Clinical epidemiology and outcomes of patients with gastric intestinal metaplasia in the Los Angeles County System.

BACKGROUND: Gastric intestinal metaplasia (GIM) is a precursor to gastric adenocarcinoma (GAC). In the United States, there is no consensus on the utility of surveillance for GIM, and minority populations most affected by GAC are understudied. Our aims were to define clinical and endoscopic features, surveillance practices, and outcomes in patients with GIM in a multicenter safety-net system. METHODS: We identified patients with biopsy-proven GIM between 2016-2020 at the three medical centers comprising Los Angeles County Department of Health Services. Demographics, findings at index esophagogastroduodenoscopy (EGD) first showing GIM, recommended interval for repeat EGD, and findings at repeat EGD were abstracted. Descriptive statistics were performed to characterize our cohort. T-tests and chi-squared (χ2) tests were used to compare patients with and without multifocal GIM. RESULTS: There were 342 patients with newly-diagnosed biopsy-proven GIM, 18 (5.2%) of whom had GAC at index EGD. Hispanic patients comprised 71.8% of patients. For most patients (59%), repeat EGD was not recommended. If recommended, 2-3 years was the most common interval. During a median time to repeat EGD of 13 months and cumulative follow-up of 119 patient-years, 29.5% of patients underwent at least one repeat EGD, of whom 14% had multifocal GIM not previously detected. Progression to dysplasia or GAC was not detected in any patients. CONCLUSION: In a predominantly minority population with biopsy-proven GIM, there was a 5% incidence of GAC on index EGD. Though progression to neither dysplasia nor GAC was detected, there was significant variability in endoscopic sampling and surveillance practices.

Gastro-gastric intussusception in the setting of a neuroendocrine tumor: A case report.

BACKGROUND: While in children intussusception is often idiopathic, in adults it is commonly caused by a pathologic condition functioning as a lead point. It is important to note that a variety of pathologic conditions may trigger intussusception, with malignancy being a relatively frequent culprit in adults; this should be considered high on the differential diagnosis during evaluation. CASE SUMMARY: This is a case of a 40-year-old female presenting to the emergency department (ED) with three days of acute on chronic, peri-umbilical abdominal pain described as waxing and waning, and pressure-like in nature. Initial computed tomography (CT) of the abdomen and pelvis with contrast in the ED (after her pain had resolved) re-demonstrated a previously noted 13 mm lesion in the gastric antrum but no clear cause of the pain. Endoscopic ultrasound was pursued, and the mass lesion was sampled via fine needle biopsy. Post-procedure the patient experienced another episode of severe pain which prompted a repeat stat CT abdomen and pelvis with contrast; this re-demonstrated the 13 mm antral lesion and in addition was remarkable for a gastro-gastric intussusception. An upper gastrointestinal gastrograffin series was ordered (completed only after the pain had subsided) and showed resolution of the intussusception. Histopathology was consistent with a diagnosis of low-grade neuroendocrine tumor (NET). Surgery was initially deferred during the hospitilization given the low grade pathology of the lesion; however further multidisciplinary discussion between Surgery, Oncology, and Gastroenterology recommended resection given the patient's recurrent abdominal pain with the NET functioning as a lead point for further intussusception, and the patient thus underwent robotically-assisted wedge resection. CONCLUSION: We present a unique case of severe, intermittent, peri-umbilical pain related to gastro-gastric intussusception caused by an antral NET lead point. The case highlights the importance of considering neoplasms as the cause of intussusception in adults and the greater diagnostic yield when imaging is obtained while symptoms (in this case severe, episodic abdominal pain) are most apparent.

Uncanny Proctopathy: A Case of Lymphogranuloma Venereum.

A 37-year-old man with a history of receptive and penetrating anal sex with men presented with abdominal pain, bright red blood per rectum, and fevers. Recent evaluation by his primary care doctor was notable for negative urine for Neisseria gonorrhea and Chlamydia trachomatis. Rectal swab on admission was positive for C. trachomatis. The patient was ultimately diagnosed with lymphogranuloma venereum, a disease typically seen in tropical climates, although it is more common now in western countries, specifically in men who have sex with men. Treatment consisted of a course of doxycycline for 3 weeks, with resolution of symptoms.

Solitary fibrous tumour of the pleura presenting as a giant intrathoracic mass.

