Chemoprophylaxis to Prevent Deep Venous Thrombosis in Patients Hospitalized for Pancreatitis: Beneficial or Harmful?

INTRODUCTION:  Vascular complications in pancreatitis generally occur in the form of hemorrhage or thrombosis. Pancreatitis resulting in splanchnic thrombosis has been well studied, but the cause of this correlation has not been studied in the current era of increasing anticoagulant use for deep venous thrombosis (DVT) prophylaxis. Hemorrhagic pancreatitis and peri-pancreatic bleeding are also known phenomena encountered in relation to pancreatitis, but these risks are not well established in the setting of chemical prophylaxis for DVT. OBJECTIVES:  Our objective was to identify whether chemical DVT prophylaxis in pancreatitis harms the patient by increasing the risk of hemorrhagic conversion of pancreatitis or peri-pancreatic hemorrhage or if it is beneficial by preventing splanchnic venous thrombosis in the abdominal vasculature that surrounds the pancreas. METHODS:  We undertook a retrospective chart review with approval from the Institutional Review Board on patients who were hospitalized for or developed pancreatitis during their hospital stay from April 2014 to July 2015. We reviewed the charts for imaging suggestive of venous thrombosis or the development of intra-abdominal hemorrhage at admission during hospitalization and within 30 days after hospitalization. We also reviewed the methods of DVT prophylaxis to identify any correlation with the risk of hemorrhage or thrombosis. A bedside index of severity in acute pancreatitis score was used within 24 hours of admission to calculate the severity of the patients' pancreatitis. The data collected were analyzed for descriptive statistics, correlation using Pearson's coefficient, and multivariate regression analysis using Microsoft Excel and SPSS Inc. Released 2009. PASW Statistics for Windows, Version 18.0. Chicago: SPSS Inc. RESULTS:  This study included 389 patients who met the inclusion criteria. Of these, 74.6% of patients received chemical prophylaxis, mostly low molecular weight heparin, and 18.5% of patients were not on chemical or mechanical means of DVT prophylaxis. Only 12 patients (3%) had complications related to thrombosis and hemorrhage. Seven patients had splanchnic venous thrombosis, one had a hemorrhagic conversion of pancreatitis, three had a peri-pancreatic hemorrhage, and one had both the hemorrhagic conversion of pancreatitis and peri-pancreatic hemorrhage. Ten patients out of 12 patients had complications before admission, and nine of the 12 patients were on chemical prophylaxis. Pearson's coefficient showed no statistically significant correlation between the incidence of complications and the use of chemical DVT prophylaxis. Multivariate analysis showed no specific variable that increased the risk of complications. CONCLUSIONS:  Our study showed that chemoprophylaxis for DVT in patients hospitalized for acute pancreatitis is neither harmful by causing hemorrhagic conversion of pancreatitis, peri-pancreatic hemorrhage nor beneficial by preventing splanchnic venous thrombosis.

A Case of Profound Secretory Diarrhea Revealing 2 Primary Neuroendocrine Tumors.

Neuroendocrine tumors (NETs) are unusual neoplasms with a diverse spectrum of clinical presentations. There is a lack of literature on cases of 2 primary histologically distinct NETs. We report a case of a 40-year-old man who presented with chronic diarrhea. A colonoscopy was performed which discovered a rectal polyp, with pathology showing a well-differentiated NET. A subsequent somatostatin scan revealed a pancreatic tail mass. Biopsy showed a histologically distinct well-differentiated vasoactive intestinal peptide-producing NET. Given that pancreatic and rectal NETs come from different embryonic origins, the diagnosis of 2 primary NETs presents a unique case.

Abdominal Cerebrospinal Fluid Pseudocyst as a Complication of Ventriculoperitoneal Shunt Placement.

The abdominal cavity has long been used for absorption of cerebrospinal fluid (CSF) in patients with hydrocephalus. Although the procedure is quite common, there are complications that can potentially arise following ventriculoperitoneal (VP) shunt insertion. Here, we report a case of a 39-year-old female patient in which a large abdominal pseudocyst was developed as a complication of VP shunt placement. Ultrasonographical evaluation of the abdomen showed a well-defined cystic mass lesion later confirmed on CT abdomen. She subsequently underwent surgical excision of the pseudocyst with resolution of previous symptoms. Clinicians should be aware of this complication since early diagnosis improves outcome and reduce patient's suffering and distress.

Rectal malakoplakia.

Malakoplakia is a rare chronic granulomatous disease with potential to affect multiple organs. Gastrointestinal involvement is considered one of the most common locations outside of the urinary tract. Herein, we present the case of a man who presented to our clinic with painless hematochezia. Physical examination findings were unremarkable; however, colonoscopy revealed a frond-like/villous, fungating, and polypoid nonobstructing circumferential mass in the rectum. Histopathological examination of the lesion revealed findings consistent with malakoplakia.

Corrigendum to "A Rare Case of New-Onset Ulcerative Colitis following Initiation of Secukinumab".

[This corrects the article DOI: 10.1155/2019/2975631.].

Histologic and Endoscopic Similarity between Nodular Gastric Antral Vascular Ectasia and Gastric Hyperplastic Polyps Potentially Causing Treatment Delays.

