Abdominal Inflammatory Myofibroblastic Tumour Presenting as a Pancreatic Mass: A Case Report.

An abdominal inflammatory myofibroblastic tumor (AIMT), is a rare benign tumor composed of inflammatory and other mesenchymal cells. It can affect the entire body, predominantly in children and young adults. The diagnosis is challenging considering the wide clinical presentation and can often be mistaken for malignant tumors. We report a rare case of a 46-year-old female patient, who presented with intermittent abdominal pain weight loss, and an abdominal palpable mass. Abdominal ultrasound found a well-defined 18 cm, rounded mass, with solid and cystic components. Abdominal CT demonstrated a well-defined, hypodense, retro gastric mass of 20 cm, with thickened wall and heterogenous enhancement. The mass had contact with the pancreatic tail, transverse colon, spleen, left kidney pedicles, abdominal aorta, superior mesenteric vein, and mesaraic trunk with no invasion signs. The mass was initially thought to be pancreatic cancer, but given the large size, other diagnoses like sarcoma, lymphoma, or abdominal hydatid cyst were suggested. Endoscopic ultrasound found a rounded retro gastric mass of 18/12 cm, with a thickened wall and well-limited calcifications. The content was both cystic and solid with mobile vegetations, with no visible Doppler flow. The mass had contact with the body and tail of the pancreas, spleen hilum, the upper pole of the spleen, and the hepatic pedicle behind, with no invasion sign. After a multidisciplinary team meeting, a decision was taken to perform surgical resection with mass resection, distal splenopancreatectomy, and transverse and sigmoid colectomy. Pathological and immunostaining results were consistent with inflammatory pseudotumor. The postoperative recovery was uncomplicated. The patient remains asymptomatic with no obvious signs of metastasis or recurrence. AIMT represents a reel diagnostic challenge. Clinical symptoms are unspecific. Radiological and endoscopic features can often be mistaken for malignant tumors. Surgical management remains to be the best therapeutic option. We report a rare case of AIMT treated by surgery with complete resection. We suggested a long-term follow-up given the local recurrence risk.

Practical guideline on obesity care in patients with gastrointestinal and liver diseases - Joint ESPEN/UEG guideline.

BACKGROUND: Patients with chronic gastrointestinal disease such as inflammatory bowel disease (IBD), irritable bowel syndrome (IBS), celiac disease, gastroesophageal reflux disease (GERD), pancreatitis, and chronic liver disease (CLD) often suffer from obesity because of coincidence (IBD, IBS, celiac disease) or related pathophysiology (GERD, pancreatitis and CLD). It is unclear if such patients need a particular diagnostic and treatment that differs from the needs of lean gastrointestinal patients. The present guideline addresses this question according to current knowledge and evidence. OBJECTIVE: The present practical guideline is intended for clinicians and practitioners in general medicine, gastroenterology, surgery and other obesity management, including dietitians and focuses on obesity care in patients with chronic gastrointestinal diseases. METHODS: The present practical guideline is the shortened version of a previously published scientific guideline developed according to the standard operating procedure for ESPEN guidelines. The content has been re-structured and transformed into flow-charts that allow a quick navigation through the text. RESULTS: In 100 recommendations (3× A, 33× B, 24 × 0, 40× GPP, all with a consensus grade of 90% or more) care of gastrointestinal patients with obesity - including sarcopenic obesity - is addressed in a multidisciplinary way. A particular emphasis is on CLD, especially metabolic associated liver disease, since such diseases are closely related to obesity, whereas liver cirrhosis is rather associated with sarcopenic obesity. A special chapter is dedicated to obesity care in patients undergoing bariatric surgery. The guideline focuses on adults, not on children, for whom data are scarce. Whether some of the recommendations apply to children must be left to the judgment of the experienced pediatrician. CONCLUSION: The present practical guideline offers in a condensed way evidence-based advice how to care for patients with chronic gastrointestinal diseases and concomitant obesity, an increasingly frequent constellation in clinical practice.

International multidisciplinary survey on the initial management of acute pancreatitis: Perspective of point-of-care specialists focused on daily practice.

