Endoscopic ultrasound fine-needle aspiration characteristics of primary adenocarcinoma versus other malignant neoplasms of the pancreas.

BACKGROUND: Endoscopic ultrasound (EUS) with fine-needle aspiration (FNA) is often used to assist in the evaluation of pancreatic lesions and may help to diagnose benign versus malignant neoplasms. However, there is a paucity of literature regarding comparative EUS characteristics of various malignant pancreatic neoplasms (primary and metastatic). OBJECTIVE: To compare and characterize primary pancreatic adenocarcinoma versus other malignant neoplasms, hereafter referred to as nonprimary pancreatic adenocarcinoma (NPPA), diagnosed by EUS-guided FNA. METHODS: The present study was a retrospective analysis of a prospectively maintained database. The setting was a tertiary care, academic medical centre. Patients referred for suspected pancreatic neoplasms were evaluated. Based on EUS-FNA characteristics, primary pancreatic adenocarcinoma was differentiated from other malignant neoplasms. The subset of other neoplasms was defined as malignant lesions that were 'NPPAs' (ie, predominantly solid or solid/cystic based on EUS appearance and primary malignant lesions or metastatic lesions to the pancreas). Pancreatic masses that were benign cystic lesions (pseudocyst, simple cyst, serous cystadenoma) and focal inflammatory lesions (acute, chronic and autoimmune pancreatitis) were excluded. RESULTS: A total of 230 patients were evaluated using EUS-FNA for suspected pancreatic mass lesions. Thirty-eight patients were excluded because they were diagnosed with inflammatory lesions or had purely benign cysts. One hundred ninety-two patients had confirmed malignant pancreatic neoplasms (ie, pancreatic adenocarcinoma [n=144], NPPA [n=48]). When comparing adenocarcinoma with NPPA lesions, there was no significant difference in mean age (P=0.0675), sex (P=0.3595) or average lesion size (P=0.3801). On average, four FNA passes were necessary to establish a cytological diagnosis in both lesion subtypes (P=0.396). Adenocarcinomas were more likely to be located in the pancreatic head (P=0.0198), whereas masses in the tail were more likely to be NPPAs (P=0.0006). Adenocarcinomas were also more likely to exhibit vascular invasion (OR 4.37; P=0.0011), malignant lymphadenopathy (P=0.0006), pancreatic duct dilation (OR 2.4; P=0.022) and common bile duct dilation (OR 2.87; P=0.039). CONCLUSIONS: Adenocarcinoma was more likely to be present in the head of the pancreas, have lymph node and vascular involvement, as well as evidence of pancreatic duct and common bile duct obstruction. Of all malignant pancreatic lesions analyzed by EUS-FNA, 25% were NPPA, suggesting that FNA is crucial in establishing a diagnosis and may be helpful in preoperative planning.

The causes and outcome of acute pancreatitis associated with serum lipase >10,000 u/l.

OBJECTIVES: Our objective was to investigate the use of serum lipase levels >10,000 U/L as a tool for predicting the etiology of acute pancreatitis (AP) and to further address the relationship between lipase elevation and disease severity. METHODS: We compared patients with AP and serum lipase >10,000 U/L (HL) with patients with AP and lower serum lipase levels (855-10,000 U/L). The etiology and severity of AP were recorded. Differences between groups were calculated. RESULTS: Of the 114 patients in the HL group, the common etiologies of AP were biliary (68%), iatrogenic trauma (14%), and idiopathic (10%). Only one patient had alcoholic AP. Conversely, the common etiologies of AP in the 146-patient comparison group (lipase 855-10,000 U/L) were broader: biliary (34%), idiopathic (23%), alcohol (14%), and iatrogenic trauma (10%). Biliary AP was twice as common in the HL group (P < 0.0001) whereas alcoholic AP was significantly less common (P < 0.0001). The positive predictive value (PPV) for biliary AP of lipase >10,000 U/L was 80% whereas the negative predictive (NPV) for alcoholic AP was 99%. No difference between groups was observed in the severity markers including ICU admission, length of hospital stay, complications, or mortality. CONCLUSIONS: In AP a serum lipase of >10,000 U/L at presentation is a useful marker and portends a biliary etiology while virtually excluding alcoholic AP. Therefore, if ultrasonography is negative for stones in this population, these data suggest workup with MRCP or EUS is warranted to evaluate for microlithiasis or sludge given the high likelihood of occult stone disease in these individuals.

