The natural history of steroid-naïve eosinophilic esophagitis in adults treated with endoscopic dilation and proton pump inhibitor therapy over a mean duration of nearly 14 years.

BACKGROUND: Despite the vast focus of research in eosinophilic esophagitis (EoE), the natural history of untreated EoE remains undefined. Current expert consensus panels are calling for natural history studies to define long-term risks, adverse events, and progression of the disease. OBJECTIVE: To address the natural course and long-term adverse events of EoE. DESIGN: Retrospective, single-center study. SETTING: Tertiary-care center. A cohort of patients from the year 1988 initially diagnosed as having congenital esophageal stenosis who were later reclassified as having EoE. PATIENTS: Ninety-five patients, with 13 meeting entrance criteria for idiopathic EoE with follow-up >5 years. INTERVENTIONS: Anti-acids and esophageal dilation. MAIN OUTCOME MEASUREMENTS: Clinical response, adverse events, long-term clinical outcomes, and progression of disease. RESULTS: Thirteen patients (mean age at diagnosis 30.3 years, 10 male) were evaluated over a 13.6-year mean follow-up (range 5-24 years). All patients experienced daily dysphagia, with 12 presenting with food impactions. Patients were treated with esophageal dilation (64% Maloney, 34% Savary, 2.5% through-the-scope balloon) and daily anti-acids. Patients were initially treated with an average of 3.2 dilations over the first year (range 1-6) to achieve a luminal size of 15.8 mm (range 14-18 mm). They were maintained successfully with dilations every 2 years, on average, based on symptoms. Two patients not adhering to recommended dilation schedules experienced repeat impactions. One adverse event from a mucosal tear required hospitalization (1 of 157, 0.6%). Seven of 13 had Barrett's esophagus, average length 2.4 cm (range 1-4 cm), 3 on initial EGD and 4 identified over a mean duration of 9.4 years. No patient developed dysplasia or malignancy. LIMITATIONS: Retrospective, small sample. CONCLUSION: The course of EoE over a 13.6-year mean duration, although persistent, appears benign and not associated with cancer risk. A program of regular esophageal dilations based on symptom recurrence appears to be a safe, long-term treatment.

Eosinophilic esophagitis: a paradigm shift for pathology.

BACKGROUND: Eosinophilic esophagitis (EoE) is an increasingly recognized disease only reported in the adult literature since 1993. Our facility has the opportunity to evaluate steroid-naive EoE patients since 1988, allowing us to describe the evolution of the histologic diagnosis of EoE. METHODS: This retrospective study analyzed 95 patient charts with initial diagnosis of congenital esophageal stenosis/EoE from 1988 to 2012. Patients had dysphagia and met endoscopic criteria consistent with current EoE histologic criteria while on chronic proton-pump inhibitor therapy. Histologic slides were obtained for only 10 patients because of limited slide availability; and the slides were reviewed by a single pathologist. EoE is defined as ≥1 biopsy specimens demonstrating >15 eosinophils/HPF. RESULTS: Following review of histologic analysis reports, pathologists in our 2 academic hospitals began recognizing EoE as separate disease entity starting in 2007, coincidental with first EoE guidelines. After 2007, there was a clear surge in histologic diagnosis of EoE. Slides from 10 patients from 1988 to 2012 were reviewed. Of 35 biopsy sets, 19 were previously interpreted as reflux esophagitis (RE) or acute/chronic inflammation, 3 as RE with eosinophils, 2 as normal, and 11 as EoE. Reevaluation revealed EoE in 79% specimens with RE/inflammation and 100% with RE and eosinophils; remaining specimens had confirmed original diagnosis. All 10 patients had at least one set of slides meeting current EoE histologic criteria. CONCLUSIONS: EoE as a disease has been present for at least 2 to 3 decades. This is the first report of a clearly demarcated time point reflecting a paradigm shift in the histologic diagnosis of EoE as a distinct entity resulting from a seminal consensus report.

Levamisole induced necrosis of the skin and neutropenia following intranasal cocaine use: a newly recognized syndrome.

Levamisole is a veterinary anti-helminthic used to treat several autoimmune conditions but also commonly utilized as an additive in cocaine distribution. Toxicity resulting in agranulocytosis and cutaneous necrosis in association with cocaine use is an infrequently described phenomenon of an emerging problem. Although levamisole is found extensively in the cocaine supply of the United States, relatively few cases of necrotic skin lesions associated with intranasal use have been reported. The skin necrosis secondary to levamisole toxicity is characterized by variable findings on biopsy, ranging from leukocytoclastic vasculitis to occlusive vasculopathy. The following case describes a 54-year-old male who developed fever, agranulocytosis, p-ANCA autoantibodies and extensive skin necrosis following heavy intranasal cocaine use. Necrosis of greater than 50% of the patient's total body surface area resulted and was followed by thorough wound debridement.