BACKGROUND: The initial management of patients with acute pancreatitis impacts both morbidity and mortality. Point-of-care decisions have been reported to differ from clinical guideline recommendations. METHODS: An online anonymous questionnaire was distributed through scientific associations and social media using REDCap. Multivariable logistic regression was used to identify the characteristics of participants associated with compliance with the recommendations. RESULTS: A total of 1054 participants from 94 countries completed the questionnaire; median age (IQR) was 39 (32-47) years; 30.7% were women. Among the participants, 37% opted for nonmoderate flow of i.v. fluid, 31% for fluid type other than Ringer's lactate; 73.4% were in favor of nil per os to patients who could eat, 75.5% for other than enteral feeding to patients with oral intolerance; 15.5% used prophylactic antibiotic in patients with severe acute pancreatitis, 34.1% in necrotizing acute pancreatitis, and 27.4% in patients with systemic inflammatory response syndrome; 27.8% delayed cholecystectomy after biliary acute pancreatitis. Participants with publications in PubMed on acute pancreatitis showed better compliance (OR, 1.62; 95% CI: 1.15-2.32; P = .007) with recommendations of the clinical guidelines. CONCLUSIONS: Feeding and nutrition require the greatest improvement efforts, but also the use of prophylactic antibiotics and timing of cholecystectomy should be improved.

Colonic schistosomiasis: A case report.

BACKGROUND: Schistosomiasis is a chronic parasitic infection endemic in many countries. Colonic schistosomiasis is a rare entity with no specific clinical manifestations or endoscopic aspects, which delays the diagnosis. Diagnosis is primarily dependent on histopathological analysis, and treatment with antihelminthics typically resolves the infection. CASE SUMMARY: We present the case of a 21-year-old male who suffered from chronic diarrhea and abdominal pain. Physical examination found no abnormalities, blood tests were normal, and stool examination was negative. A colonoscopy revealed a nodular terminal ileal mucosa, two cecal polypoid lesions with no particular surface pattern, and millimetric erosions in the rectum. The presence of Schistosoma eggs with thick peripheral capsules and viable embryos inside and numerous eosinophils surrounding the egg capsule were observed on histopathological examination. The patient received praziquantel, and his symptoms were resolved. CONCLUSION: Colonic schistosomiasis should be considered as a differential diagnosis, especially in endemic countries. Endoscopy and histopathological examination can confirm the diagnosis, and antihelminthics are an effective treatment.

Solitary pancreatic metastasis from squamous cell lung carcinoma: A case report and review of literature.

BACKGROUND: Pancreatic metastases from squamous cell lung carcinoma (SCLC) are unusual. These lesions are often asymptomatic and detected incidentally or during follow-up investigations, occasionally several years after removal of the primary tumor. CASE SUMMARY: A 56-year-old male with SCLC developed jaundice 1 mo after the cancer diagnosis. An abdominal computed tomography (CT) scan showed a mass in the pancreatic head with distention of both intra- and extrahepatic biliary ducts. Endoscopic retrograde cholangiopancreatography and sphincterotomy were performed first, culminating with plastic biliary stent placement. Cytological examination of the pancreatic mass sample collected by fine-needle aspiration (FNA) under endoscopic ultrasound (EUS) guidance revealed the presence of malignant cells compatible with well-differentiated squamous cell carcinoma. After liver function normalized, chemotherapy was initiated with carboplatin and paclitaxel; however, 4 d later, the patient presented dysphagia. Cervico-thoraco-abdominal CT showed tracheoesophageal fistula and stent migration. After replacement with a 10 cm/10 mm uncovered metallic biliary stent and treatment of the tracheoesophageal fistula with a fully covered esophageal stent, the patient was able to start oral feeding progressively. He died 9 mo after the initial diagnosis. CONCLUSION: The diagnosis of pancreatic metastasis from SCLC is challenging for clinicians. EUS-FNA is the primary exam for confirmatory diagnosis.

European guideline on obesity care in patients with gastrointestinal and liver diseases - Joint European Society for Clinical Nutrition and Metabolism / United European Gastroenterology guideline.

