Cystic Lymphangioma: Are Triglycerides Always Measurable?

The presence of chylous fluid with high triglycerides levels on endoscopic ultrasound- (EUS-) guided fine needle aspiration (FNA) is very pathognomonic for the diagnosis of cystic lymphangiomas of the pancreas. In our case report the puncture of the pancreatic cyst showed a typical milky fluid though measurable triglyceride concentrations were absent in the laboratory. Two possible explanations were found. First of all grossly lipemic samples show a slower rate of color development than do clear serums which can produce a false negative result if the sample is insufficiently diluted. Secondly, high lipase levels can divide triglycerides in glycerol and fatty acids, making the concentration of triglycerides undetectable.

Advances in radiotherapy delivery for rectal cancer: a European perspective.

Preoperative chemoradiotherapy and radiotherapy with an integrated boost offer excellent local control rates in patients with rectal cancer. The introduction of intensity-modulated radiotherapy and image-guided radiotherapy has drastically improved the tolerance of these treatments. The new challenge is developing organ-preserving strategies and curative treatments for medically inoperable patients. Contact radiotherapy seems efficient for small tumors. Tumor hypoxia limits the success of radiotherapy for locally advanced cancers. Modulation of the L-arginine/iNOS pathway and implementation of hypoxia imaging in radiotherapy planning may overcome this hurdle.

[A man with a strange mass in his defecation]. / Een man met een vreemde massa in zijn ontlasting.

A 56-year-old patient underwent a preventive colonoscopy. We found a large mass in his colon with a benign aspect. The 'unroofing' technique was used for further diagnosis and we suspected the diagnosis of 'lipoma'. Nine days after the colonoscopy, a part of the lipoma was evacuated through the stool. Histopathological examination of this tissue confirmed the diagnosis of 'lipoma'.

Pancreatic panniculitis: a rare complication of pancreatitis secondary to ERCP.

Panniculitis is an uncommon and rare complication of systemic fat necrosis in patients with pancreatic diseases. The skin manifestations are independent of the severity of the pancreatic pathology and can occur at any time. The lesions can precede, be concomitant with or rarely follow the pancreatic illness. We report a case of acute pancreatitis post Endoscopic Retrograde Cholangio Pancreatography (ERCP) for common bile duct stone, with subcutaneous panniculitis. We noted a complete resolution within two weeks after the treatment of the pancreatic pathology.

Gastroesophageal reflux evaluation in patients affected by chronic cough: Restech versus multichannel intraluminal impedance/pH metry.

OBJECTIVES/HYPOTHESIS: Oropharyngeal (OP) pH monitoring has been developed to detect supra-esophageal gastric reflux (SEGR). The results obtained with OP pH-metry and multichannel intraluminal impedance/pH monitoring (MII/pH) were compared. STUDY DESIGN: Diagnostic study. METHODS: Ten patients (age 46.33 ± 9.86 years) presenting with chronic coughing underwent simultaneous OP and MII/pH recording. A 2-minute interval was allowed between events detected with both techniques to be considered simultaneous. RESULTS: A total of 515 reflux episodes were recorded with MII/pH (acid: 181; weakly acid: 310; weakly alkaline: 24); 180 (35%) reached the highest impedance channel (hypo-pharynx); 74/180 (41%) were not related to a change in pH, according to the antimony electrode of the MII/pH catheter located at the upper esophageal sphincter. The OP monitoring measured 39 acid events; 17 (43.6%) were swallows according to MII, and 15 (38.5%) were not associated with MII or pH change. Only seven episodes were detected simultaneously with both techniques (1.3% for MII vs. 18% for OP; P = 0.0002). We found 49 pH-only refluxes at the pH sensor in the hypo-pharynx with MII/pH; only three (6.1%) correlated with OP reflux. Correlation in time between cough and reflux events was positive in 5/10 patients for MII (symptom index 5/10, symptom association probability 4/10), but in 0/10 patients according to OP pH metry. CONCLUSION: OP pH metry detected less reflux episodes than MII/pH; 35% of the OP events were swallows according to impedance. Time correlation between cough and reflux could not be demonstrated with OP pH metry.

Factors affecting satisfaction with treatment in European women with chronic constipation: An internet survey.

BACKGROUND: Data on factors affecting treatment satisfaction in European women with chronic constipation are limited. OBJECTIVE: To assess factors associated with treatment satisfaction among European women with chronic constipation. METHODS: A 2011-2012 internet survey was conducted in men and women from 12 European countries. Respondents analysed were female with self-reported chronic constipation (≥1 symptoms for ≥6 months of lumpy/hard stools, feeling of incomplete evacuation, and pain during defecation, as well as <3 bowel movements/week). For laxative users, satisfaction with treatment, factors affecting satisfaction, and interactions with healthcare professionals were collected. RESULTS AND CONCLUSIONS: In total, 4805/50,319 participants fulfilled the inclusion criteria (female with chronic constipation). Of the laxative users (1575/4805), 57% (n = 896) were satisfied with their treatment, while 26% were neutral, and 17% dissatisfied. Dissatisfied respondents visited their GP less frequently in the past 12 months, were more likely to obtain over-the-counter laxatives, and took a dose higher than recommended more frequently than those satisfied. Respondents were most satisfied with ease of use of treatment and least satisfied with relief from bloating. Newer treatments aimed at alleviating symptoms, particularly bloating, are required for respondents neutral or dissatisfied with their current treatment.