INTRODUCTION: Gastric antral vascular ectasia (GAVE) is the underlying cause for 4% of nonvariceal upper GI bleeding. Nodular GAVE and gastric hyperplastic polyps have similar appearance on upper GI endoscopy (EGD) as well as histology, which could delay specific targeted therapy. We herein, through this case, would like to highlight that high clinical suspicion is required to diagnose nodular GAVE. CASE REPORT: A 70-year-old male with a past medical history significant for coronary artery disease s/p drug-eluting stent placement on Plavix, coronary artery bypass grafting, mechanical aortic valve replacement on warfarin, and iron deficiency anemia on replacement was admitted for the evaluation of fatigue and melena for a month. Physical examination was positive for black stool. The only significant lab was a drop in hemoglobin/hematocrit (Hg/dl/H%) of 10/32 to 4/12.5. Fibrosure was sought which suggested that the patient had an F4 cirrhosis. Endoscopy showed nodules in the gastric antrum which were presumptively treated as GAVE with argon plasma coagulation (APC). Surgical pathology showed reactive gastropathy and gastric polyps. Review of the past histology suggested that because of the overlap in the histopathological features of hyperplastic polyps and GAVE, they were misinterpreted as hyperplastic polyp rather than nodular GAVE. DISCUSSION: GAVE can be classified endoscopically as punctate, striped, nodular, or polypoidal form. The light microscopic findings considered specific to GAVE are vascular hyperplasia, mucosal vascular ectasia, intravascular fibrin thrombi, and fibromuscular hyperplasia. However, these findings do not differentiate GAVE from hyperplastic gastric polyp. The first line of treatment for GAVE is endoscopic ablation with Nd:YAG laser or argon plasma coagulation. Response to therapy was seen with a mean of 2.6 treatment sessions. There is not a lot of evidence supportive of pharmacological treatment of GAVE with estrogen-progesterone, tranexamic acid, and thalidomide. Serial endoscopic band ligation as well as detachable snares in the management of nodular GAVE refractory to argon plasma coagulation has also been tried. CONCLUSION: Oftentimes, there is a delay in the diagnosis and treatment of nodular GAVE as the histopathological appearance could be similar to gastric polyps. The diagnosis of GAVE especially nodular GAVE requires a high level of clinical suspicion. Misdiagnosis of nodular GAVE can delay targeted therapy and have fatal outcomes.

A Rare Case of New-Onset Ulcerative Colitis following Initiation of Secukinumab.

Secukinumab is an IgG monoclonal antibody widely used for treatment of ankylosing spondylitis, psoriasis, and psoriatic arthritis. Recently, there has been increasing controversy regarding potential adverse effects of the drug especially in those with underlying inflammatory bowel disease. We present the case of a young male patient who developed severe new-onset ulcerative colitis following initiation of secukinumab for psoriasis, with excellent response and rapid resolution of symptoms with infliximab.

Primary Diffuse Large B-Cell Lymphoma of the Descending Colon.

Primary non-Hodgkin lymphoma of the gastrointestinal tract is rare with an incidence of 10-15% of all non-Hodgkin lymphoma cases and 1-4% of all gastrointestinal tumors. The most common sites of involvement include the stomach, small intestines, colon and rectum. Primary colorectal lymphoma is extremely rare representing only 0.2-0.6% of all colorectal malignancies. The presentation is usually non-specific leading to delay in diagnosis. Imaging is used to locate the tumor and its extension. Colonoscopy usually shows a fungating mass, infiltrative or ulcerative lesion. Diffuse large B-cell lymphoma is the most common histological subtype. Management of diffuse large B-cell lymphoma usually involves chemotherapy, radiation, surgery or a combination approach.

Clostridium septicum: An Unusual Link to a Lower Gastrointestinal Bleed.

Clostridium septicum is a highly virulent pathogen which is associated with colorectal malignancy, hematological malignancy, immunosuppression, diabetes mellitus and cyclical neutropenia. Presentation may include disseminated clostridial infection in the form of septicemia, gas gangrene, and mycotic aortic aneurysms. We report the case of a 62-year-old female presenting with necrotizing fasciitis of her left thigh and subsequently developing rectal bleeding. While she was being treated with empiric antibiotics, her blood culture was found to be positive for C. septicum. We would like to highlight the importance of early colorectal cancer screening in minimizing the occurrence of undetected tumors which provide an optimal growth environment for C. septicum, leading to localized and/or remote infection.

Cytomegalovirus Colitis Mimicking Rectal Carcinoma in a Young Immunocompetent Patient.

Cytomegalovirus (CMV) infection is often seen in immunocompromised patients. Rarely, immunocompetent patients may present with CMV as a self-limiting, flu-like illness, though a few cases of significant organ-specific complications have been reported in these patients. We report a case in which a previously healthy man presented with hematochezia and an obstructing rectal mass thought to be rectal adenocarcinoma. Biopsy was positive for CMV, which was treated with full resolution of rectal mass confirmed with colonoscopy and barium contrast enema. This is the first reported case of CMV colitis mimicking rectal adenocarcinoma in an immunocompetent patient.