BACKGROUND: Patients with chronic gastrointestinal (GI) disease such as inflammatory bowel disease (IBD), irritable bowel syndrome (IBS), celiac disease, gastroesophageal reflux disease (GERD), pancreatitis, and chronic liver disease (CLD) often suffer from obesity because of coincidence (IBD, IBS, celiac disease) or related pathophysiology (GERD, pancreatitis and CLD). It is unclear if such patients need a particular diagnostic and treatment that differs from the needs of lean GI patients. The present guideline addresses this question according to current knowledge and evidence. OBJECTIVE: The objective of the guideline is to give advice to all professionals working in the field of gastroenterology care including physicians, surgeons, dietitians and others how to handle patients with GI disease and obesity. METHODS: The present guideline was developed according to the standard operating procedure for European Society for Clinical Nutrition and Metabolism guidelines, following the Scottish Intercollegiate Guidelines Network grading system (A, B, 0, and good practice point [GPP]). The procedure included an online voting (Delphi) and a final consensus conference. RESULTS: In 100 recommendations (3x A, 33x B, 24x 0, 40x GPP, all with a consensus grade of 90% or more) care of GI patients with obesity - including sarcopenic obesity - is addressed in a multidisciplinary way. A particular emphasis is on CLD, especially fatty liver disease, since such diseases are closely related to obesity, whereas liver cirrhosis is rather associated with sarcopenic obesity. A special chapter is dedicated to obesity care in patients undergoing bariatric surgery. The guideline focuses on adults, not on children, for whom data are scarce. Whether some of the recommendations apply to children must be left to the judgment of the experienced pediatrician. CONCLUSION: The present guideline offers for the first time evidence-based advice how to care for patients with chronic GI diseases and concomitant obesity, an increasingly frequent constellation in clinical practice.

European guideline on obesity care in patients with gastrointestinal and liver diseases - Joint ESPEN/UEG guideline.

BACKGROUND: Patients with chronic gastrointestinal (GI) disease such as inflammatory bowel disease (IBD), irritable bowel syndrome (IBS), celiac disease, gastroesophageal reflux disease (GERD), pancreatitis, and chronic liver disease (CLD) often suffer from obesity because of coincidence (IBD, IBS, celiac disease) or related pathophysiology (GERD, pancreatitis and CLD). It is unclear if such patients need a particular diagnostic and treatment that differs from the needs of lean GI patients. The present guideline addresses this question according to current knowledge and evidence. OBJECTIVE: The objective of the guideline is to give advice to all professionals working in the field of gastroenterology care including physicians, surgeons, dietitians and others how to handle patients with GI disease and obesity. METHODS: The present guideline was developed according to the standard operating procedure for ESPEN guidelines, following the Scottish Intercollegiate Guidelines Network (SIGN) grading system (A, B, 0, and good practice point (GPP)). The procedure included an online voting (Delphi) and a final consensus conference. RESULTS: In 100 recommendations (3x A, 33x B, 24x 0, 40x GPP, all with a consensus grade of 90% or more) care of GI patients with obesity - including sarcopenic obesity - is addressed in a multidisciplinary way. A particular emphasis is on CLD, especially fatty liver disease, since such diseases are closely related to obesity, whereas liver cirrhosis is rather associated with sarcopenic obesity. A special chapter is dedicated to obesity care in patients undergoing bariatric surgery. The guideline focuses on adults, not on children, for whom data are scarce. Whether some of the recommendations apply to children must be left to the judgment of the experienced pediatrician. CONCLUSION: The present guideline offers for the first time evidence-based advice how to care for patients with chronic GI diseases and concomitant obesity, an increasingly frequent constellation in clinical practice.

A rare case report of an adult with down syndrome and gallbladder cancer.