Biliary fascioliasis mimicking sphincter of Oddi dysfunction.

Fasciola hepatica, a liver fluke of livestock, rarely presents as chronic biliary tract infection in humans. We report a 38-year-old woman from Ethiopia who presented with right upper quadrant pain and a dilated common bile duct on ultrasound and magnetic resonance cholangiopancreatography (MRCP) without other abnormalities. She was suspected to have type II sphincter of Oddi dysfunction. She underwent endoscopic retrograde cholangiopancreatography (ERCP) and had a fluke, diagnosed as Fasciola hepatica, in the common hepatic duct. This report confirms the diagnostic and therapeutic role of ERCP in the management of biliary fascioliasis, and highlights the need to include fascioliasis in the differential diagnosis of biliary pain in patients emigrating from areas where this infection is endemic.

Colonic stasis and chronic constipation: Demystifying proposed risk factors for colon polyp formation in a spinal cord injury veteran population.

BACKGROUND AND AIMS: Patients with spinal cord injury (SCI) suffer significant morbidity from neurogenic bowel. Chronic constipation has long-been a proposed risk factor for polyp development. We performed a retrospective cohort study in veterans with SCI to assess polyp presence in the setting of colonic stasis. METHODS: All consecutive patients at the James A. Haley Veterans Affairs Hospital with SCI and neurogenic bowel who completed screening colonoscopy between January 1, 2004 to June 30, 2013 were included. Colonoscopies were excluded if they were aborted, not completed to the cecum, of less than adequate preparation, or if polypectomy was precluded. Patient data included level, duration, and completeness of SCI. Polyp data included number, location, and histology. RESULTS: 325 patients ultimately met inclusion criteria. Most were male (96%). The average age at screening colonoscopy was 62.8 years. The majority of patients had injury to the cervical spine (41.5%). Colon polyps were detected in 130 patients (40%). Adenomatous change was seen in 95 (73%) of these patients. The adenoma detection rate (ADR) across all patients was 29.2%. Polyp presence and ADR demonstrated no statistically significant correlation with level, degree, or duration of SCI. Only patient age at time of screening colonoscopy had a significant correlation with polyp and adenoma presence (P<0.05). CONCLUSIONS: SCI had no statistically significant correlation with polyp or adenoma presence. The ADR in our veteran SCI population with chronic constipation is comparable with that reported in the general population.

The Black Esophagus: A Rare But Deadly Disease.

We present a series of cases of acute esophageal necrosis along with a video demonstration. The video captures a case showing the severity of necrosis of the esophageal mucosa; an orogastric tube easily passed through the esophageal lumen and into the right hemithorax. The series also demonstrates the severity of this illness, with an associated high mortality rate.

Embedded Fishhook in the Gastric Cardia: Novel Removal Utilizing Electrocautery Needle-Knife Dissection.

Foreign body ingestions often consist of benign objects that will readily pass through the gastrointestinal tract (GI) without necessitating further intervention. While several retrieval devices and techniques are available to the endoscopist, we present a novel method of implementing a needle-knife sphincterotome in the removal of an ingested fishhook embedded in the gastric cardia of a 36-year-old man with underlying schizophrenia. The hook was successfully dissected from the gastric submucosa after several unsuccessful attempts at manual extraction with forceps. To our knowledge, our case represents one in only a handful of other reports of the successful removal of ingested foreign bodies utilizing this method.

Negative predictive value of positron emission tomography/computed tomography in patients with a clinical suspicion of pancreatic cancer.

OBJECTIVES: The aim of this study was to determine the negative predictive value of positron emission tomography (PET)/computed tomography (CT) in patients with lesions suggestive of pancreatic cancer. METHODS: A retrospective review from January 2005 to August 2008 of all patients who underwent a PET/CT to evaluate a lesion suggestive of pancreatic cancer based on prior imaging. One hundred eighty-four patients underwent PET/CT, of which 60 patients had a negative PET scan. Of these 60 patients, 56 patients (30 women, 26 men) had endoscopic ultrasound-guided fine-needle aspiration or surgical pathology for clinical correlation. The Fisher exact test was used for statistical analysis. RESULTS: The negative predictive value of PET/CT was 75%. Eighteen patients had a benign lesion, 24 patients had a premalignant lesion, and 14 patients had a malignant lesion. In the cystic group, 72.4% of the PET/CT-negative lesions were premalignant compared with the solid group that was only 5.9%. This was in contrast to the solid group, where 64.7% was malignant versus 6.9% in the cystic group. Two of 14 patients with malignancy had metastatic disease. CONCLUSIONS: The negative predictive value of PET/CT in pancreatic lesions suggestive of pancreatic cancer was 75%. A negative PET/CT does not exclude pancreatic cancer, and further workup of these PET-negative lesions is warranted.