ABSTRACT
EGID is a recently described condition with an unknown etiology and pathogenesis. There are three case reports of duodenal stricture associated with EGID: one in an adult requiring pancreaticoduodenectomy due to the suspicion of malignancy and 2 cases in a child and a young adult, who responded to oral steroids. We report the case of a 10-year-old who presented to A&E with a 9-month history of epigastric abdominal pain and 1 episode of haematemesis, on a background of asthma. He was treated for Helicobacter pylori, based on a positive stool antigen. Abdominal pain and vomiting persisted, therefore an oesophago-gastro-duodenoscopy (OGD) was performed. This identified widespread white plaques throughout the oesophagus, erythema and nodularity of the gastric antrum and white nodules in the first part of the duodenum. Histology revealed changes of EGID and eosinophilic oesophagitis (EOE) and patient was commenced on Montelukast, oral viscous Budesonide (OVB), Cetirizine and continued proton pump inhibitor (PPI). After the allergy workup identified house dust mites, cat sensitisation and fish allergy, a 6-food elimination diet was initiated. During the next 2 years, symptoms subsided, and endoscopy changes improved, with only mild signs of active EOE while on OVB, PPI and diary/egg/fish free diet. However, the patient relapsed due to poor compliance to treatment. He became more unwell during the Covid pandemic with recurrent vomiting and static weight. A trial of dupilumab was considered, however his reassessment OGD had to be delayed due to restricted access to theatre. He was treated empirically with a reducing course of oral prednisolone, with temporary response. The endoscopic assessment performed subsequently showed erythema, erosions and white plaques in the distal oesophagus and gastric antrum with narrowing between the first and the second part of the duodenum (D2), that could not be entered. Histology identified mild upper oesophagitis (4 eosinophils (eos)/HPF), active middle and lower oesophagitis (20 eos/HPF and 12 eos/HPF, respectively), chronic gastritis (80 eos/HPF) and nonspecific reactive changes of the proximal duodenum. A barium meal confirmed a duodenal stricture. At this stage, we recommended a sloppy diet and a second weaning course of oral prednisolone, along with Montelukast. He was subsequently commenced on azathioprine for maintenance of remission. A repeat barium study and small bowel MRI performed post course of steroids and on azathioprine revealed stable appearances of the proximal duodenal stricture, excluding the presence of further strictures. While the patient has responded to the course of oral steroids and azathioprine, a repeat upper GI endoscopy is currently planned to dilate the duodenal stricture. The challenges posed by this case were the rarity of the condition, limited treatment options and access to endoscopy during the Covid pandemic and the fact that unlike previous case reports a sustained remission could not be obtained on steroids, and a maintenance immunosuppressive medication was required. We can conclude that this subgroup of patients should be monitored closely for signs of bowel obstruction and will require more intense treatment, including immunomodulators, endoscopic dilatation and or surgery.
ABSTRACT
Introduction There are approximately 15,000 new diagnoses of oesophageal and gastric cancer every year, in the UK (Cancer Research UK, 2022). Timely detection of cancer remains a key marker in prognosis and success of disease outcomes. Upper GI cancers diagnosed within 36 months of a previous oesophago-gastro-duodenoscopy (OGD) are defined as 'missed' cancer diagnoses. The British Society of Gastroenterology (BSG) states the acceptable rate of missed cancers is 10% or less (Beg S et al., 2017). Methods Retrospective case audit of 71 patients (6 patients excluded, 65 patients analysed), derived from the Somerset database, split into two cohorts of 2019-20 (pre- COVID-19 pandemic) and 2020-21 (during pandemic). Patient demographics, endoscopic, radiological and pathology reports of those diagnosed with oesophageal and gastric cancers were analysed. The number of endoscopies in the preceding 36 months were audited against BSG guidelines, to determine 'missed' cancer diagnoses. Results There were 47 male patients and 18 female patients in the cohort. The average age of patients (in years) diagnosed with oesophageal/gastric cancers in this sample population was 71.6. The age range of the sample population ranged from 50 years to 94 years. Total number of oesophageal cancers diagnosed in 2019-20 and 2020-21 were 31 and 15, respectively. The total number of gastric cancers diagnosed in 2019-20 and 2020-21 were 14 and 5, respectively. The total population area served by the hospital is approximately 200,000 people. The proportion of patients diagnosed with oesophageal/gastric cancer, during the audit timescale, who had had an endoscopy in the preceding 36 months was 7.7%. Accounting for explained anomalies, the number of patients who were diagnosed with a post-OGD oesophageal/gastric cancer was below the nationally acceptable upper limit for 'missed' cancers (10%). Conclusions 1) There was a reduction in the number of diagnoses of oesophageal and gastric cancers during the pandemic period, compared to the pre-pandemic period 1) The 'missed' oesophageal and gastric cancer rate was below the national acceptable limit of 10% 2) The emphasis on quality of endoscopy, regular training, use of descriptive classifications, image capture, biopsy numbers and minimum examination time of at least 7 minutes should be adhered to, to continue to improve detection rates (Beg S et al., 2017) 3) Further evaluation with artificial intelligence-based technology for lesion recognition should be evaluated to consider further reduction in rates of 'missed' cancer.