Introduction: The most frequent malignancies observed on adult with Down syndrome are lymphoblastic and myeloblastic leukemia. The incidence and the relationship between gallbladder cancer and Down syndrome is unknown. Case presentation: We report a rare case of a 25-year-old male with Down syndrome who consulted to the emergency because of deterioration in overall health associated with post-meal food vomiting, abdominal distension and diffuse abdominal pain. CECT scan reveal suspicious locally advanced parietal tissue thickening of the gallbladder, associated with peritoneal carcinosis, and a bilateral massive pulmonary embolism, in addition to a large bilateral pleurisy and moderate pericardial effusion. The patient died three weeks later. Discussion: Solid tumors are rare among population with Down syndrome, especially gallbladder cancer. Main risk factors are: cholelithiasis and gallbladder abnormalities, which are frequent in these patients. Management of this lethal disease depends on precocity of diagnosis. For this we suggest an abdominal ultrasound in children with DS to screen previously cholelithiasis and prevent this fatal cancer. Conclusion: Some Authors found that the rate of gallbladder disease especially cholelithiasis, was 25% among Down syndrome group, compared to 4.5% among the control group (p = 0.002). We suggest that cholelithiasis is the main risk factor of gallbladder cancer in this population. However, other prospective studies should be accomplished so as to confirm this outcome.

How to get new guidelines in United European Gastroenterology: Follow the gold!

Development of new high-quality guidelines is necessary to improve patients' care and reduce diseases burden. United European Gastroenterology (UEG) quality of care taskforce in collaboration with specialist member societies promote and guide guidelines developers through an activity grant scheme that fund new guidelines in gap areas of GI diseases with high-quality methodology and multidisciplinary collaborative project teams. UEG quality of care taskforce helps dissemination and implementation of guidelines published in UEG journal through different initiatives including a free of charge GI guidelines app. The guidelines included are user friendly, interactive and patient oriented.

Pancreatic schwannoma- CT and MRI findings: A rare case report and review of literature.

INTRODUCTION: Pancreatic schwannoma (PS) is an extremely rare benign tumor. Here we describe the Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) results of PS in a 59 years old woman, as well as a review of the literature. CASE PRESENTATION: A 59-year-old woman consulted for atypical epigastralgia without fatigue, weight loss or fever. CT scan and MRI showed a 35 mm inhomogeneous lesion with well-defined margins located in the pancreas head. The diagnosis of pancreatic tumor was made. The pathologic examination of the biopsied mass yielded a diagnosis of pancreatic schwannoma. CLINICAL DISCUSSION: On CT scans, almost all benign PS are well-defined cystic or low-density masses. MRI is helpful in characterizing their typical encapsulation. CONCLUSION: The detection of pancreatic schwannoma is extremely rare. Although multiple imaging modalities are currently available, it is challenging to make an accurate diagnosis before operation.

Overcoming the barriers to dissemination and implementation of quality measures for gastrointestinal endoscopy: European Society of Gastrointestinal Endoscopy (ESGE) and United European Gastroenterology (UEG) position statement.

The European Society of Gastrointestinal Endoscopy (ESGE) has developed performance measures and established a framework for quality assessment for gastrointestinal endoscopy in Europe. Most national societies actively undertake initiatives to implement and explicitly endorse these quality indicators. Given this, ESGE proposes that, at a national level, strong leadership should exist to disseminate and implement quality parameters. Thus, understanding the potential barriers that may vary locally is of paramount importance. ESGE suggests that each national society should prioritize quality and standards of care in gastrointestinal endoscopy in their activities and should survey/understand which measures are a local priority to their members and make measuring quality intrinsic to daily endoscopy practice.

UEG framework for the development of high-quality clinical guidelines.

The 48 national member societies and 17 specialist member societies which operate under the umbrella of United European Gastroenterology (UEG) increasingly develop clinical practice guidelines for both national and international implementation. The methodologies and strategies used in these guidelines vary considerably. The UEG Quality of Care Taskforce aimed to provide a framework for quality guidelines in order to assist member societies in the process of developing guidelines, and to provide a tool for readers of guidelines to critically appraise their quality. We outline the steps necessary to begin the guideline development process, how to build working groups, how to search for evidence, how to grade the quality of the evidence, how to reach consensus on statements and how to write the guideline document. We believe that using this framework will increase the potential to produce a high-quality guideline which is transparent, independent, reproducible and implementable.

