Esophageal dysmotility in patients undergoing photodynamic therapy.

OBJECTIVE: To study the esophageal motility of patients with esophageal adenocarcinoma or Barrett esophagus with high-grade dysplasia before and after photodynamic therapy. PATIENTS AND METHODS: In this prospective study conducted between January 1998 and October 1999, esophageal motility testing of the lower esophageal sphincter and esophageal body was performed with a water-perfused catheter, 2 days before and at least 3 weeks after patients underwent photodynamic therapy for esophageal adenocarcinoma or Barrett esophagus. Results were classified as normal motility, ineffective esophageal motility, or aperistalsis. RESULTS: Twenty-three patients were studied, 13 with carcinoma and 10 with Barrett esophagus. Overall, 11 patients (48%) had normal motility, 6 (26%) had ineffective esophageal motility, and 6 (26%) had aperistalsis. Five patients with aperistalsis had carcinoma. Follow-up tracings after photodynamic therapy found that 6 patients (26%) had normal motility, 7 (30%) had ineffective esophageal motility, and 10 (43%) had aperistalsis. CONCLUSIONS: Esophageal dysmotility is common in patients with esophageal adenocarcinoma or Barrett esophagus. Photodynamic therapy may worsen esophageal motility in some patients. Dysphagia after photodynamic therapy therefore may be related to underlying esophageal dysmotility and may not always be caused by stricture or underlying carcinoma.

Primary hepatic lymphoma in hepatitis C: case report and review of the literature.

Primary B-cell lymphoma of the liver is an extremely rare tumor. The higher incidence of hepatocellular carcinoma in hepatitis C is well known, but the relationship with lymphoma is unclear. An increased incidence has been reported in patients with chronic hepatitis C. Hepatitis C virus is known to be a lymphotropic virus. Mixed cryoglobulinemia, which is a benign lymphoproliferative disorder, has a definite association with hepatitis C. It is postulated that the virus may also induce a malignant transformation. We describe an unusual presentation of a case of asymptomatic left hepatic mass in a patient with hepatitis C with a preoperative diagnosis of hepatocellular carcinoma. He underwent a left lateral segmentectomy, and the pathologic examination revealed non-Hodgkin's lymphoma. The clinical features, radiologic investigations, and pathologic findings are presented. A review of the literature discussing clinical features, postulated pathogenetic mechanisms, and management options is also presented.

Gastric metaplasia of the proximal esophagus associated with esophageal adenocarcinoma and Barrett's esophagus: what is the connection? Inlet patch revisited.

BACKGROUND/AIM: The inlet patch is an area of heterotopic gastric mucosa found in the proximal esophagus at the level of the upper esophageal sphincter. Limited data are available regarding this form of gastric metaplasia and its incidence, significance, and possible association with other esophageal diseases. We report our observations of such gastric metaplasias in patients with esophageal adenocarcinoma or Barrett's esophagus and high-grade dysplasia. METHODS: All patients having Barrett's esophagus and adenocarcinoma referred for photodynamic therapy were included in this study. The patients were prospectively evaluated endoscopically for the presence of gastric metaplasia of the proximal esophagus (salmon-colored area of a least 5 mm in diameter with cardia-type gastric metaplasia on biopsy). RESULTS: A total of 36 patients were included in this study: 11 patients with dysplastic Barrett's esophagus (8 males, mean age 79 years) and 25 adenocarcinoma patients (18 males, mean age 71 years). At endoscopy prior to photodynamic therapy, 11 patients (31%; 8 adenocarcinoma, 3 dysplastic Barrett's esophagus) were noted to have an area of gastric mucosa in the proximal esophagus. In each patient, there was at least 5 cm of normal squamous mucosa between gastric metaplasia and distal esophageal pathology. CONCLUSIONS: In this selected group of patients with high-grade dysplastic Barrett's esophagus or adenocarcinoma referred for photodynamic therapy, gastric metaplasia of the proximal esophagus was found in nearly one third. Prospective studies are under way to test more widely for this association and to determine whether this is a marker of disease severity and the result of similar pathogenetic mechanisms.

