Chameleonic Chloroma: A Case of Myeloid Sarcoma Presenting as a Pancreatic Head Mass.

We report a case of pancreatic myeloid sarcoma (MS), an extremely rare manifestation of acute myeloid leukemia (AML), in a 35-year-old male who presented with epigastric pain and watery stools. Initial diagnostic testing was inconclusive; however, following an extensive evaluation, endoscopic biopsies suggested AML, which was confirmed by a bone marrow biopsy. Given that few cases are documented in the literature, pancreatic MS without a preexisting hematologic malignancy poses a significant diagnostic challenge.

Bleeding Gastrointestinal Stromal Tumor (GIST) Results in a Sticky Situation: The Good and Bad of Hemostatic Spray.

A 50-year-old female presented with symptomatic anemia and hematemesis due to a 3.3 cm gastric gastrointestinal stromal tumor (GIST), which was located in the fundus. Adequate endoscopic views were only achieved in the retroflexed position and attempts at hemostasis via endoscopic clips were unsuccessful. Subsequently, TC-325 hemostatic powder was sprayed on the bleeding lesion and given retroflexed positioning, the powder also coated the esophagogastroduodenoscopy (EGD) scope where it abutted the gastroesophageal junction (GEJ). Hemostasis was successful, but the scope was unable to be withdrawn due to adherence to the surrounding mucosa. With torque maneuvering and a moderate amount of withdrawal force, the scope was successfully freed. The patient was started on imatinib mesylate and did not experience further bleeding episodes. This case highlights the challenge of achieving hemostasis in a bleeding GIST, the beneficial role of hemostatic powder spray, and the need for caution when utilizing it in a retroflexed manner.

Taking Caution at Road's End: Incidental Finding of Appendiceal Goblet Cell Tumor on Colonoscopy.

Cancer of the appendix is an uncommon malignancy that is rarely diagnosed on colonoscopy. We present a case of incidentally discovered goblet cell adenocarcinoma of the appendix and the subsequent management. The patient initially presented with progressive epigastric pain in the setting of a family history of gastric cancer and personal history of colon polyps, for which surveillance was due. Bidirectional endoscopy was performed, from which biopsied tissue of an abnormal-appearing appendiceal orifice confirmed goblet cell adenocarcinoma. This case highlights the importance of identification of the appendiceal orifice in all colonoscopies and tissue sampling in cases of atypical-appearing anatomy.

Loop-and-Let-Go: Treatment of a Large Colonic Lipoma After Unsuccessful Unroofing.

Gastrointestinal lipomas are benign subepithelial tumors arising from adipose tissue. Most colonic lipomas are clinically silent and do not require intervention. However, if the lipomas are large or symptomatic, removal can be considered. Of the endoscopic techniques available, endoscopic ligation, also known as "loop-and-let-go," provides a safe and easy alternative to other endoscopic therapies and does not require any specialized equipment or advanced training. We describe a case of a patient found to have large colonic lipoma that recurred after endoscopic unroofing but was successfully treated with "loop-and-let-go."

Systems-based Strategies Improve Positive Screening Fecal Immunochemical Testing Follow-up and Reduce Time to Diagnostic Colonoscopy.

INTRODUCTION: Fecal immunochemical testing (FIT) is the most commonly used colorectal cancer (CRC) screening tool worldwide and accounts for 10% of all CRC screening in the United States. Potential vulnerabilities for patients enrolled to facilities within the military health system have recently come to light requiring reassessment of best practices. We studied the impact of a process improvement initiative designed to improve the safety and quality of care for patients after a positive screening FIT given previously published reports of poor organization performance. METHODS: During a time of increased utilization of nonendoscopic means of screening, we assessed rates of colonoscopy completion and time to colonoscopy after positive FIT after a multi-faceted process improvement initiative was implemented, compared against an institutional control period. The interventions included mandatory indication labeling at the time of order entry, as well as utilization of subspecialty nurse navigators to facilitate rapid follow-up even the absence of a referral from primary care. RESULTS: Preintervention, 34.8% of patients did not have appropriate follow-up of a positive FIT. Those that did had a variable and prolonged wait time of 140.1 ± 115.9 days. Postintervention, a standardized order mandating test indication labeling allowed for proactive gastroenterology involvement. Colonoscopy follow-up rate increased to 91.9% with an average interval of 21.9 ± 12.3 days. CONCLUSION: The addition of indication labels and patient navigation after positive screening FIT was associated with 57.1% absolute increase in timely diagnostic colonoscopy. Similar highly reliable systems-based solutions should be adopted for CRC screening, and further implementation for other preventative screening interventions should be pursued.