The Outcome of Neoadjuvant Imatinib Therapy Combined With Surgery for Rectal Gastrointestinal Stromal Tumors: A Report of Three Cases and a Review of the Literature.

Gastrointestinal stromal tumors (GISTs) represent the most frequent mesenchymal tumors of the gastrointestinal tract. They occur most frequently in the stomach. Rectal localization remains rare and represents only 5% of all GIST cases and 0.1% of all rectal tumors. Immunohistochemical staining (CD117, DOG1) and molecular analysis remain the gold standard for diagnosis; DOG1 represents a very sensitive marker regardless of CD117 expression. Complete en-bloc resection constitutes the only curative treatment; however, surgical management of rectal GIST remains challenging and can involve extensive surgery such as abdominoperineal resection with significant morbidity. The role of neoadjuvant Imatinib therapy in rectal GISTs is controversial and mainly indicated in a locally advanced tumor or sphincter invasion to increase the chance of complete resection and sphincter preservation. Herein, we report three cases of a rectal GIST treated with neoadjuvant Imatinib therapy and who underwent extensive surgery with complete resection (R0), as well as a recent review of the literature, to study clinicopathological features, surgical challenges, and perioperative Imatinib therapy outcome of rectal GISTs.

Non-Bismuth Quadruple Therapy, Sequential Therapy or High-Dose Esomeprazole and Amoxicillin Dual Therapy for First-Line Helicobacter pylori Eradication: A Prospective Randomized Study.

AIM: The study aims were to evaluate and compare the effectiveness and safety of non-bismuth quadruple therapy with sequential therapy and dual therapy with high dose esomeprazole and amoxicillin as an empirical first-line approach to eradicate Helicobacter pylori infection. PATIENTS AND METHODS: Prospective randomized trial included 393 patients infected with H. pylori naïve to eradication therapy, randomized to receive a 10-day non-bismuth quadruple or concomitant (CT) therapy, 10-day sequential therapy (SQ), or 14-day high-dose esomeprazole and amoxicillin (BT). Treatment outcome was assessed by C13-urea breath test at least six weeks after therapy. Adverse events and compliance were assessed with questionnaires and residual medication count. RESULTS: The baseline demographic clinical and endoscopic characteristics were similar among the three groups. The intention to treat (ITT) analysis was performed in 130, 132, and 131 patients in the BT, SQ, and CT groups, respectively. The eradication rates in ITT were 64.6%, 83.1%, and 92.3%, respectively, in the BT, SQ and CT groups (p = 0.0001). The eradication rates per protocol were 67.7%, 88.5%, and 95.3% (p = 0.0001), respectively, in the BT, SQ, and CT groups. The CT and SQ groups were higher than the BT group (p = 0,0001) but no significant results were seen in the eradication rate between CT and SQ, both in PP analysis and in ITT analysis (p = 0.09). The prevalence of the side effects following the non-bismuth quadruple therapy was 38.2%, significantly higher (p = 0.001) than the BT group (13.80%) and SQ group (22%). There were no significant differences in compliance among the three therapies (p = 0.16). CONCLUSION: This study found that non-bismuth quadruple therapy yielded a higher H. pylori eradication rate over sequential regimen as a first-line treatment in Morocco, with no statistical difference between the two protocols studied, while the eradication rate of dual high-dose of esomeprazole and amoxicillin did not exceed 60%. All three therapy schemes showed excellent compliance. However, the prevalence of side events was more important and significantly higher with non-bismuth quadruple therapy.

Prevalence of hepatitis B and C in blood transfusion center, Oujda Morocco (2013-2015).