CT portography with gastric variceal volume measurements in the evaluation of endoscopic therapeutic efficacy of tissue adhesive injection into gastric varices: a pilot study.

BACKGROUND: N-butyl-2-cyanoacrylate (NBCA) injection is used for treating gastric varices (GV). Determining the degree of obliteration of GV is not readily evident at endoscopy. AIMS: The aim of this study was to evaluate CT portography with gastric variceal volume calculations to assess endoscopic therapeutic efficacy of NBCA injection. METHODS: The study design is a retrospective series pilot study. The setting is a single, tertiary care academic medical center. Ten patients underwent esophagogastroduodenoscopy (EGD) with NBCA injection of GV and had biphasic CT scans performed before and after injection therapy. Based on portal venous images, 3D reconstruction and semi-automated volume calculations of GV were performed. Pre and post injection GV volume calculations were compared. RESULTS: The mean pre-procedure GV volume was 89.84 cm3. Eight patients had significant improvement in GV volume from pre-treatment versus post-treatment (95.65 cm3 vs. 49.65 cm3, P-value 0.04). Pre-procedure GV volume was not significantly different in patients treated for active hemorrhage versus no hemorrhage (101.66 cm3 vs. 72.11 cm3, P-value 0.33). Two patients had a subsequent GV hemorrhage after NBCA injection. The mean residual GV volume in these patients versus those that did not re-bleed was significantly more (127.77 cm3 vs. 38.00 cm3, P-value 0.005). CONCLUSIONS: CT portography with measurement of GV volume is a potentially useful tool in determining the therapeutic efficacy NBCA injection of GV. Patients with higher residual GV volumes are at increased risk of hemorrhage and may benefit from repeat injection to reach ideal GV volumes.

Colonoscopy training in gastroenterology fellowships: determining competence.

BACKGROUND: Although 140 colonoscopies is the recommended minimal requirement for gastroenterology fellows, it is unclear whether this minimum is a surrogate for competence. OBJECTIVE: To assess whether 140 colonoscopies is an adequate threshold to determine > or =90% colonoscopy performance independence. DESIGN: Retrospective analysis on a database constructed for quality control/improvement. SETTING: Gastroenterology fellowship training program at a veterans hospital. PATIENTS: Consecutive patients who underwent colonoscopy primarily for symptoms, previous polyps, or family history of cancer (a minority were performed for screening only) from April 2007 to September 2008. This study involved 11 gastroenterology fellows who performed 770 colonoscopies during 18 individual month-long rotations. INTERVENTION: Assessment of various procedure-related parameters. MAIN OUTCOME MEASUREMENTS: Determining when > or =90% independence in colonoscopy performance was reached. RESULTS: Total colonoscopy time, time to cecal intubation, withdrawal time, and independent completion rates all significantly improved when first and third years of training were compared (P < .001 for all comparisons). The adenoma detection rate did not change between years of training. Independent completion was achieved in > or =90% of cases for all fellows after 500 colonoscopies, whereas no fellow reached a > or =90% independent colonoscopy completion rate after 140 colonoscopies. LIMITATIONS: Number of participants, single center. CONCLUSIONS: Becoming a competent colonoscopist requires repeated practice. Our study suggests that, although there is variability between a trainee's ability to become colonoscopy independent, 500 colonoscopies are likely required to ensure reliable (> or =90%) independent completion rates. Competency requires more than a single parameter.

Screening colonoscopy and detection of neoplasia in asymptomatic, average-risk, solid organ transplant recipients: case-control study.