Prediction of response to neoadjuvant radiotherapy in patients with locally advanced rectal cancer by means of sequential 18FDG-PET.

PURPOSE: Morphologic imaging techniques perform poorly in assessing the response to preoperative radiotherapy (RT), mainly because of desmoplastic reactions. The aim of this study was to investigate the potential of sequential 18-fluoro-2-deoxy-d-glucose (18FDG-PET) in assessing the response of rectal cancer to neoadjuvant RT and to determine which parameters can be used as surrogate markers for histopathologic response. METHODS AND MATERIALS: 18FDG-PET scans were acquired before and during the 5th week after the end of RT. Tracer uptake was assessed semiquantitatively using standardized uptake values (SUV). The percentage differences (%Δ) between pre- and post-RT scans in SUV(max), SUV(mean), metabolic volume (MV), and total glycolytic volume (tGV) were calculated. RESULTS: Forty-five consecutive patients with histologically confirmed rectal adenocarcinoma were enrolled. After neoadjuvant RT, 20 of the 45 patients were classified as histopathologic responders and 25 as non-responders. Intense 18F-FDG uptake was seen in all tumors before neoadjuvant RT (average SUV(max) 12.9 ± 6.0). When patients were classified as histologic responders and nonresponders, significant differences in %ΔSUV(max) (55.8% vs. 37.4%, p = 0.023) and %ΔSUV(mean) (40.1% vs. 21.0%, p = 0.001) were observed between the two groups. For %ΔMV and %ΔtGV, decreases were more prominent in responders but were not significantly different from those in nonresponders. As demonstrated by receiver operating characteristic analysis, %ΔSUV(mean) was a more powerful discriminator than was %ΔSUV(max). The sensitivity, specificity, accuracy, positive predictive value, and negative predictive value for optimal threshold of %ΔSUV(mean) (24.5%) were 80%, 72%, 76%, 70%, and 82% respectively. CONCLUSION: Sequential 18FDG-PET allows assessment of the response to preoperative RT. Both %ΔSUV(mean) and %ΔSUV(max) correlate with histopathologic response and can be used to evaluate and compare the effectiveness of different neoadjuvant treatment strategies. The maximum accuracy figures and the positive predictive value figures for both Δ%SUV(mean) and Δ%SUV(max) are, however, too low to justify modification of the standard treatment protocol of an individual patient.

Capsule endoscopy for detection of small bowel malignancies.

Capsule Endoscopy (CE) is a recent diagnostic tool for detection of small bowel disease. The tiny imaging capsule has to be swallowed by the patient, which allows transmission by radiofrequency two images each second, to sensors worn around the patient's abdomen. After eight hours, the pictures can be downloaded and read by a Gastroenterologist. CE allows for exploration of the entire small bowel mucosa, which involves segments not accessible by classical endoscopy. Moreover, it is the only technique that involves a visualization of the entire small bowel without sedation. Tumors of the small intestine are rather infrequent and could account for approximately 2% of gastrointestinal neoplasms. As symptoms of small bowel tumors are not specific, most published series include patients with bleeding or anemia of undetermined origin, the main indication for performing CE. Currently, no doubt exists of the ability regarding the CE to increase the diagnostic yield of small bowel tumors, or to alter their management and improve their outcome in the absence of metastases. Overall, tumors along the small intestine are located by CE in 2.5%-8.9% of patients who undergo this procedure. While being an evident improvement, CE has some limitations, such as the inability to treat lesions locally or take tissue specimens. This last point is an important shortcoming, because small bowel tumors can be malignant (approximately 2/3 of the cases) or benign. The future of CE is bright, and special capsule devices already exist to specifically explore the esophagus as well as the large intestine.

Regulation of sinusoidal perfusion in portal hypertension.

Portal hypertension, a major complication of cirrhosis, is caused by both increased portal blood flow and augmented intrahepatic vascular resistance. Even though the latter is primarily caused by anatomical changes, it has become clear that dynamic factors contribute to the increased hepatic vascular resistance. The hepatic sinusoid is the narrowest vascular structure within the liver and is the principal site of blood flow regulation. The anatomical location of hepatic stellate cells, which embrace the sinusoids, provides a favorable arrangement for sinusoidal constriction, and for control of sinusoidal vascular tone and blood flow. Hepatic stellate cells possess the essential contractile apparatus for cell contraction and relaxation. Moreover, the mechanisms of stellate cell contraction are better understood, and many substances which influence contractility have been identified, providing a rationale and opportunity for targeting these cells in the treatment of portal hypertension in cirrhosis.

Expression of somatostatin receptors in splanchnic blood vessels of normal and cirrhotic rats.

