Oroesophageal Pemphigus vulgaris Secondary to Lisinopril Use: A New Side Effect.

Pemphigoid diseases are a group of blistering autoimmune pathologies including pemphigus vulgaris (PV) and pemphigus foliaceous, which affect mucocutaneous tissues. Non-steroidal anti-inflammatory drugs, penicillamine, and angiotensin-converting enzyme inhibitors such as captopril and enalapril are associated with drug-induced pemphigoid. We present a case of lisinopril-associated PV which has not been previously reported.

Survival Trends for Resectable Pancreatic Cancer Using a Multidisciplinary Conference: the Impact of Post-operative Chemotherapy.

PURPOSE: Despite advances in various treatment modalities, surgical resection for pancreatic ductal adenocarcinoma (PDA) remains the only curative treatment. Data remains limited regarding survival rates for resectable PDA when managed by a multidisciplinary pancreas conference (MDPC). The aim of this study is to assess survival rates, identify significant predictors of mortality, and assess the benefits of adjuvant chemotherapy for resectable PDA following presentation at a MDPC. METHODS: All patients presented from April 2013 to August 2016 with resectable PDA were discussed at a MDPC at a tertiary care center and were followed prospectively until November 2017. Survival analysis was performed using Kaplan-Meier for age, tumor size, tumor differentiation, T-stage, lymph node status, and completion of adjuvant chemotherapy cycles. Independent predictors of survival were determined using multivariate Cox regression modeling. RESULTS: After MDPC consensus and exclusions, total of 64 patients underwent successful surgery. Amongst this cohort, 1-, 2-, and 3-year survival was 78.13%, 46.30%, and 27.27%, respectively. A total of 37 patients (58%) initiated and 16 patients (25%) finished chemotherapy following surgery. Log-rank analysis revealed that tumor size, age, surgical margins, lymph node status, and number of adjuvant chemotherapy cycles received significantly influenced post-operative survival. Tumor size (p < 0.001), lymph node status (p = 0.035), and number of adjuvant chemotherapy cycles (p = 0.041) remained significant after multivariate Cox regression model. CONCLUSIONS: Our results suggest that patients with PDA with tumor size > 50 mm and/or lymph node involvement have poor outcomes despite being surgically resectable. Successful completion of adjuvant chemotherapy has better survival outcomes as compared with incomplete or no adjuvant chemotherapy. The role of alternative management such as down-staging with neoadjuvant therapy should be considered.

Defining Pancreatitis as a Risk Factor for Pancreatic Cancer: The Role, Incidence, and Timeline of Development.

OBJECTIVES: Acute and/or chronic pancreatitis has been implicated as an important risk factor for pancreatic cancer; however, the incidence and temporal relationship of pancreatitis before pancreatic cancer diagnosis are unclear. We aim to understand the role and incidence of pancreatitis temporally with the development of pancreatic cancer. METHODS: A population-based study was used to investigate a temporal relationship between pancreatitis and pancreatic cancer diagnoses. Intervals of 3, 6, 12, 24, and 36 months were developed. Demographical data including age, sex, and race were also recorded and analyzed. RESULTS: A total of 50,080 patients were found to have a diagnosis of pancreatic cancer, of which 7420 (14.8%) had prior diagnoses of pancreatitis. Of those, 92% were between the ages of 40 and 89 years. African Americans had a higher rate of pancreatitis before cancer diagnosis when compared with whites (21.2% vs 14.8%, P < 0.0001). Further analysis revealed that pancreatitis occurred in 81.3% of patients 3 months before a diagnosis of pancreas cancer and 98.9% had established diagnoses of pancreatic cancer within 3 years. CONCLUSIONS: Screening of patients older than 40 years who have pancreatitis and unclear etiology of pancreatitis may be warranted, especially in African Americans and male individuals.

Endoscopic ultrasound guided fine-needle aspiration vs core needle biopsy for solid pancreatic lesions: Comparison of diagnostic accuracy and procedural efficiency.