Solitary fibrous tumours (SFTs) are relatively rare neoplasms thought to originate from the submesothelial connective tissue. SFTs have been described in a variety of sites, including the pleura, orbit, lower respiratory tract, peritoneal cavity and heart. These neoplasms are usually benign, though locally aggressive, and metastatic behaviour has been observed in some cases. We describe a case of a 61-year-old man presenting with weight loss, poor appetite, malaise, worsening dyspnoea on exertion and lower extremity oedema, who was found to have a gigantic-21×21 cm-tumour occupying the entire right hemithorax causing compression and displacement of the mediastinum and liver. Transthoracic CT-guided biopsy revealed SFT of the pleura. The patient underwent preoperative angiography and embolisation of the tumour followed by successful surgical resection via thoracotomy.

Strong expression of chemokine receptor CCR9 in diffuse large B-cell lymphoma and follicular lymphoma strongly correlates with gastrointestinal involvement.

The gastrointestinal (GI) tract is the most common site of extranodal B-cell lymphomas. However, it is unclear how neoplastic lymphoid cells preferentially home there. We hypothesize that expression of the GI-homing chemokine receptor CCR9 may account for the dissemination of B-cell lymphomas to the GI tract. To test our hypothesis, we compared the expression of CCR9 using immunohistochemistry on GI versus nodal diffuse large B-cell lymphoma and follicular lymphoma. We found that 27 (66%) of 41, 12 (29%) of 41, and 2 (5%) of 41 of GI lymphoma cases demonstrated 3+, 2+, and 1+ CCR9 staining, respectively. In contrast, 2 (5%) of 39, 5 (13%) of 39, 8 (20.5%) of 39, and 24 (61.5%) of 39 nodal-restricted lymphoma cases demonstrated 3+, 2+, 1+, and 0+ CCR9 staining (P < .0001). This was observed for both diffuse large B-cell lymphoma (P < .001) and follicular lymphoma (P < .001). We also compared the expression of CCR9 on nodal B-cell lymphomas with involvement of the GI tract with those restricted to the lymph node. We found that 10 (62%) of 16, 3 (19%) of 16, and 3 (19%) of 16 nodal lymphomas with GI involvement showed 3+, 2+, and 1+ CCR9 staining, respectively. In contrast, 2 (5%) of 39, 5 (13%) of 39, 8 (20.5%) of 39, and 24 (61.5%) of 39 nodal lymphomas without GI involvement demonstrated 3+, 2+, 1+, and 0+ CCR9 staining, respectively (P < .001). Our finding that CCR9 expression is elevated in the nodal lymphomas of patients with GI involvement suggests the potential clinical utility of chemokine receptor status, as assessed by immunohistochemistry, to potentially predict GI dissemination and progression to higher stage in patients who initially present with limited nodal-restricted disease.

Anti-Ge2: further evidence for lack of clinical significance.

Anti-Ge2 may be immune or naturally occurring, and it reacts with an antigen on glycophorin D. Ge2 is encoded by a gene, GYPC, which is located on the long arm of chromosome 2. Anti-Ge2 is usually an immunoblobulin G (IgG) antibody. In the available literature, we have not been able to find any reported cases of proven acute hemolytic transfusion reactions caused by Anti-Ge2. We present the case of a 67-year-old man with metastatic pancreatic carcinoma who had symptomatic anemia and a hemoglobin concentration of 6.3 g/dL. During pretransfusion testing, Anti-Ge2 was identified in his serum. Only a single unit of compatible, Ge:-2 frozen red blood cells (RBCs) could be provided by the blood supplier. A second unit of crossmatched, least-incompatible, leukocyte-reduced RBCs, presumably Ge:-2, was also transfused. The transfusion was completed without incident, and the patient's hemoglobin concentration rose appropriately. Posttransfusion values for haptoglobin, lactate dehydrogenase, and urine hemoglobin were within normal limits. A monocyte monolayer assay performed on this anti-Ge2 supports the data that antibodies of this specificity do not cause hemolysis. The clinical and laboratory data obtained in our patient clearly indicated that no hemolysis of transformed RBCs occurred during and for 24 hours after transfusion. We believe that this report adds to a limited experience with anti-Ge2 and provides further evidence for concluding that, to all likelihood, this is not a clinically important RBC antibody. The risk of transfusing apparently "incompatible" (Ge:2) RBCs seems remote and should allow for timely administration of RBCs when treating patients with serious anemia.