The aim of this study was to evaluate the detection of colonic neoplasia in an average-risk population of SOT recipients. Studies regarding colonic neoplasia in solid organ transplantation (SOT) recipients have demonstrated mixed results due to the inclusion of above average-risk patients. We performed a case-control study of 102 average-risk SOT recipients who underwent screening colonoscopy, compared with an average-risk, age and sex-matched control group (n=287). Cancer rates were compared with an age-matched cohort from the National Cancer Institute's Survival, Epidemiology, and End Results (SEER) database. There was no difference in number of patients with adenomas (P=1.00). There was no difference in polyps per patient (P=0.31). Although the number of advanced lesions (excluding adenocarcinoma) between groups did not differ (P=0.25), there were two adenocarcinomas identified in the SOT group and none in the control group (P=0.068). Detection of colorectal cancer was an unexpected finding in the SOT cohort and was more likely when compared to age-matched cancer incidence generated by the SEER database. These results suggest no increased adenoma detection in SOT recipients, but with more cases of colorectal cancer than anticipated. Given previous, larger, transplant database studies demonstrating increased colorectal cancer rates, more frequent screening may be justified.

Surgical resident's training in colonoscopy: numbers, competency, and perceptions.

BACKGROUND: There is currently great discrepancy in the training requirements between medical societies regarding the recommended threshold number of colonoscopies needed to assess for technical competence. Our goal was to determine the number of colonoscopies performed by surgical residents, rate of cecal intubation, as well as trainee perceptions of colonoscopy training after completion of their training period. METHODS: This study consisted of a 12-item electronic survey completed by 21 surgical residents after their 2-month endoscopy rotation at a tertiary care, urban referral center. This survey assessed numbers of colonoscopies performed, number successful to the cecum, and perceptions of training in colonoscopy. The cecal intubation rate was used as a surrogate marker of technical competence. RESULTS: Twenty-one surgical residents performed a mean of 80 ± 35 total colonoscopies during the 2-month rotation. The average cecal intubation rate was 47% (range 9-78%). Resident comfort level for independently performing a total colonoscopy was scored a mean 3.6 on scale of 1-5 (5 = most comfortable), and 43% of the surgical residents planned on performing colonoscopy after residency training. CONCLUSIONS: Surgical residents can obtain the recommended threshold for colonoscopy (N = 50) during a standard 2-month rotation. However, no resident was able to achieve technical competence in colonoscopy as defined by a 90% cecal intubation rate. These data suggest that the method of training of general surgery residents in colonoscopy may need reappraisal.

Predictors of malignancy and recommended follow-up in patients with negative endoscopic ultrasound-guided fine-needle aspiration of suspected pancreatic lesions.

BACKGROUND: Endoscopic ultrasound (EUS) with fine-needle aspiration (FNA) can characterize and diagnose pancreatic lesions as malignant, but cannot definitively rule out the presence of malignancy. Outcome data regarding the length of follow-up in patients with negative or nondiagnostic EUS-FNA of pancreatic lesions are not well-established. OBJECTIVE: To determine the long-term outcome and provide follow-up guidance for patients with negative EUS-FNA diagnosis of suspected pancreatic lesions based on imaging predictors. METHODS: A retrospective review of patients undergoing EUS-FNA for suspected pancreatic lesions, but with negative or nondiagnostic FNA results was conducted at a tertiary care referral medical centre. Patient demographics, EUS imaging characteristics and follow-up data were examined. RESULTS: Seventeen of 55 patients (30.9%) with negative/nondiagnostic FNA were subsequently diagnosed with pancreatic malignancy. The risk of cancer was significantly higher for patients who had associated lymph nodes on EUS (P<0.001) and vascular involvement on EUS (P=0.001). The mean time to diagnosis in the group with falsenegative EUS-FNA diagnosis was 66 days. The true-negative EUSFNA patients were followed for a mean of 403 days after negative EUS-FNA results without the development of malignancy. CONCLUSION: For patients undergoing EUS-FNA for a suspected pancreatic lesion, a negative or nondiagnostic FNA does not provide conclusive evidence for the absence of cancer. Patients for whom vascular invasion and lymphadenopathy are detected on EUS are more likely to have a true malignant lesion and should be followed closely. When a patient has been monitored for six months or more with no cancer being diagnosed, there appears to be much less chance that a pancreatic malignancy is present.