BACKGROUND: Endoscopic ultrasound (EUS) guided core needle biopsies (CNB) are increasingly being performed to diagnose solid pancreatic lesions. However, studies have been conflicting in terms of CNB improving diagnostic accuracy and procedural efficiency vs fine-needle aspiration (FNA), which this study aims to elucidate. METHODS: Data were prospectively collected on consecutive patients with solid pancreatic or peripancreatic lesions at a single tertiary care center from November 2015 to November 2016 that underwent either FNA or CNB. Patient demographics, characteristics of lesions, diagnostic accuracy, final and follow-up pathology, use of rapid on-site evaluation (ROSE), complications, and procedure variables were obtained. RESULTS: A total of 75 FNA and 48 CNB were performed; of these, 13 patients had both. Mean passes were lower with CNB compared to FNA (2.4 vs 2.9, P = .02). Use of ROSE was higher for FNA (97.3% vs 68.1%, P = .001). Mean procedure time was shorter with CNB (34.1 minutes vs 51.2 minutes, P = .02) and diagnostic accuracy was similar (89.2% vs 89.4%, P = .98). There was no difference in diagnostic accuracy when ROSE was performed for CNB vs not performed (93.5% vs 85.7%, P = .58). Additionally, diagnostic accuracy of combined FNA and CNB procedures was 92.3%, which was comparable to FNA (P = .73) or CNB (P = .52) alone. CONCLUSION: FNA and CNB had comparable safety and diagnostic accuracy. Use of CNB resulted in less number of passes and shorter procedure time as compared to FNA. Moreover, diagnostic accuracy for CNB with or without ROSE was similar.

Complete Endoscopic and Histopathological Remission of Mantle Cell Lymphoma of the Gastrointestinal Tract.

Mantle cell lymphoma (MCL) is a rare and incurable subtype of non-Hodgkin's lymphoma (NHL). Primary gastrointestinal (GI) MCLs are even rarer, accounting for only 1%-4% of GI lymphomas. We describe a case of a 77-year-old female who presented with complaints of indigestion and abdominal bloating. An upper endoscopy was performed which revealed a duodenal bulb polyp, biopsies of which were consistent with MCL. She was initially observed without any chemotherapy; however, a repeat endoscopy two years later revealed that she now also had MCL of the ileocecal valve. The patient was initiated on treatment with rituximab, cyclophosphamide, vincristine, and prednisone (R-CVP). She underwent regular surveillance with her oncologist after completion of her chemotherapy and repeat surveillance scans remained negative for any recurrence. A repeat upper endoscopy with endoscopic ultrasound and colonoscopy were performed which showed complete endoscopic and histopathological remission of her lymphoma. Patients with MCL typically have a poor prognosis; however, our patient remains symptom free and in complete remission six years from her initial diagnosis.

Fecal microbiota transplantation in recurrent Clostridium difficile infection: A retrospective single-center chart review.

BACKGROUND AND AIM: Fecal microbiota transplantation (FMT) has been proposed as a treatment option for patients with recurrent Clostridium difficile (C. difficile) infection but remains a novel option. We examined if FMT is an effective means of treating recurrent C. difficile infection. METHODS: A retrospective review of 35 patients who underwent FMT was completed. Demographics and other variables, including the use of proton pump inhibitor therapy and history of inflammatory bowel disease, were collected. RESULTS: Twenty-five patients (71.4%) belonged to a high-risk population (working in a hospital setting, rehabilitation center, or nursing facility) and a total of 74.3% of patients (n = 26 patients) had no history of proton pump inhibitor use. Twenty-five patients (71.4%) had used metronidazole prior to transplantation, 35 patients (100%) had used vancomycin, and 7 patients (20%) had used fidaxomicin for prior infection. Four patients (11.4%) had used all three antibiotics during prior treatment. Of the eight patients who had a history of inflammatory bowel disease, six (75%) experienced resolution of symptoms after transplantation. A total of 30 patients (85.7%) had resolution of their symptoms 6-8 weeks' posttransplant, while 5 patients (14.3%) continued to have symptoms. CONCLUSIONS: Our retrospective chart review supports that patients benefit from FMT in the setting of recurrent C. difficile infection.

Performance of a Multidisciplinary Pancreatic Cancer Conference in Predicting and Managing Resectable Pancreatic Cancer.

