Endoscopic Mucosal Resection for Colonic Mucosal Neoplasia and Evaluation of Long-Term Recurrence: A Single-Center Experience of 500 Cases.

OBJECTIVES: Endoscopic mucosal resection (EMR) is an alternative to surgery for the treatment of large laterally spreading lesions. Residual or recurrent adenoma is a major limitation. This study aimed to quantify early and late recurrences and to assess its associated risk factors. METHODS: The study was a single-center, multiendoscopist, longitudinal study conducted between January 1, 2013 and April 26, 2017. A total of 480 patients with 500 polyps who underwent an endoscopic resection were included. Surveillance colonoscopy (SC) was performed at 4 to 6 months (SC1) and 16 to 18 months (SC2). RESULTS: At SC1, early recurrence was noted in 77 of 354 (21.8%) lesions; 76 (98.7%) were treated endoscopically. The remaining 277 of 354 (78.2%) lesions had no recurrence at SC1; only 41 lesions (15%) were followed up at SC2. Recurrence at SC2 was found in 4 lesions (9.8%), all of which were treated endoscopically. Lesion size >40 mm was associated with recurrence. Recurrence at both SC1 and SC2 was successfully treated endoscopically in 78 of 81 lesions (96.3%). CONCLUSIONS: EMR is an effective, minimally invasive technique for the treatment of large laterally spreading lesions. Although recurrence is a concern, its risk is low (21.8% on SC1 and 9.8% on SC2) and was managed endoscopically in 96.3% cases on follow-up endoscopy.

Giant Gastric Ulcers: An Unusual Culprit.

Mycophenolate Mofetil (MMF) is routinely used immunosuppressant in solid organ transplantation is commonly associated with several gastrointestinal (GI) side effects. Here we present a case of giant gastric ulcer of 5 cm from MMF use post cardiac transplant. CASE DESCRIPTION: A 56-year-old male with history of severe ischemic cardiomyopathy post heart transplant was on immunosuppression with MMF, tacrolimus and prednisone for 5 months. He presented with severe epigastric pain and intermittent episodes of melena for 1 month. His pain radiated to back that is worsened with eating. Associated with loss of appetite, vomiting and 16-pound weight loss in 3 months. He never smoked, drank alcohol or used over the counter pain medications. He was profoundly anemic requiring blood transfusions. EGD performed demonstrated very large clean-based ulcer of 5 cm diameter in the body, smaller ulcer of 8 mm diameter in pre-pyloric region and 5-10 small aphthous ulcers in the gastric body and fundus. Gastric biopsies taken from the ulcer were negative for Helicobacter pylori, cytomegalovirus and malignancy. Flexible sigmoidoscopy revealed non-bleeding inflamed internal hemorrhoids. Consequently, MMF was discontinued and switched to azathioprine. He was treated with twice daily proton pump inhibitor therapy with resolution of abdominal pain, improved appetite and weight gain. DISCUSSION: MMF is well known for common GI side-effects such as nausea, diarrhea, vomiting, ulcers, abdominal pain and rarely gastrointestinal bleeding. Few studies reported 3 to 8% incidence of ulcer perforation and GI bleeding within 6 months. Risk of gastroduodenal erosions is nearly 1.83 times for MMF, with the highest lesions associated with MMF-tacrolimus-corticosteroid combination treatment as seen in our patient. Hypothesis is that GI tract is vulnerable because of dependence of enterocytes on de novo synthesis of purines, which is disrupted by MMF. Typically, upper GI mucosal injuries of mucosal irritation leading to esophagitis, gastritis and/or ulcers are seen. Endoscopy is both diagnostic and therapeutic if bleeding gastric ulcers are noted. Minor complications improve with reduction of drug dose or use of enteric coated preparation if feasible. Discontinuation of the drug is main stay in the management of MMF related ulcer disease. Simple medical treatment with either H2-receptor antagonists, proton-pump inhibitors, coating agents, prostaglandins or combination has proven effective in most cases. Considering excellent results with medical management of ulcer, role of surgery is limited.

