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A late adolescent man diagnosed with cystic fibrosis and presenting with predominantly gastrointestinal symptoms, including chronic constipation, exocrine pancreatic insufficiency and gastro-oesophageal reflux disease, experienced recurrent episodes of nausea, vomiting and abdominal pain. CT of the abdomen unveiled the presence of chronic appendicitis, alongside constipation without evidence of distal intestinal obstruction syndrome. Endoscopic biopsies revealed small bowel eosinophilic infiltrates. Subsequently, the patient underwent an appendectomy, and a tailored regimen was established to address constipation, resulting in an initial alleviation of his symptoms. Three months later, a resurgence of symptoms occurred, coinciding with persistent intestinal eosinophilic infiltrates. A diagnosis of eosinophilic enteritis was rendered, and treatment commenced with an oral dosage of 40 mg of prednisone. Two weeks later, the patient experienced symptom resolution, corroborated by the findings of an endoscopic biopsy conducted 8 weeks later. During a follow-up examination 6 months later, the patient remained asymptomatic.
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Fibrose Cística , Enterite , Gastrite , Masculino , Adolescente , Humanos , Fibrose Cística/complicações , Fibrose Cística/diagnóstico , Enterite/complicações , Enterite/diagnóstico , Enterite/tratamento farmacológico , Gastrite/complicações , Gastrite/diagnóstico , Gastrite/tratamento farmacológico , Constipação IntestinalRESUMO
Barrett's esophagus (BE) is a condition that results from replacement of the damaged normal squamous esophageal mucosa to intestinal columnar mucosa and is the most significant predisposing factor for development of esophageal adenocarcinoma. Current guidelines recommend endoscopic evaluation for screening and surveillance based on various risk factors which has limitations such as invasiveness, availability of a trained specialist, patient logistics and cost. Trans-nasal endoscopy is a less invasive modality but still has similar limitations such as limited availability of trained specialist and costs. Non-endoscopic modalities, in comparison, require minimal intervention, can be done in an office visit and has the potential to be a more ideal choice for mass public screening and surveillance, particularly in patents at low risk for BE. These include newer generations of esophageal capsule endoscopy which provides direct visualization of BE, and tethered capsule endomicroscopy which can obtain high-resolution images of the esophagus. Various cell collection devices coupled with biomarkers have been used for BE screening. Cytosponge, in combination with TFF3, as well as EsophaCap and EsoCheck have shown promising results in various studies when used with various biomarkers. Other modalities including circulatory microRNAs and volatile organic compounds that have demonstrated favorable outcomes. Use of these cell collection methods for BE surveillance is a potential area of future research.
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Esôfago de Barrett , Neoplasias Esofágicas , MicroRNAs , Compostos Orgânicos Voláteis , Esôfago de Barrett/diagnóstico por imagem , Biomarcadores , Neoplasias Esofágicas/diagnóstico por imagem , Neoplasias Esofágicas/etiologia , Esofagoscopia/efeitos adversos , HumanosRESUMO
Background Acute cholangitis results in significant mortality unless treated promptly. The diagnostic grading criteria of the 2018 Tokyo Guidelines (TG18) are used worldwide as the standard for acute cholangitis (AC) management but validation in clinical practice is required. Aim Use of the Tokyo 2018 (TG18) guidelines in improving the diagnostic accuracy and early detection of AC compared to fellow clinical assessment. Methods A retrospective review of patient records from 1/2010-9/2019 seen at Augusta University - Medical College of Georgia with the International Classification of Diseases, Ninth Revision (ICD-9) code "cholangitis" and/or ICD-10 codes "acute cholangitis, other cholangitis, and calculus of bile duct with cholangitis" was performed. Inclusion criteria were gastroenterology inpatient consult fellow evaluation and clinical diagnosis of AC. A definitive diagnosis of AC was determined following endoscopic retrograde cholangiopancreatography (ERCP). TG18 scoring for AC was then performed, categorized as either diagnostic/non-diagnostic, and compared to fellow clinical assessments following definitive diagnosis post-ERCP. Data were analyzed with chi-square testing. Results Two hundred six patients were identified using ICD codes. Ninety-one met inclusion criteria and were analyzed. The mean patient age of the overall group was 67 years old (standard deviation of 13.3 years) with males comprising 69% and non-Hispanic white 56% of the study group. TG18 criteria assessment had a sensitivity of 86% and specificity of 63% for patients with AC post ERCP (p <0.05). TG18 accuracy was 81%. In comparison, fellow clinical suspicion had a sensitivity of 90.3% and specificity of 0% (NS). Fellow accuracy was 71%. No difference in fellows' diagnosis of suspected AC was noted based on the training year. Conclusion Application of the TG18 criteria for AC reduces the false positive rate and improves diagnostic accuracy, thus decreasing costs along with avoiding unnecessary ERCPs with associated complications.