OBJECTIVES: Surgery is the curative treatment for pancreatic ductal adenocarcinoma (PDA). Guidelines recommend utilizing a multidisciplinary pancreatic cancer conference (MDPC) in treatment; however, data are limited. The objective of this study was to assess the accuracy of an MDPC. METHODS: Patients with PDA presented at an MDPC were prospectively collected from April 2013 to August 2016. Patients were included if the MDPC predicted them to have resectable PDA and underwent upfront surgery. Secondary aims were to compare differences in tumor characteristics, time to surgery, and resection rates with patients prior to MDPC implementation (pre-MDPC). RESULTS: A total of 278 patients were presented at the MDPC. After excluding borderline and nonresectable cases, 91 patients were predicted as resectable on evaluation, and 70 were fit for surgery. The MDPC predicted resection in 91.4%. The MDPC had larger tumor size (32.6 vs 24.0 mm), greater proportion of stage II tumor, and a shorter time from diagnosis to resection (27.3 vs 35.5 days) compared with the pre-MDPC. Microscopically negative resections were similar between MDPC and pre-MDPC (85.9% vs 88.0%) despite advanced tumor size and stage. CONCLUSIONS: The MDPC demonstrates a high resection rate. Compared with a pre-MDPC, MDPC provides shorter time to surgery and selects for advanced tumors.

Esophageal Granular Cell Tumor in a 28-year-old: A Unique Cause for Dysphagia.

This is the case of a 28-year-old female who presented with a complaint of dysphagia and was diagnosed with the rare disease of esophageal granular cell tumor (GCT) after esophagogastroduodenoscopy (EGD) and endoscopic ultrasound (EUS). The case acknowledges the wisdom of maintaining a broad differential for a common complaint. It also serves to reiterate the clinical and pathologic criteria for the diagnosis of a granular cell tumor of the esophagus.

Mantle cell lymphoma: a rare cause of a solitary duodenal mass.

Mantle cell lymphoma is a very aggressive lymphoma with a very poor prognosis. It commonly involves the gastrointestinal tract but rarely presents as primary gastrointestinal lymphoma. The most notable cases of primary gastrointestinal mantle cell lymphomas have been described as multiple lymphomatous polyposis and have a very poor prognosis. We report a case of primary gastrointestinal mantle cell lymphoma that was discovered by endoscopic biopsy of a single duodenal polyp in a 70-year-old woman who was previously treated for Helicobacter pylori gastritis. She presented with a 6-month history of indigestion, heartburn and abdominal bloating. A subsequent workup revealed one extranodal site of involvement, lymphatic involvement below the diaphragm and a normal bone marrow biopsy. We followed a wait-and-watch approach including serial CT scans and blood tests. Two years later, her symptoms have not progressed and her disease has remained stable.

Comparison of the outcomes of endoscopic ultrasound based on community hospital versus tertiary academic center settings.

OBJECTIVE: Endoscopic ultrasound (EUS) is an established tool in the management of gastrointestinal diseases. The majority of EUS procedures are performed in tertiary care hospitals but the technology has also disseminated to community hospitals. The data from community hospitals are limited and there are no published studies comparing EUS-fine needle aspiration (FNA) outcomes in community versus tertiary settings. Our objective is to compare EUS procedures performed in these two separate settings. METHODS: EUS procedures performed for pancreatobiliary indications in an academic tertiary care hospital and a community hospital were retrospectively reviewed and compared. The patient demographics, procedure time, procedure indications, FNA performed, pass counts, needle size, rapid onsite evaluation (ROSE) and final cytological diagnosis were compared between the two centers. Cytological diagnosis was categorized as satisfactory and unsatisfactory samples. RESULTS: There was no significant difference in patient age, gender, indications, procedure time, FNA performed, needle size, or pass counts between the tertiary hospital (n = 361) and community hospital (n = 119). ROSE was a significant determinant factor for adequacy of sample. There was a positive linear relationship between adequacy of the sample and number of pass counts. After performing a logistic regression and adjusting for target site, the overall odds of having an unsatisfactory specimen were not significantly different at the two centers (OR 0.51, CI 0.23-1.17, p = 0.11). Percentages of unsatisfactory samples were not significantly different at the two centers for solid lesions (7.4 vs. 3.1%, p = 0.33), cysts (33.3 vs. 23.8%, p = 0.31,) or lymph nodes (25.0 vs. 0%, p = 0.063). CONCLUSION: Cytological yield of EUS-FNA in a community hospital is similar to that of a tertiary hospital. Community hospitals can provide EUS services with reasonable success.