Migration of Over-the-scope Clip Resulting in Anal Pain and Obstructed Defecation.

Iatrogenic perforation is a known and feared complication of diagnostic and therapeutic colonoscopy. Specific locations in the gastrointestinal tract, such as the jejunum, have a higher risk of perforation owing to its difficult anatomical position. Over-the-scope clips have recently been used for the management of these perforations. We present the case of a 40-year-old male patient treated with over-the-scope (Ovesco®, Ovesco Endoscopy AG, Tübingen, Germany) clips for an iatrogenic postpolypectomy perforation with subsequent anal pain and inability to evacuate stool occurring as a result of the migration of the clip, followed by a review of the literature.

A Rare Case of Bowel Obstruction due to Metastatic Breast Cancer.

Breast cancer is the most common malignancy affecting women and has a high mortality rate. It commonly metastasizes to the skeletal and pulmonary systems. Rare reports have described breast cancer spreading to the gastrointestinal tract. We present a female patient diagnosed with and treated for primary lobular-type breast cancer, who developed recurrent bowel obstruction due to metastasis.

Endoscopic detection and resection of dysplasia in inflammatory bowel disease-techniques with videos.

BACKGROUND: Patients with ulcerative colitis and Crohn's colitis have an increased risk of developing dysplasia and colorectal cancer as compared to the general population; surveillance colonoscopy is recommended in this patient population. METHODS: This review of the published literature aimed to assess the published evidence. RESULTS: Detection of dysplasia requires examination of mucosa with targeted biopsies of the visible lesions as well as random biopsies to detect invisible lesions. Newer endoscopic techniques, in particular chromoendoscopy, increase the yield of identifying dysplastic lesions. The surveillance for Colorectal Endoscopic Neoplasia Detection and Management in Inflammatory Bowel Disease Patients International Consensus (SCENIC) guidelines recommends that colonoscopy using chromoendoscopy is the optimal endoscopic surveillance strategy to detect dysplasia. Once dysplastic lesions are discovered on surveillance endoscopic examination, careful and meticulous descriptions of lesions is mandatory to aid in further decision making. Management of dysplastic lesions in inflammatory bowel disease patients depends on endoscopic (morphological) and histologic findings and patient characteristics such as age, general condition of the patient, and patient preferences. Endoscopic mucosal resection, endoscopic submucosal dissection, and surgery are different therapeutic options for colonic dysplastic lesions detected in the setting of inflammatory bowel disease. CONCLUSIONS: In this review, we discuss the various techniques for endoscopic resection of dysplasia in patients with inflammatory bowel disease. Further research is required to determine the optimal approach to diagnosis and management of dysplasia in patients with inflammatory bowel disease.

A Case of Pancreatic Pseudocyst Complicated by Pseudoaneurysm.

Pancreatic pseudocyst is a complication that can arise in both acute and chronic pancreatitis. Overtime, this encapsulated enzyme-rich fluid collection may erode into surrounding vasculature and result in the formation of a pseudoaneurysm. Pseudoaneurysms can rupture into the gastrointestinal tract and present as upper, lower, and biliary bleeding. Evaluation of pancreatic pseudocysts involves computed tomography imaging or magnetic resonance imaging for both identification and monitoring. Esophagogastroduodenoscopy (EGD) and endoscopic ultrasound (EUS) can be done to further visualize the lesion. In the presence of gastrointestinal bleed, management involves the combination of interventional radiology and surgery.

Triple Pancreatic Walled-off Fluid Collections Treated Simultaneously with Endoscopic Transmural Drainage.

Pancreatic pseudocysts and walled-off pancreatic necrosis arise as a complication of pancreatitis. Multiple fluid collections are seen in 5-20% of the patients who have walled-off peripancreatic fluid collections. There is a paucity of data regarding the role of endoscopic transmural drainage in the management of multiple pancreatic fluid collections. In this case report, we present the case of a 72-year-old male with three walled-off pancreatic fluid collections in the setting of acute necrotizing pancreatitis. The patient underwent simultaneous endoscopic ultrasound-assisted cyst gastrostomy and cyst duodenostomy and aggressive irrigation without index endoscopic necrosectomy of the three peripancreatic fluid collections. Significant improvement in the size of the fluid collections was seen on the computed tomography scan, as well as a remarkable immediate clinical improvement after 24 hours of the endoscopic intervention.