A case of newly diagnosed metastatic pancreatic cancer presenting with associated immune thrombocytopenic purpura.

Metastatic pancreatic adenocarcinoma presenting with immune thrombocytopenic purpura is a very rare association. To date, only 1 case report found in the literature delineates such an association. We present a case of a patient with newly diagnosed, biopsy-proven metastatic pancreatic adenocarcinoma with new-onset immune thrombocytopenic purpura. The patient's platelet count returned to normal limits after being treated with oral corticosteroid therapy. In conclusion, immune thrombocytopenic purpura can be associated with metastatic pancreatic adenocarcinoma and responds well to corticosteroid therapy.

Bleeding stomal varices: case series and systematic review of the literature.

BACKGROUND & AIMS: Bleeding stomal varices are a common problem in patients with surgical stomas and portal hypertension, and remain difficult to diagnose and manage. METHODS: We identified all patients at our institution with bleeding stomal varices from 1989 to 2004. We surveyed all patients undergoing ileal pouch-anal anastomosis from 1997 to 2007 for bleeding anastomotic varices. Finally, we performed a systematic review of the literature focusing on diagnosis and treatment of bleeding stomal varices that included 74 English language studies of 234 patients. RESULTS: We identified 8 patients with bleeding stomal varices. Recognition of stomal varices typically was delayed, particularly when failing to examine the ostomy without the appliance. Stomal variceal bleeding was confirmed by Doppler ultrasound or angiographic imaging. Simple local therapy usually stopped bleeding, albeit temporarily. Sclerotherapy was effective, but at the expense of unacceptable stomal damage. Decompressive therapy was required for secondary prophylaxis, including transjugular intravascular transhepatic shunts (2 patients), surgical portosystemic shunts (2 patients), and liver transplantation (1 patient). No patient with an ileal pouch-anal anastomosis developed anastomotic bleeding from varices. CONCLUSIONS: Primary prevention of bleeding stomal varices requires avoidance of creating enterocutaneous stomas in patients with portal hypertension. Careful inspection of the uncovered ostomy is essential for bleeding stomal varices diagnosis. Once identified, conservative measures will stop bleeding temporarily with definitive therapy required, including transjugular intravascular transhepatic shunts, surgical shunts, or liver transplantation.

Risk factors and outcomes in post-liver transplantation bile duct stones and casts: A case-control study.

Bile duct stones and casts (BDS) after liver transplantation are associated with significant morbidity. Risk factors for BDS formation and the efficacy of treatment in liver transplant recipients have not been systematically studied. The aim of this study was to evaluate potential risk factors for the formation of BDS in patients post-liver transplant. A case-control study of consecutive liver transplant recipients at a university hospital from 1989 to 2007 was performed to identify risk factors for BDS formation. Cases included all liver transplant recipients with BDS, excluding those with concurrent t-tubes or biliary stents. Controls were chosen randomly from the total liver transplant population matched for year of transplantation. Pre- and post-OLT risk factors were analyzed with univariate and multivariate analyses. There were 49 cases and 101 controls over an 18-year-period (1289 liver transplants performed) with an incidence of 3.8% for BDS. In the cases, the median time to BDS diagnosis was 613 days from time of transplant. The controls had a median follow-up of 1530 days. Use of ursodeoxycholic acid was protective (P = 0.005), whereas bile duct pathology (P = 0.003), total cholesterol >/= 200 mg/dL (P = 0.008), and triglyceride >/= 150 mg/dL (P = 0.008) were significant risk factors for BDS formation. Endoscopic retrograde cholangiopancreatography (ERCP) was technically successful in all cases with resolution or improvement of liver chemistries in 59% (29) of patients. In conclusion, significant risk factors for forming BDS included bile duct pathology and elevated total cholesterol and triglyceride levels. Ursodeoxycholic acid had a significant effect in preventing the development of posttransplant BDS and should be used in those that are at increased risk. ERCP is a safe and effective diagnostic and therapeutic modality for these patients.