Diarrhoea, weight loss and polyposis: think Cronkhite-Canada syndrome.

A 71-year-old male presented with nausea, diarrhoea and weight loss. He had mild to moderate alopecia, paucity of eyebrow hair, erythematous non-pruritic nodular rash on the wrists, toenail onychomychosis and scalp hyperpigmentation. A colonoscopy revealed an irregular, haemorrhagic 5 cm rectosigmoid mass. Biopsies revealed mucin distended glands and focal ischemic changes. A CT scan showed numerous polypoid-like lesions in the stomach. Upper endoscopy showed mucosal erythema and nodularity with polypoid-like lesions. Biopsies showed cystic glandular dilatation, lamina propria oedema and chronic inflammation consistent with Cronkhite-Canada syndrome (CCS). The patient was started on nutrition supplementation. His skin manifestations were treated topically and with mineral supplements. He improved within 10 weeks and is currently asymptomatic. A high index of suspicion for CCS should exist in patients who present with weight loss, diarrhoea and polyposis. If diagnosed early, the disease can be treated with the goal of clinical remission.

Idiopathic eosinophilic esophagitis in adults: the ringed esophagus.

PURPOSE: To retrospectively assess the findings of idiopathic eosinophilic esophagitis (IEE) at barium studies and determine the frequency of the ringed esophagus in patients with this condition. MATERIALS AND METHODS: The institutional review board approved all aspects of this retrospective study and did not require informed consent from patients whose records were included in the study. The study was compliant with the Health Insurance Portability and Accountability Act. A review of the pathology and radiology databases at the authors' institution revealed 14 patients (11 men and three women; mean age, 41.3 years) with IEE (defined as more than 20 eosinophils per high-power field in biopsy specimens) who had undergone barium studies and endoscopy. The radiographs were reviewed for strictures, esophagitis, or other abnormalities. The endoscopic reports, clinical records, and laboratory data were also reviewed and compared with the radiographic findings. RESULTS: Seven of the 14 patients (50%) had a history of allergies, and two of nine patients with complete blood cell counts (22%) had peripheral eosinophilia. Thirteen patients (93%) had dysphagia, six (43%) had food impactions, and six (43%) had reflux symptoms. Ten patients (71%) had a total of 11 strictures at barium studies (two in the upper part of the esophagus, two in the middle part, three in the distal part, one in the middle and distal parts, and three at the gastroesophageal junction). The strictures had a mean length of 5.1 cm. In seven patients (50%), the strictures contained multiple fixed ringlike indentations that produced a ringed esophagus. The ringlike indentations appeared as multiple, fixed, closely spaced, concentric rings traversing the stricture. Four patients (28%) had esophagitis. Of 13 patients who underwent recumbent imaging, 10 (77%) had hiatal hernias and nine (69%) had reflux. Eight of the 10 patients (80%) with strictures underwent endoscopic dilation procedures, which resulted in only temporary relief of dysphagia. CONCLUSION: The findings suggest that most patients with IEE have esophageal strictures, often with distinctive ringlike indentations that produce a ringed esophagus.

Schatzki ring and Barrett's esophagus: do they occur together?

Our purpose was to determine the prevalence of Barrett's esophagus in the presence of Schatzki ring. We performed a retrospective case-control study with an endoscopic database. Barrett's esophagus was present in 3 of 409 (0.73%) patients with Schatzki ring and in 16 of 888 (1.80%) patients without Schatzki ring. Short segment Barrett's esophagus was present in 3 cases and 10 controls. Long segment Barrett's esophagus was present in no cases and six controls. Logistic regression models adjusting for the presence of a hiatal hernia revealed a significant decrease in the odds of Barrett's esophagus in cases compared to controls (OR, 0.24; 95% CI, 0.07-0.87; P = 0.029). Barrett's esophagus is less prevalent in patients with Schatzki ring compared to patients without Schatzki ring. Long segment Barrett's esophagus was not observed in patients with Schatzki ring. A responsible protective effect or mutually exclusive pathophysiology should be considered.