Postgastric bypass hypoglycaemia in a patient with end-stage renal disease: a diagnostic and management pitfall.

Roux-en-Y gastric bypass (RYGB) surgery is currently one of the most popular procedures to aid weight loss. Hypoglycaemia associated with gastric bypass surgery is an underdiagnosed but life-threatening potential consequence of the surgical procedure. We present a case of a 44-year-old woman with end-stage renal disease presenting with refractory hypoglycaemia after 10 years of RYGB. Extensive history and work-up excluded medications, renal disease, insulinoma and dumping syndrome as the cause of hypoglycaemia. Dietary modifications or pharmacological trial of drugs did not ameliorate her symptoms with progressive worsening of hypoglycaemia leading to continuous dextrose infusion. Distal pancreatectomy was performed with subsequent resolution of hypoglycaemia. Surgical pathology results showed diffuse hyperplastic islet cells, confirming the diagnosis of postgastric bypass hypoglycaemia.

A Heart too Stiff to Beat: A Case of Familial Transthyretin Amyloidosis Cardiomyopathy.

Heart failure is a common clinical syndrome caused by a variety of cardiac diseases. We report a rare case of familial transthyretin amyloidosis cardiomyopathy to heighten the awareness of this rare but lethal cause of heart failure, as therapeutic interventions such as liver or heart transplant could be curative in selected patients.

Clinical Cholecystitis in the Absence of the Gallbladder.

The congenital absence of the gallbladder (CAG) is a rare condition with an incidence of 13-65 cases/ 100,000 in the general population. This occurs when the gallbladder and the cystic duct fail to bud from the common bile duct during the fifth week of gestation. Most commonly, the patients with congenital absence of the gallbladder are asymptomatic. When symptomatic, they present as biliary colic, dyspepsia, jaundice or very rarely as acute cholecystitis. We present a case of a 27-year-old female who presented with acute right upper quadrant abdominal pain. Further evaluation with an ultrasound revealed a contracted gallbladder with stones. The hepatobiliary iminodiacetic acid scan was significant for non-visualization of the gallbladder, consistent with cystic duct obstruction. The laparoscopic cholecystectomy was attempted, however, the gallbladder was not visualized, and the procedure was aborted. The post-operative magnetic resonant cholangiopancreatography was consistent with the diagnosis of congenital absence of gallbladder.

Evaluation of the awareness and perception of professional students in medicine, business and law schools of Karachi, regarding the use of (recreational) cannabis.

OBJECTIVE: To assess the awareness and perception of students attending professional medicine, law and business schools regarding recreational use of cannabis. METHODS: The cross-sectional study was conducted between June 2010 and November 2010. Using convenience sampling, 150 students from medical, business and law schools from both private and public sectors were enrolled. Government institutions included, Sindh Medical College, Institute of Business Administration and S.M. Law College, private schools were Ziauddin Medical College, SZABIST and Lecole for advanced studies. Data was collected through self-administered questionnaire. SPSS 17 was used for statistical analysis. RESULTS: A total of 250 students were approached out of which 150(60%) filled the questionnaire. Of them 91(60.7%) were males and the overall mean age of the respondents was 22 ± 2 years. A total of 68 (45.3%) students were from the medical field, 53 (35.3%) from business and 29 (19.3%) from law. The private and public sectors were equally represented at 75 (50%) each. Overall, 93 (62%) agreed that hashish is a serious problem concerning student population. When asked to identify factors encouraging abstinence, 67 (44.7%) respondents each cited religion and health risks. CONCLUSION: Our youth is not only concerned about the menace of hashish and but want proper awareness to be provided.