Narrative review of the role of gastroenterologist in the diagnosis, treatment and palliation in gastric and gastroesophageal cancer.

Esophageal cancer (EC) and gastric cancer (GC) carry a high mortality rate. Unfortunately, a majority of patients are asymptomatic and at the time of diagnosis, the disease may invariably be in its advanced stages with limited curative options. Thus, it is imperative to recognize certain risk factors including gastroesophageal reflux disease (GERD), male gender, pre-existing Barrett's esophagus, smoking history, obesity, Helicobacter pylori infection, atrophic gastritis among others for both EC and GC, intervene on time with screening and surveillance modalities if indicated and optimize treatment plans. With advances in endoscopic techniques, early neoplastic lesions are increasingly managed by gastroenterologists, offering an alternative to surgery. The gold standard for diagnosis of EC and GC is high definition endoscopy with adequate targeted biopsies. Endoscopic ultrasound (EUS) is a key in the staging of early cancers dictating the pathway for treatment options. We also play a key role in palliation cases with the aim to reduce the symptoms like nausea, vomiting and even when possible, restore oral intake and improve nutrition in both advanced GC and EC. This review article discusses the risk factors, diagnostic and endoscopic treatment modalities of early EC and GC and palliation of advanced cancer where gastroenterologists play a key role.

Vedolizumab-Induced De Novo Extraintestinal Manifestations.

Background: Vedolizumab is an α4ß7 integrin antagonist with gut-specific effects on lymphocyte and monocyte trafficking. Although the treatment is beneficial for inflammatory bowel disease (IBD), the effects of vedolizumab on extraintestinal manifestations (EIMs) have not been well described. The gut-specific effects of the medication may have diverse outcomes on EIMs. We hypothesize that EIMs may be unmasked by systemic availability of gut-homing effector cells. Aim: The goal of this study is to describe de novo EIMs of IBD patients who were started on vedolizumab. Methods: A retrospective chart review of 71 patients from January 2011 to October 2017, including clinical and medication history and colonoscopy results, was performed. Results: EIMs occurred in 26.7% of patients who were started on vedolizumab. The most common EIMs were arthralgias, perianal fistula, and pyoderma gangrenosum. There was a trend toward a greater occurrence of EIMs in patients with Crohn's disease compared to ulcerative colitis. Conclusion: Our retrospective study suggests that inhibition of gut-specific effector cells results in activated lymphocytes and/or monocytes that cause inflammation in other tissues. More studies are needed to confirm these observations and to develop biomarkers that predict patients at risk for EIMs and perianal fistulas while on vedolizumab.

Management patterns of gastric polyps in the United States.

OBJECTIVE: Recent guidelines on endoscopic sampling recommend complete gastric polyp removal for solitary fundic polyps >10 mm, hyperplastic polyps >5 mm and all adenomatous polyps. We aim to describe endoscopic approach to polyps in the time period prior to the American Society of Gastrointestinal Endoscopy (ASGE) guidelines and to identify opportunities for clinical practice improvements. DESIGN: Retrospective review of the Clinical Outcome Research Initiative (CORI) database, including all oesophagogastroduodenoscopies (OGDs). Reviewers grouped interventions during procedures based on instruments used for polyp sampling by forceps or snare polypectomy. Logistic regression estimated the effect of variables of interest on method of polypectomy. RESULTS: Of 783 037 OGDs reported in the CORI database, 25 670 (3.3%) described gastric polyps and met the inclusion criteria. Mean gastric polyp size was 6.5±4.9 mm, and 46.2% and 14.5% were located in the corpus and antrum, respectively. Polyps in the forceps group were smaller than polyps in the snare group (5.7±4.0 mm vs 9.3±6.4 mm, respectively, p<0.001). We identified 1056 polyps (41.3%) >10 mm that only underwent forceps biopsy. Forceps were used more frequently in the gastric fundus. CONCLUSIONS: Snare polypectomy was underused in gastric polyps, per current ASGE guidelines. Anatomical location and endoscopic features of polyps were important predictors of the approach to gastric polypectomy.

Recurrent Cardiac Tamponade: An Unusual Presentation of Intrahepatic Cholangiocarcinoma.

A 48-year-old Egyptian woman presented with 8 months of sharp right upper chest pain and weight loss. She was discovered to have an enlarged cardiac silhouette on chest x-ray, and an echocardiogram revealed a large pericardial effusion with diastolic right atrial collapse. Pericardial window was done, and epithelial membrane antigen-positive neoplastic cells were identified in the pericardial fluid. Computed tomography showed a 6-cm hypermetabolic lesion on the liver segment IV, confirmed on biopsy to be a moderately differentiated adenocarcinoma consistent with intrahepatic cholangiocarcinoma.