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BACKGROUND: Antiangiogenic agents (AAs) are increasingly used to treat malignant tumors and have been associated with gastrointestinal (GI) bleeding and perforation. Elective surgeries and endoscopy are recommended to be delayed for 31 d until after AAs treatment. Data regarding the safety of endoscopy while on antiangiogenic agents is extremely limited. No guidelines are in place to address the concern about withholding these anti-angiogenic drugs. AIM: To evaluate the risks of endoscopy in patients on antiangiogenic agents from 2015 to 2020 at our institution. METHODS: This is a single centered retrospective study approved by the institutional review board statement of the institution. Patients that underwent endoscopy within 28 d of antiangiogenic agents' treatment were included in the study. Primary outcome of interest was death, and secondary outcomes included perforation and GI bleeding. Data were analyzed utilizing descriptive statistics. Fifty-nine patients were included in the final analysis and a total of eighty-five procedures were performed that were characterized as low risk and high risk. RESULTS: Among the 59 patients a total of 85 endoscopic procedures were performed with 24 (28.2%) categorized as high-risk and 61 (71.8%) procedures as low-risk. Of the total number of patients, (50%) were on bevacizumab and the rest were on imatinib (11.7%), lenvatinib (6.7%) and, ramucirumab (5%). The average duration between administration of AAs and the performance of endoscopic procedures was 9.9 d. No procedure-related adverse events were noted among our study population. We did observe two deaths with one patient, on lenvatinib for metastatic hepatocellular carcinoma, who had persistent bleeding despite esophageal variceal banding and died 4 d later from hemorrhagic shock. Another patient was diagnosed with acute myeloid leukemia died 24 d after an esophagogastroduodenoscopy with biopsy after transition to comfort care. CONCLUSION: As per this single center retrospective study, the rate of endoscopic procedure-related adverse events and death within 28 d of AA administration appears to be low.
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Human intestinal spirochetosis (HIS) is a condition where spirochetes, a group of spiral-shaped bacteria, attach to the apical membrane of the human colorectal epithelium. Although most findings of HIS are simply incidental discoveries found during screening colonoscopies, the ability to mimic the presentation of inflammatory bowel diseases should prompt consideration of this condition as part of a working differential diagnosis. Herein, we present the case of a 57-year-old bisexual, African American male with a medical history of Human Immunodeficiency Virus (HIV) on antiretroviral therapy (ART) with an undetectable viral load that presented for an elective, outpatient colonoscopy after experiencing four months of intermittent bloating and hematochezia. Histologic examination of colonic biopsies confirmed a diagnosis of HIS. The nonspecific clinical presentation in the setting of well-controlled HIV makes HIS a formidable diagnostic challenge that requires increased awareness.
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Hepatopatias , Rim Policístico Autossômico Dominante , Humanos , Fígado , Hepatopatias/diagnóstico , RimRESUMO
The ketogenic diet (keto diet) has become an increasingly popular approach for both weight loss and as an alternative diet for type 2 diabetes mellitus (T2DM). Owing to the nature of the keto diet, patients are at risk of developing hypertriglyceridemia (HTG) due to the high amount of triglycerides consumed by individuals during the initiation of this diet. Acute pancreatitis can result from HTG. We present a case of a 19-year-old African American male with well-controlled T2DM and no history of HTG who developed severe necrotizing HTG-induced pancreatitis after an unsupervised three-month trial of the keto diet.