BACKGROUND/AIMS: Somatostatin has been used for over two decades to treat acute variceal bleeding. Although it is assumed that somatostatin lowers portal pressure by constriction of the splanchnic arteries, little is known about the expression of somatostatin receptors (SSTR) in splanchnic blood vessels. In this study we investigated SSTR expression in splanchnic blood vessels from normal and cirrhotic rats. METHODS/RESULTS: Cirrhosis was induced by intraperitoneal injection of 50 mg thioacetamide twice a week for 14 weeks. In portal vein, mesenteric artery and aorta of normal and cirrhotic rats, mRNA for the five known SSTR was measured by quantitative reverse transcriptase-polymerase chain reaction. SSTR subtypes 1, 2, 3 and 4 were expressed, but subtype 5 was undetectable. In the portal vein of cirrhotic animals, SSTR1 was significantly down-regulated as compared with controls. Otherwise, no major differences in receptor expression between normal and cirrhotic animals were observed. Using immunohistochemistry, we identified all five receptors, although the staining of receptor 5 was very weak. CONCLUSION: All five SSTR are expressed in splanchnic blood vessels. Our results suggest that cirrhosis reduces expression of SSTR1 in portal vein. In other vessels, no major differences between the normal and cirrhotic state were noted.

Capsule endoscopy in paediatrics: multicentric Belgian study.

BACKGROUND AND STUDY AIMS: Capsule Endoscopy (CE) is a noninvasive procedure for evaluating small bowel disease. Data concerning children are scarce. The aim of the present report was to review all paediatric cases investigated by CE in Belgium. PATIENTS AND METHODS: The seven Belgian academic hospitals using the CE device (Given) were asked to collect information on CE performed in patients < or = 18 years. Main indications for performing VCE, former radiological and endoscopic procedures were collected, as well as final diagnosis and clinical impact of VCE findings. RESULTS: From November 2002 until December 2005, VCE was performed in 17 children (mean age : 11.9 years, range : 5-18). Indications were occult gastro-intestinal bleeding (OGIB) and/or iron deficiency anaemia (IDA) (10 cases) and chronic and/or recurrent abdominal pain (7 cases). Mean duration of symptoms was 8.6 months. The mean number of endoscopic and radiological procedures before performing CE was 4.2 per patient. Detected lesions were ulcerations (6 cases), jejunal varices (1), ileo-ileal invagination (2), active bleeding (1), and normal findings (7). In the indication of OGIB/IDA, relevant findings having an impact on the diagnosis were found in 60% of the cases. In the group with chronic and recurrent abdominal pain, CE brought relevant findings in 43%. CE findings had an impact on therapy in 44% of the patients. CONCLUSIONS: CE could be a useful tool for clinical work-up of difficult paediatric cases, not only in the indication of IDA/OGIB, but also for selected cases of recurrent abdominal pain, but prospective controlled trials including emerging techniques like CT enterography are mandatory.

Somatostatin at nanomolar concentration reduces collagen I and III synthesis by, but not proliferation of activated rat hepatic stellate cells.

Previous studies have shown antifibrotic effects of somatostatin. Since hepatic stellate cells (HSC) express somatostatin receptors and play a key role in hepatic fibrogenesis, we investigated the in vitro antifibrotic effect of somatostatin on rat HSC. At day 12 after isolation, cells were exposed to different concentrations of somatostatin (10(-6)-10(-9) mol l(-1)). mRNA expression of collagen types I and III, and of smooth muscle alpha-actin (alpha-SMA) was analysed by Northern blotting. At 10(-9) mol l(-1), somatostatin significantly reduced mRNA expression of collagen I (72.3 +/- 10.7%; 95% confidence interval (95% CI): 45.5-99.0), collagen III (79.0 +/- 4.5%; 95% CI: 67.6-90.4) and alpha-SMA (65.7 +/- 5.9%; 95% CI: 51.1-80.2), as compared to control normalized at 100%. These results were confirmed by quantitative RT-PCR. Cycloheximide experiments indicated that somatostatin has no direct transcriptional effect.Using immunoprecipitation, we demonstrated that somatostatin also decreased de novo synthesis of collagen I (73 +/-10%; 95% CI: 48-98%), collagen III (65 +/- 13%; 95% CI: 33-97%) and alpha-SMA (47 +/- 9%; 95% CI: 25-69%). Remarkably, at higher concentrations, somatostatin did not suppress collagen mRNA expression nor de novo protein synthesis. We ascribe this observation to desensitization of the cells for somatostatin. Cell proliferation, as measured by 5-bromo-2'-deoxyuridine labelling, was not altered by somatostatin. No significant effect on the intermediate and actin cytoskeleton were detected by immunohistochemistry and Western blotting. Our findings imply that in vivo antifibrotic effects of somatostatin could result partially from a direct action of somatostatin on HSC, but other, in vivo effects are probably also involved.

Metastases to the thyroid gland-a report of six cases.

The association of an asymptomatic mass, normal thyroid function, and a cold nodule can occur months to years after a primary cancer. Work-up should include ruling out other metastases and fine-needle aspiration cytology. We report six cases of secondary thyroid cancer. Two of the patients in our series presented with hyperthyroidism, which may be due to invasion and disruption of thyroid follicles.