Amyloidosis presenting as lower gastrointestinal hemorrhage.

AL-Amyloid rarely presents in the gastrointestinal tract as acute gastrointestinal hemorrhage, especially in the absence of clinical disease elsewhere in the body. There are no reported cases of monoclonal gammopathy of undetermined significance progressing to AL-Amyloid presenting as lower gastrointestinal hemorrhage. We report a case of a patient initially diagnosed with monoclonal gammopathy of undetermined significance who progressed to AL-Amyloid over the course of 1 year. His progression resulted in primary colonic amyloidosis that manifested as lower gastrointestinal hemorrhage. The diagnosis was made by biopsy of a sigmoid plaque demonstrating necrotic material on histopathology. Amyloid deposition was seen on congo red and on birefringence. The bleeding stopped spontaneously without intervention and he was discharged his fourth day in the hospital. Further evaluation revealed no involvement in other organ systems. The plan is to treat with melphalan and dexamethasone. We conclude that early endoscopic examination and biopsy of the surrounding intestinal tissue is indicated when patients with monoclonal gammopathy of undetermined significance present with gastrointestinal hemorrhage to evaluate for the progression to AL-Amyloidosis. Treatment to prevent recurrent hemorrhage and further progression of the disease should be considered.

Pilot study using PET/CT as a novel, noninvasive assessment of disease activity in inflammatory bowel disease.

BACKGROUND: A pilot study was performed investigating the possibility that positron emission tomography (PET) activity using 18-fluorodeoxyglucose (FDG) with nearly simultaneous computerized tomography (CT) for anatomic accuracy would identify regions of active inflammation in both ulcerative colitis (UC) and Crohn's disease (CD). METHODS: Prospective clinical data was collected in 12 patients experiencing an exacerbation of their inflammatory bowel disease; 7 with CD and 5 with UC. A PET/CT scan (GE Discovery LS PET/CT scanner) was performed in all patients. Twenty patients undergoing PET/CT because of solitary pulmonary nodules served as controls. We graded the small bowel and 4 colon regions (ascending, transverse, descending, and rectosigmoid) with PET activity scores assigned to each region based on the amount of FDG uptake using the liver as the reference organ. RESULTS: In UC patients, PET activity was seen in 13 of 24 (52%) regions. There was high (23 of 24; 95.8%) correlation between PET activity and disease activity as determined by colonoscopy, disease activity indices, and radiology. In patients with CD, PET activity was seen in 19 of 32 (59.4%) regions. Again, there was a high (26 of 32; 81.3%) correlation between PET activity and clinical disease activity. Of the 20 controls, significant PET activity (Grades 2 and 3) was seen in only 2 of 100 regions (2%). CONCLUSIONS: We found that PET activity correlated well with active inflammation in both UC and CD, suggesting that this may be a noninvasive method of identifying disease activity in patients with inflammatory bowel disease.

Predictors of recurrent ingestion of gastrointestinal foreign bodies.