Brunner's Gland Hamartomas: Two Cases of This (Sometimes) Distinctive Lesion.

Brunner's gland hamartomas (BGHs) are rare, benign, primary duodenal tumors. The clinical presentations can vary, and confirming a diagnosis can be challenging because of the submucosal nature of the lesions. We report two cases of BGHs with different clinical presentations. The diagnoses were not determined initially, despite utilizing endoscopy, mucosal biopsies, endoscopic ultrasound, and, in one case, fine-needle aspiration. Confirmation of BGHs was subsequently made following endoscopic or surgical resection.

A surprising cause of acute right upper quadrant pain.

A 42 year-old African-American woman was admitted for severe acute right upper quadrant pain. Her liver function tests showed a cholestatic pattern of hepatitis. She had no known history of liver disease or sarcoidosis. Imaging of her liver and biliary tree did not reveal any apparent cause for her right upper quadrant pain. A liver biopsy was performed which showed granulomatous disease. This prompted a CT chest that showed mediastinal lymphadenopathy. Biopsy of the mediastinal lymphnode revealed non-caseating granulomas. Despite having no pulmonary symptoms or history of pulmonary sarcoidosis, she was diagnosed with systemic pulmonary sarcoidosis. She was treated with corticosteroids and had complete resolution of symptoms over the next several weeks.

Anti-gliadin antibodies identify celiac patients overlooked by tissue transglutaminase antibodies.

For patients with suspected celiac disease, the American Gastroenterological Association recommends initial screening with anti-tissue transglutaminase antibody (tTG) and confirmation testing with small bowel biopsy. However, at Tripler Army Medical Center we routinely screen patients with both tTG and anti-gliadin antibodies (AGA) in combination. The purpose of this study was to evaluate whether this dual screening method adds to the evaluation of patients with suspected celiac disease or results in more false-positive results than tTG screening alone. A retrospective chart review of all tTG and AGA screening serologies at Tripler Army Medical Center between September 2008 and March 2012 was performed. For patients with positive serologic testing, small bowel biopsy results or reasoning for deferring biopsy were investigated. tTG was found to have a higher positive predictive value for celiac disease than AGA, however AGA identified 5 patients (19% of biopsy confirmed celiac disease) that had a negative tTG and would not have been identified by tTG screening alone. Using AGA in combination with tTG should be considered if the goal of screening is to identify all patients with celiac disease, with the understanding that this strategy will generate more false positive tests and result in additional patients undergoing small bowel biopsy.

Postpolypectomy electrocoagulation syndrome: a mimicker of colonic perforation.

Postpolypectomy electrocoagulation syndrome is a rare complication of polypectomy with electrocautery and is characterized by a transmural burn of the colon wall. Patients typically present within 12 hours after the procedure with symptoms mimicking colonic perforation. Presented is the case of a 56-year-old man who developed abdominal pain six hours after colonoscopy during which polypectomy was performed using snare cautery. CT imaging of the abdomen revealed circumferential thickening of the wall of the transverse colon without evidence of free air. The patient was treated conservatively as an outpatient and had resolution of his pain over the following four days. Recognition of the diagnosis and understanding of the treatment are important to avoid unnecessary exploratory laparotomy or hospitalization.

Atrophic-appearing pancreas on magnetic resonance cholangiopancreatography as initial presentation of cystic fibrosis.

Cystic fibrosis is an autosomal recessive disease typically diagnosed in early childhood secondary to pulmonary manifestations. We present the unusual case of a 20-year-old man being diagnosed with cystic fibrosis after he was incidentally noted to have an atrophic pancreas on magnetic resonance cholangiopancreatography. He had no sign of chronic pancreatitis or symptoms of exocrine pancreatic insufficiency. As pancreatic atrophy is rare in young adults, the patient was evaluated for cystic fibrosis by genetic testing and the patient was noted to have the deltaF508 and p.R347L mutations of the cystic fibrosis transmembrane receptor. The patient was counseled on the implications of these findings for his potential children, but no treatment was undertaken at this time.