Viral hepatitis is a serious public health problem. Its epidemiology is not precisely known in Morocco. Our objective was to assess the prevalence of HBV and HCV in a particular population of "blood donors" at the Regional Blood Transfusion Centre in Oujda. A retrospective study was conducted from May 1, 2013 to May 31, 2015. Thirty-one thousand nine hundred and fifty-two blood donors were tested. Antigen detection was made according to ELISA technique (MonolisaTMHBs Ag ULTRA). HCV research was performed by ELISA using the kit « Monolisa HCV Ag-Ab ULTRA ¼. 177 blood donors included, they are divided into 155 male (87.6%) and 22 female (12.4%) subjects with a ratio of 7. The average age was 37.64 ± 12 years. Six cases were positive for HCV with an overall prevalence of 0.02%. The population study by sex shows a prevalence of 0.004% for 23177 male sera and 0.057% for 8775 female sera. Six donors were HCV positive, of which 05 were female (83.33%) and one was male (16.66%). The average age was 43 ± 14 years. Co-infection with HCV HBV-HCV and HCV-Syphilis and HCV-HIV are absent. Co-infection with HBV and HIV was found in one case. HBV-syphilis co-infection was found in 04 cases. Chronic viral hepatitis is a real global health problem. Its prevalence is currently estimated at 0.55% for HBV and 0.02% for HCV, reclassifying Morocco as a low endemic area. The prevention remains the most effective method to successfully control HBV and HCV infection.

Perspectives of patients and physicians about neuroendocrine tumors. A qualitative study.

PURPOSE: Gastrointestinal neuroendocrine tumors (NETs) are rare, complex to manage, and often have a chronic course. Qualitative methods are a tool of choice for focusing on patients' and physicians' points of view especially when dealing with a complex and rare disease. Nonetheless, they remain undeveloped in research related to NETs. This study aimed to explore the experience of NETs among both patients and their physicians and to cross their perspectives for the purpose of finding pathways to improving care. RESULTS: Our analysis found two themes: (1) the questions raised by this disease, and (2) the complex experience of this singular disease. Our findings underlined the experience of confusion found among patients regarding the patient's unusual somatic experience and around the question of vocabulary, i.e. the naming of the disease and the semantic field of severity in the medical discourse. CONCLUSION: Means for reducing the confusion that patients experience in this disease are needed. The explanations that the physician offers to the patient must clarify the issues related to NETs. We therefore propose a statement that all physicians can use to support patients diagnosed with neuroendocrine tumors to clear up potential confusion. METHODS: We conducted a qualitative study, based on 40 semi-structured interviews, in a specialized department of gastro-pancreatology. Participants, purposively selected until data saturation, came from two different sub-samples: (i) patients with a metastatic NETs (N = 20) and (ii) their referring physicians (N = 10). The data were examined by thematic analysis.

The long term risk of malignancy in patients with branch duct intraductal papillary mucinous neoplasms of the pancreas.

UNLABELLED: In patients (pts) with branch duct intraductal papillary mucinous neoplasms of the pancreas (BD-IPMN), the risk of malignant progression is well described at short- and mid-term. Few data beyond 5 years are available. PATIENTS AND METHODS: Prospective study in consecutive patients (pts) with BD-IPMN and follow-up (F/U) ≥60 months to assess long term risk of malignant progression. All computed tomographies and magnetic resonance cholangiopancreatographies performed every 1 or 2 years (depending on the maximum size of cyst) were read by the same radiologist. EUS was performed in case of occurrence of main pancreatic duct (MPD) dilation or mural nodule >5 mm. Size increase was considered significant if >5 mm. Size variation, criteria suggestive of malignancy, operative therapy and pathology were recorded. RESULTS: 53 pts were included (median age at diagnosis: 61 years, median F/U: 84 months (range: 60-132) including 5 F/U >120 months). Lesions were stable in 38 pts (72%). Size increased in 8 pts (15%) (median increase : 11 (5-33) mm) without mural nodule (MN). One of those was operated on (low-grade dysplasia). A MN appeared in 5 pts (9%). ≥5 mm in 2 pts (5 and 15 mm) who were operated on (intermediate-grade dysplasia in both). The 3 remaining pts (MN < 5 mm) were carefully followed-up. Invasive advanced carcinoma occurred in 2 pts, both after 84 months F/U. In one of these, no imaging changes were noted 12 months before diagnosis of malignancy. CONCLUSION: In BD-IPMN, the risk of malignant evolution persists after 60 months F/U including invasive carcinomas. F/U imaging surveillance is still necessary beyond this delay in patients fit for potential surgery.