BACKGROUND: Gastrointestinal foreign bodies are commonly encountered; however, little knowledge exists as to the causes of foreign body ingestions and why they occur repeatedly in some patients. OBJECTIVE: To identify and define patients at high risk for recurrent foreign body ingestion. METHODS: A retrospective chart review of foreign body ingestion was conducted at a tertiary care medical centre over an 11-year period. Variables analyzed included age, sex, incarceration status, Diagnostic and Statistical Manual of Mental Disorders-IV diagnosis, success of endoscopy, type of sedation used, method of extraction, complications, presence of gastrointestinal pathology, and incidence of recurrent food impaction or foreign body. RESULTS: A total of 159 patients with a foreign body ingestion were identified. One hundred fourteen (77%) experienced a single episode of ingestion and 45 (23%) experienced multiple ingestions. Of the patients with multiple ingestions, 27 (60%) had recurrent food impactions while 18 (40%) ingested foreign objects. In the recurrent ingestor group, a psychiatric disorder had been diagnosed in 16 patients (35.6%) and there were 13 incarcerated individuals (28.9%). The average number of recurrences was 2.6 per patient (117 total recurrences). Individuals with a psychiatric disorder experienced 3.9 recurrences per patient, while prisoners averaged 4.1 recurrences per patient. The combination of a psychiatric disorder and being incarcerated was associated with the highest recurrence rate (4.33 per patient). Multivariable logistic regression revealed that male sex (OR 2.9; P=0.022), being incarcerated (OR 3.0; P=0.024) and the presence of a psychiatric disorder (OR 2.5; P=0.03) were risk factors for recurrent ingestion. CONCLUSION: Risk factors for recurrent ingestion of foreign bodies were male sex, being incarcerated and the presence of a psychiatric disorder.

Ossification within an adenomatous polyp: a case report and review of the literature.

Osseous metaplasia within the gastrointestinal tract is rare and occurs in benign, premalignant, and malignant neoplasms. Here, we report the youngest case of an adenomatous polyp with the presence of ossification and a concomitant review of the literature with regard to ossification of colonic polyps. A 28-year-old man underwent colonoscopy for 8 months of rectal bleeding. A 4.5-cm pedunculated polyp was found in the descending colon and excised. Histological examination showed adenomatous change with an area of calcification and osteoid formation. Ossification of colonic polyps is mainly associated with the clinical symptom of bleeding and may warrant consideration as a high-risk feature.

Clinical utility of positron emission tomography/computed tomography in inflammatory bowel disease.

PURPOSE: The clinical utility of positron emission tomography/computed tomography (PET/CT) in comparison to standard workup in patients with known or suspected inflammatory bowel disease (IBD) is unknown. PROCEDURES: Clinical data were collected on seven patients with known or suspected IBD undergoing PET/CT. Standard workup included history, physical exam, laboratory tests, colonoscopy and/or cross-sectional imaging. We divided the intestine into five regions [small bowel and four colon (ascending, transverse, descending and rectosigmoid)] and graded relative standard uptake values 0, 1, 2 or 3 by comparison to the liver, using a region-of-interest analysis (0 = no activity, 1 = liver, 2 and 3 = significant inflammation). RESULTS: In patients 1 and 2, PET/CT demonstrated more activity than we thought clinically present. The other patients avoided unnecessary escalation or initiation of IBD therapy based on PET/CT results. Compared with standard workup, all seven patients had superior results when therapeutic decisions were based on PET/CT. CONCLUSIONS: We found PET/CT to be very useful in diagnosis and management in patients with known or suspected IBD.

Outcomes of sphincter of oddi manometry when performed in low volumes.

Background. Sphincter of Oddi manometry is a highly specialized procedure associated with an increased risk of procedural complications. Published studies have typically been performed in large volume manometry centers. Objective. To examine the outcomes and complication rate of SOM when performed in small volumes. Design. Retrospective analysis at a tertiary care referral hospital that infrequently performs Sphincter of Oddi manometry. Patient records were reviewed for procedural details, patient outcomes, and complications after sphincter of Oddi manometry. Results. 36 patients, 23 (23 type II sphincter of Oddi dysfunction (SOD), 13 type III SOD) underwent sphincter of Oddi manometry and were followed up for mean of 16 months. Nine Type II patients (90%) with elevated basal sphincter pressures noted symptom improvement after sphincterotomy compared with only 3 patients (43%) of the patients with normal basal pressures. In type III SOD, 7 patients had elevated basal SO pressure and underwent sphincterotomy. Three patients (43%) improved. There were six (16%) procedure-related complications. There were four cases of post ERCP pancreatitis (11%), all of which were mild. Conclusion. In low numbers, sphincter of Oddi manometry can be performed successfully and safely by experienced biliary endoscopists with results that are comparable to large volume centers.