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BACKGROUND: Cocaine is a synthetic alkaloid initially viewed as a useful local anesthetic, but which eventually fell out of favor given its high addiction potential. Its predominantly sympathetic effects raise concern for cardiovascular, respiratory, and central nervous system complications in patients undergoing procedures. Peri-procedural cocaine use, often detected via a positive urine toxicology test, has been mostly addressed in the surgical and obstetrical literature. However, there are no clear guidelines on how to effectively risk stratify patients found to be positive for cocaine in the pre-operative setting, often leading to costly procedure cancellations. Within the field of gastroenterology, there is no current data available regarding safety of performing esophagogastroduodenoscopy (EGD) in patients with recent cocaine use. AIM: To compare the prevalence of EGD related complications between active (≤ 5 d) and remote (> 5 d) users of cocaine. METHODS: In total, 48 patients who underwent an EGD at John H. Stroger, Jr. Hospital of Cook County from October 2016 to October 2018 were found to have a positive urine drug screen for cocaine (23 recent and 25 remote). Descriptive statistics were compiled for patient demographics. Statistical tests used to analyze patient characteristics, procedure details, and preprocedural adverse events included t-test, chi-square, Wilcoxon rank sum, and Fisher exact test. RESULTS: Overall, 20 periprocedural events were recorded with no statistically significant difference in distribution between the two groups (12 active vs 8 remote, P = 0.09). Pre- and post-procedure hemodynamics demonstrated only a statistically, but not clinically significant drop in systolic blood pressure and increase in heart rate in the active user group, as well as drop in diastolic blood pressure and oxygen saturation in the remote group (P < 0.05). There were no significant differences in overall hemodynamics between both groups. CONCLUSION: Our study found no significant difference in the rate of periprocedural adverse events during EGD in patients with recent vs remote use of cocaine. Interestingly, there were significantly more patients (30%) with active use of cocaine that required general anesthesia as compared to remote users (0%).
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Neurofibromatosis-1 (NF-1) is an autosomal dominant condition characterized by cutaneous pigmentation and tumour formation along nerves in the brain, skin, and other organs. Gastrointestinal stromal tumours (GIST) are rare mesenchymal tumours involving the gastrointestinal tract (GI) associated with NF-1. We present a case of life-threatening GI bleeding from GIST in a patient with NF-1. In NF-1 patients presenting with GI bleeding, GISTs should be part of the differential. Clinicians must have a low threshold for urgent abdominal imaging if endoscopy does not detect the source of GI bleeding.
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Sinistral portal hypertension (SPH), also known as left-sided portal hypertension or segmental portal hypertension, is a rare cause of upper gastrointestinal bleeding. Historically, SPH is a result of obstruction of the splenic vein often secondary to pancreatic pathology. To our knowledge, there are no reported cases of idiopathic SPH in which the findings cannot be attributed to any etiology. It is important to do a detailed workup to rule out common pathologies of SPH before making a diagnosis of idiopathic SPH. Treatment of gastric variceal bleed secondary to idiopathic SPH can be challenging and requires a multidisciplinary approach with surgery and interventional radiology. Our patient's history, examination findings, and imaging revealed no identifiable cause for SPH suggesting idiopathic SPH. We describe a case of isolated gastric variceal hemorrhage due to idiopathic SPH that was successfully treated.
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Background and aim Adenomatous polyps are precursor lesions for colorectal cancer (CRC). Serrated adenomas/polyps are considered a risk factor for the development of proximal and interval CRC. African-Americans are at higher risk for right-sided CRC. Minimal data evaluating serrated adenoma characteristics by race/ethnicity on initial screening colonoscopy (SC) exist. The aim of this investigation was to compare the characteristics of serrated adenomas found in non-Hispanic whites (nHw) and African-Americans (AA) undergoing initial SC. Methods The University of Florida-Jacksonville endoscopy database was searched for all SC performed between January 2000 and December 2014. Inclusion criteria were nHw or AA race/ethnicity and histologically proven serrated adenoma found at SC. Data were collected for all included age at SC, sex, number, location, and size of serrated adenomas found. Results A total of 8693 individuals (nHw - 4199 and AA - 4494) underwent SC between January 2000 and December 2014. Serrated adenomas were found in 479 individuals (nHw, n=294; AA, n=185), and AA were significantly less likely than nHw to have serrated adenomas on SC (AA 4.1% vs nHw 7%; p< 0.0001). No difference was observed in mean age, location, or size between nHw and AA with serrated adenomas. Conclusions Serrated adenomas are more frequent in nHw compared to AA at initial SC. No difference was seen in size or location of serrated adenomas, as well as patient age, between AA and nHw. A study of genetic factors predisposing to serrated adenoma formation and the impact of socioeconomic disparities should be performed across ethnic groups to understand this difference.