Wedge and needle liver biopsies show discordant histopathology in morbidly obese patients undergoing Roux-en-Y gastric bypass surgery.

BACKGROUND: Controversy exists over whether or not single-needle liver biopsies are sufficient to compare histological parameters in patients with non-alcoholic fatty liver disease. AIMS: To identify sampling variability, we biopsied four liver specimens per patient, based on biopsy size (needle vs wedge) and location (left vs right lobe), immediately prior to bariatric Roux-en-Y gastric bypass surgery. METHODS: Ten prospectively enrolled, morbidly obese patients underwent 40 laparoscopy-guided biopsies; two needle and two wedge from each of 16 left and 16 right liver lobes. The Kappa coefficient for concordance compared histological parameters from left and right lobe needle- and wedge biopsies. Wedge biopsies were considered our 'Gold Standard'. RESULTS: Each patient had two wedge- and two needle liver biopsies. Kappa concordance between all needle and wedge biopsies from right and left lobes showed variability. Wedge- and needle liver biopsies from contralateral lobes had higher concordance with each other, compared to ipsilateral needle/wedge biopsy pairs. Contralateral wedge pairs had higher concordance than contralateral needle/needle pairs. There were no biopsy complications. CONCLUSIONS: Wedge biopsy pairs had the best Kappa concordance but contralateral needle/needle biopsy pairs had good Kappa concordance. There were no complications from the 40 needle- and wedge liver biopsies, confirming the safety of laporoscopic multi-biopsy in both liver lobes.

Digital quantification is more precise than traditional semiquantitation of hepatic steatosis: correlation with fibrosis in 220 treatment-naïve patients with chronic hepatitis C.

BACKGROUND: Steatosis, as associated with chronic hepatitis C (CHC) and non-alcoholic fatty liver disease (NAFLD), has been considered a risk factor for development of fibrosis. AIMS: Our aims were to determine if correlations existed between the degree of steatosis and fibrosis in treatment-naïve CHC patients, and to compare the accuracy of digital image analysis with semiquantification (manual assessment) to quantify hepatic steatosis. METHODS: We studied 220 treatment-naïve, liver biopsy-proven CHC patients, including a serial biopsy sub-cohort of 37 patients with a mean interval of 3.82 years. Steatosis and fibrosis % were evaluated using digital quantification of steatosis (DQS) and fibrosis contrasted with manual assessment. RESULTS: Most patients had <6% steatosis measured manually and digitally. Overall, manual assessment of steatosis was 3.78 times greater than DQS. Increasing steatosis % was associated with advancing fibrosis stage, both manually and digitally. Intraobserver reliability for DQS showed higher intraclass correlation reproducibility (r = 0.98, P < 0.001) than the manual method (r = 0.81, P < 0.01). Interobserver concordance for DQS had an average measure intraclass correlation of r = 0.99. Cirrhotics were more likely than non-cirrhotics to have grade 2 steatosis. CONCLUSIONS: Increased steatosis was associated with increased fibrosis. DQS was consistently more precise and reproducible than manual assessment of steatosis in grades 1 (1 to <6%) and 2 (6 to <34%), and may prove to be especially preferable in clinical trials of pharmacotherapeutic agents.

Diagnostic accuracy of serum hyaluronic acid, FIBROSpect II, and YKL-40 for discriminating fibrosis stages in chronic hepatitis C.

OBJECTIVES: Noninvasive serum markers of liver fibrosis are being used as an alternative to liver biopsy. Currently available tests distinguish, with accuracy, only absent/minimal fibrosis (Ishak stages 0-1) and advanced fibrosis/cirrhosis (Ishak stages 4-6), but not intermediate fibrosis (Ishak stages 2-3). Our aim was to evaluate the diagnostic accuracy of hyaluronic acid (HA), FIBROSpect II (FS-II), and YKL-40 (chondrex, human cartilage glycoprotein-39) in various clinically important categories of fibrosis, and further correlate these serum markers with digital quantification of fibrosis (DQF) and Ishak stages. METHODS: Serum HA, YKL-40, and FS-II were retrospectively assessed and correlated with Ishak stages and DQF scores in 75 patients with chronic hepatitis C (HCV). Spearman's rho statistics assessed relationships among all parameters, and receiver operator characteristic curves evaluated accuracy of each parameter when compared to the Ishak stages. RESULTS: All three serum markers and DQF correlated highly with one another (P < or = 0.01) and with Ishak stages of fibrosis. Among the serum markers, HA was effective in discriminating between Ishak stages 0-1 and Ishak stages 2-3 compared with FS-II, with an area under the curve of 0.76 versus 0.66 and a false-positive rate of 0.33 versus 0.67, respectively. All three serum markers predicted advanced fibrosis and cirrhosis. YKL-40 had the highest false-positive rates in all categories of fibrosis. CONCLUSIONS: HA can be utilized as a reliable surrogate marker in distinguishing three clinically relevant stages of fibrosis: absent/minimal, intermediate, and advanced/cirrhosis. HA should be considered as a cost-effective alternative to other serum markers for staging fibrosis and for determining the timing and selection of HCV treatment.