. AIMS: The aim of the study was construe clinicopathological features, imaging findings, differential diagnosis, management, and follow-up of IPT involving the liver. SETTINGS AND DESIGN: It is a retrospective study. SUBJECTS AND METHODS: Cases included were of IPT, diagnosed on histopathology, at our center from June 2009 to December 2016. Details studied were clinical presentation, imaging studies, laboratory investigations, pathological features, treatment, and follow-up of the cases and compared with reports in the literature. RESULTS: A total of cases of IPT included were 17. The age of the patients ranged from 21 to 62 years. Common presenting features were intermittent fever, upper abdominal pain, and weight loss. Radiological diagnosis varied from neoplastic (13) to infectious etiologies (4), with hepatocellular carcinoma being the most common differential (7/17). Laboratory investigations revealed leukocytosis, hyperbilirubinemia, raised transaminases, and raised serum alkaline phosphatase. Core biopsy of a tumor conceded increased fibrosis along with mixed inflammatory cell infiltrates. Eleven cases were managed conservatively and showed regression or complete recovery. Six patients underwent surgical resection. None of these had any recurrence in median follow-up of 22 months. CONCLUSIONS: IPT of the liver can masquerade as a fatality, either primary or metastatic. It will be well managed with conservative modalities and can avoid redundant hepatectomy, reserved for complicated cases. For this intent, accurate preoperative diagnosis is the requisite, and needle biopsy with or without fine-needle aspiration cytology plays as a significant rescuer in this field.

Risk factors for small bowel bleeding in an overt gastrointestinal bleeding presentation after negative upper and lower endoscopy.

INTRODUCTION: A small bowel source is suspected when evaluation of overt gastrointestinal (GI) bleeding with upper and lower endoscopy is negative. Video capsule endoscopy (VCE) is the recommended next diagnostic test for small bowel bleeding sources. However, clinical or endoscopic predictive factors for small bowel bleeding in the setting of an overt bleeding presentation are unknown. We aimed to define predictive factors for positive VCE among individuals presenting with overt bleeding and a suspected small bowel source. METHODS: We included consecutive inpatient VCE performed between September 1, 2012 to September 1, 2015 for melena or hematochezia at two tertiary centers. All patients had EGD and colonoscopy performed prior to VCE. Patient demographics, medication use, and endoscopic findings were retrospectively recorded. VCE findings were graded based on the P0-P2 grading system. The primary outcome of interest was a positive (P2) VCE. The secondary outcome of interest was the performance of a therapeutic intervention. Data were analyzed with the Fisher exact test for dichotomous variables and logistic regression. RESULTS: Two hundred forty-three VCE were reviewed, and 117 were included in the final analysis. A positive VCE (P2) was identified in 35 (29.9%) cases. In univariate analysis, a positive VCE was inversely associated with presence of diverticula on preceding colonoscopy (OR: 0.44, 95% CI: 0.2-0.99), while identification of blood on terminal ileal examination was associated with a positive VCE (OR: 5.18, 95% CI: 1.51-17.76). In multivariate analysis, only blood identified on terminal ileal examination remained a significant risk factor for positive VCE (OR: 6.13, 95% CI: 1.57-23.81). Blood on terminal ileal examination was also predictive of therapeutic intervention in both univariate (OR: 4.46, 95% CI: 1.3-15.2) and multivariate analysis (OR: 5.04, 95% CI: 1.25-20.32). CONCLUSION: Among patients presenting with overt bleeding but negative upper and lower endoscopy, the presence of blood on examination of the terminal ileum is strongly associated with a small bowel bleeding source as well as with small bowel therapeutic intervention. Presence of diverticula on colonoscopy is inversely associated with a positive VCE and therapeutic intervention in univariate analysis.

Gastric antral webs in adults: A case series characterizing their clinical presentation and management in the modern endoscopic era.

AIM: To investigate the current management of gastric antral webs (GAWs) among adults and identify optimal endoscopic and/or surgical management for these patients. METHODS: We reviewed our endoscopy database seeking to identify patients in whom a GAW was visualized among 24640 esophagogastroduodenoscopies (EGD) over a seven-year period (2006-2013) at a single tertiary care center. The diagnosis of GAW was suspected during EGD if aperture size of the antrum did not vary with peristalsis or if a "double bulb" sign was present on upper gastrointestinal series. Confirmation of the diagnosis was made by demonstrating a normal pylorus distal to the GAW. RESULTS: We identified 34 patients who met our inclusion criteria (incidence 0.14%). Of these, five patients presented with gastric outlet obstruction (GOO), four of whom underwent repeated sequential balloon dilations and/or needle-knife incisions with steroid injection for alleviation of GOO. The other 29 patients were incidentally found to have a non-obstructing GAW. Age at diagnosis ranged from 30-87 years. Non-obstructing GAWs are mostly incidental findings. The most frequently observed symptom prompting endoscopic work-up was refractory gastroesophageal reflux (n = 24, 70.6%) followed by abdominal pain (n = 11, 33.4%), nausea and vomiting (n = 9, 26.5%), dysphagia (n = 6, 17.6%), unexplained weight loss, (n = 4, 11.8%), early satiety (n = 4, 11.8%), and melena of unclear etiology (n = 3, 8.82%). Four of five GOO patients were treated with balloon dilation (n = 4), four-quadrant needle-knife incision (n = 3), and triamcinolone injection (n = 2). Three of these patients required repeat intervention. One patient had a significant complication of perforation after needle-knife incision. CONCLUSION: Endoscopic intervention for GAW using balloon dilation or needle-knife incision is generally safe and effective in relieving symptoms, however repeat treatment may be needed and a risk of perforation exists with thermal therapies.