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Congenital sucrase isomaltase deficiency (CSID) is an autosomal recessive disorder which leads to chronic intestinal malabsorption of nutrients from ingested starch and sucrose. Symptoms usually present after consumption of fruits, juices, grains, and starches, leading to failure to thrive and malnutrition. Diagnosis is suspected on detailed patient history and confirmed by a disaccharidase assay using small intestinal biopsies or sucrose hydrogen breath test. Treatment of CSID consists of limiting sucrose in diet and replacement therapy with sacrosidase. Due to its nonspecific symptoms, CSID may be undiagnosed in many patients for several years. We present a case of a 50-year-old woman with persistent symptoms of bloating in spite of extensive evaluation and treatment.
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Anastomotic strictures are a known complication of colorectal surgery. Despite a wide range of medical devices that have been deployed for this complication, outcomes remain challenging. Lumen-apposing metal stents (LAMSs) have recently emerged as a potentially superior therapeutic option. We herein report a patient with a past medical history of pT3, N0 adenocarcinoma of the colon with anastomotic stricture recurrence who underwent successful placement of an LAMS. We suggest that patients with a predisposition for keloid formation or fibrosis-prone anastomotic wound healing should be considered for LAMS deployment early in the treatment course.
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Basaloid squamous cell carcinoma (BSCC) is a poorly differentiated variant of squamous cell carcinoma (SCC) with distinct morphologic characteristics. Yet, there are no clearly defined guidelines established for management. BSCC in the esophagus is a very rare entity, with the proportion of esophageal BSCC ranging from 0.068% to 11%. This wide range is thought to be secondary to difficulty making the diagnosis on small biopsy specimens and the lack of a universally defined proportion of BSCC components necessary to make the diagnosis. We present the case of a 57-year-old African American female, who underwent esophagogastroduodenoscopy (EGD) after an abnormal barium swallow in the setting of two months history of dysphagia and weight loss and was diagnosed with BSCC of the esophagus on histopathology.
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Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Neoplasias Hepáticas/diagnóstico por imagem , Neoplasias Hepáticas/tratamento farmacológico , Linfoma Difuso de Grandes Células B/diagnóstico por imagem , Linfoma Difuso de Grandes Células B/tratamento farmacológico , Dor Abdominal/etiologia , Idoso , Ciclofosfamida/uso terapêutico , Doxorrubicina/uso terapêutico , Feminino , Humanos , Neoplasias Hepáticas/patologia , Neoplasias Hepáticas/cirurgia , Linfoma Difuso de Grandes Células B/patologia , Linfoma Difuso de Grandes Células B/cirurgia , Imageamento por Ressonância Magnética , Prednisona/uso terapêutico , Rituximab/uso terapêutico , Ultrassonografia Doppler , Vincristina/uso terapêutico , Redução de PesoRESUMO
Colonic lipomas are rare benign, non-epithelial tumors of mesenchymal origin. They are often solitary lesions of submucosal origin found in the proximal colon and typically measure less than 2 cm in size. Giant colonic lipomas are greater than 4 cm and present with non-specific gastrointestinal symptoms such as abdominal pain, abdominal distention, constipation, or gastrointestinal bleeding. Traditionally, giant colonic lipomas have been surgically rather than endoscopically resected due to concerns for bowel wall perforation and life-threatening hemorrhage. However, in recent years, advances in endoscopic tools and hemostatic techniques have lessened these risks. The following case details the successful endoscopic resection of an intermittently obstructing giant colonic lipoma (6 cm) located in the descending colon utilizing the loop-assisted-snare resection technique.
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Splenic artery pseudoaneurysms (SAPs) are rare causes of upper gastrointestinal bleeding (UGIB), with less than 250 reported cases in the literature. The highest incidence of SAPs is in patients with a history of acute or chronic pancreatitis or splenic artery trauma. SAP in the setting of gastric malignancy is an exceedingly rare finding. We present the unusual hospital course of an 82-year-old male with advanced gastric cancer presenting with UGIB secondary to a visceral communication between his known gastric malignancy and a SAP.