Nutrition supplementation in patients with acute and chronic pancreatitis.

Acute pancreatitis is a hypermetabolic state characterized by increased protein catabolism, lipolysis, and glucose intolerance. Most patients presenting with acute pancreatitis are better within 5 to 7 days and can be resume a regular diet. Patients with severe pancreatitis and who are unable to eat within 7 to 10 days should receive nutritional support. The decision to use parenteral or enteral nutrition is controversial. More recent data suggest that jejunal feedings are just as beneficial, if not better, than parenteral nutrition. Marked weight loss and abdominal pain are the features of chronic pancreatitis. Steatorrhea develops when greater than 90% of pancreatic exocrine dysfunction occurs. Treatment focuses on pain control and pancreatic enzyme replacement. Pancreatic enzymes should be given with meals. Patients with refractory steatorrhea may benefit from the addition of an H2 antagonist or proton-pump inhibitor with pancreatic enzyme replacement. Micronutrients, including antioxidants, should be replaced if serum levels suggest a deficiency.

Manometry of the upper esophageal sphincter and pharynx is not useful in unselected patients referred for esophageal testing.

OBJECTIVE: We sought to determine whether routinely performing upper esophageal sphincter/pharyngeal (UES/P) manometry in patients referred for esophageal testing alters clinical practice. METHODS: Clinical history along with radiography and manometry studies were reviewed in 470 patients referred for manometry. A total of 435 (92.6%) were found to have adequate evaluation of the UES/P and were included in the study. RESULTS: Of 435 studies, 80 (17.7%) had one or more UES/P abnormalities. Indications for these 80 studies were dysphagia in 30 cases (37.5%), chest pain in 26 (32.5%), both in four (5.0%), and other in 20 (25%). There were 85 manometric abnormalities in the 80 studies: hypertensive UES in 16 cases (18.8%), incomplete UES relaxation in 38 (44.7%), hypertensive pharynx in seven (8.2%), hypotensive pharynx in 15 (17.6%), and abnormal coordination in nine (10.6%). A total of 41 patients had a barium study, which was normal in 11 cases (26%), confirmed the problem in 16 (40%), and suggested another problem in 14 (34%). In 17 patients (21%), there was clinical suspicion for an oropharyngeal disorder before manometry, whereas in 58 cases it was an unexpected finding. Of the 58 patients with an unexpected finding, therapy based on this finding was offered in six (three esophageal dilations, two dietary changes, and one swallowing therapy). If patients with concomitant esophageal body disorders are excluded, in only three patients an unexpected UES finding led to change in management. CONCLUSIONS: An unexpected UES/P finding resulted in a change in therapy in only six of the manometries. Barium esophagogram was diagnostic of the oropharyngeal abnormality in nearly two-thirds of the patients in whom it was clinically suspected. These data, along with limited therapeutic options, suggest limited usefulness for routine UES/P manometry.

Prostate cancer metastasizing to the small bowel.

Although prostate cancer is one of the most commonly encountered malignancies in clinical practice, it is very unusual for prostate cancer to metastasize to the small bowel. Our search of the literature found no such cases published from 1966 to the present. We report the case of a 69-year-old man who presented for evaluation of anasarca and anorexia. He had a history of prostate cancer diagnosed 9 years before and had undergone a radical prostatectomy with subsequent radiotherapy for positive tumor margins. He developed anasarca 2 years before presentation to us. His serum albumin ranged between 1.5 and 2.5 g/dL. Upper endoscopy was performed for possible protein-losing enteropathy and the appearance of gastric and duodenal mucosa was found to be normal. Random small bowel biopsies revealed submucosal infiltrating adenocarcinoma with positive prostate-specific antigen stains consistent with the diagnosis of prostate cancer metastatic to the small bowel. This is a rare presentation of metastatic prostate cancer. Even though prostate cancer is the most commonly diagnosed cancer in American men, antemortem diagnosis of small bowel metastasis has not been reported. In patients with unexplained anasarca, especially with a history of malignancy, an upper endoscopy with small bowel biopsy may be useful in establishing the diagnosis.