Endoscopic management of pancreaticopleural fistula after recurrent acute pancreatitis.

Pancreaticopleural fistula is an extremely rare complication of pancreatitis. We present a case of pancreaticopleural fistula in a patient with recurrent acute pancreatitis who presented with right-sided symptomatic pleural effusion. Pancreatic sphincterotomy and pancreatic duct stenting led to resolution of pleural effusion and withdrawal of the chest tube within 3 weeks.

Keep an Eye Out for Crohn's Disease: Orbital Myositis as the Initial Sign before Gastrointestinal Manifestations.

Extraintestinal manifestations of Crohn's disease sometimes occur and can present prior to intestinal symptoms. Ocular manifestations of Crohn's disease are considered rare, with orbital myositis an even rarer manifestation with only a handful of cases reported in the literature. We present the case of a young woman who was diagnosed with orbital myositis, which was initially attributed to pseudotumor cerebri after an extensive negative work-up. Months later, the patient presented with haematochezia, and was subsequently diagnosed with Crohn's disease. LEARNING POINTS: Orbital myositis is a rare manifestation of inflammatory bowel disease (IBD), and even more rarely is the initial presentation before the development of intestinal luminal disease.Orbital myositis is a rare extraintestinal manifestation of Crohn's disease and mimics thyroid ophthalmopathy. When a thyroid function test is negative, it is important to keep IBD in mind.

Quadruple therapy for gastric high-grade B-cell lymphoma.

Most low-grade gastric lymphomas arising from the mucosa-associated lymphoid tissue (MALT) are directly related to Helicobacter pylori infection. Most cases of MALT lymphoma limited to the stomach can be cured with H. pylori eradication and remain in remission for years. In contrast, high-grade lymphomas of the stomach, although potentially related to H. pylori, do not usually respond to H. pylori eradication. Here, we present the case of a woman with high-grade diffuse large B-cell lymphoma who achieved complete remission following H. pylori eradication.

Myxedema ascites complicated by ischemic colitis.

Myxedema Ascites is a rare finding of primary hypothyroidism, thereby leading to delayed diagnosis. However, prompt treatment with levothyroxine leads to complete resolution of the condition. We present a rare case of myxedema ascites in an elderly female and highlight the importance of early diagnosis and management. We also present ischemic colitis in the same patient, which has not been reported thus far in literature as a complication of myxedema ascites.

Self-Expanding Metal Stenting in the Management of a Benign Colonic Stricture.

Colonic postanastomotic strictures occur in 1.5-8% of patients following colorectal surgery. Traditionally, colonic strictures were treated by multiple modalities including endoscopic dilatation. Self-expanding metal stents (SEMS) have been indicated in the management of benign colonic strictures; however, there are limited available data with regard to their efficacy. We present the case of a 68-year-old male who had perforated sigmoid diverticulitis followed by Hartmann's procedure with eventual reanastomosis 6 months later. He subsequently developed benign colonic stricture, which was treated with a metal stent. SEMS are associated with a low mortality rate and are appropriate in treating acute colonic obstruction as a result of benign stricture in the setting of postanastomosis.

Multispectral scanning during endoscopy guides biopsy of dysplasia in Barrett's esophagus.

Esophageal cancer is increasing in frequency in the United States faster than any other cancer. Barrett's esophagus, an otherwise benign complication of esophageal reflux, affects approximately three million Americans and precedes almost all cases of esophageal cancer. If detected as high-grade dysplasia (HGD), most esophageal cancers can be prevented. Standard-of-care screening for dysplasia uses visual endoscopy and a prescribed pattern of biopsy. This procedure, in which a tiny fraction of the affected tissue is selected for pathological examination, has a low probability of detection because dysplasia is highly focal and visually indistinguishable. We developed a system called endoscopic polarized scanning spectroscopy (EPSS), which performs rapid optical scanning and multispectral imaging of the entire esophageal surface and provides diagnoses in near real time. By detecting and mapping suspicious sites, guided biopsy of invisible, precancerous dysplasia becomes practicable. Here we report the development of EPSS and its application in several clinical cases, one of which merits special consideration.

Periductal hypoechoic sign: an endosonographic finding associated with pancreatic malignancy.

BACKGROUND: Despite advances in imaging, differentiating benign from malignant causes of pancreatic duct dilation is difficult. OBJECTIVE: The aim of our study was to assess the accuracy of the periductal hypoechoic sign (PHS), defined as patchy hypoechoic areas adjacent to a dilated pancreatic duct, for the diagnosis of pancreatic malignancy. DESIGN: Single-center, retrospective analysis. SETTING: Tertiary care university hospital. PATIENTS: All patients who underwent EUS from 2006 to 2008 for evaluation of pancreatic pathology were identified. Those with pancreatic duct dilation of 4 mm or more in the head of the pancreas or 3 mm or more in the body or tail were included. Digitally recorded EUS images were analyzed for PHS by 1 endoscopist blinded to final results. The final diagnosis was based on pathology results or clinical follow-up. RESULTS: During the study period, 84 of 427 patients who underwent EUS for pancreas pathology had dilated pancreatic ducts. Of these, 42 patients had benign disease and 42 had pancreatic malignancy. The PHS was noted in 31 (73.8%) of 42 patients with malignancy compared with 6 (14.3%) of 42 patients with benign disease (P < .001). The PHS had a sensitivity of 73.8%, a specificity of 85.7%, and an accuracy of 79.8% for the diagnosis of pancreatic malignancy. After adjusting for age, patients with the PHS were 17 times more likely to have a malignancy (odds ratio 16.66; 95% CI, 5.01-55.44). Pancreatic duct diameter or dilation of both bile and pancreatic ducts were not predictive of malignancy. LIMITATION: A retrospective design. CONCLUSIONS: The PHS was an accurate and independent predictor of pancreatic malignancy in patients with a dilated pancreatic duct.

Mesenteric ischemia in the elderly.

Intestinal ischemia is a relatively common disorder in the elderly and, if not treated promptly, still carries a high morbidity and mortality rate. High degree of clinical suspicion is of paramount importance in diagnosis, because there is no specific laboratory test available and physical examination findings may be subtle. Once the diagnosis is made, management relies on early resuscitation, identification, and treatment of the predisposing conditions, along with careful planning of the therapeutic invasive interventions, which altogether may help reduce the mortality and morbidity associated with this condition.

Midazolam-induced sedation for upper gastrointestinal endoscopy: assessment of endoscopist and patient satisfaction.

Upper gastrointestinal endoscopy can be performed without intravenous sedation but the evidence suggests most patients and endoscopists prefer some form of premedication. Intravenous diazepam or midazolam are used by the majority of endoscopists in the United States, though it is not common practice in Turkey where this study was conducted. This study aimed to evaluate the efficacy and safety of midazolam in performing upper gastrointestinal endoscopy. A total of 352 patients undergoing upper gastrointestinal endoscopy were sedated with midazolam given as a bolus injection over 5 seconds. Ages of the patients ranged between 16 and 79 years (average: 41.6 +/- 12.7 years). The course of endoscopy, anterograde memory, degree of cooperation, degree of sedation, side effects, and acceptability of further intervention were evaluated by a questionnaire given to the patients and endoscopists.

Long-term outcomes of thymosin-alpha 1 and interferon alpha-2b combination therapy in patients with hepatitis B e antigen (HBeAg) negative chronic hepatitis B.

Hepatitis B e antibody (HbeAb) and hepatitis B virus (HBV) DNA positive chronic hepatitis is a clinical entity, distinct from classical hepatitis B e antigen (HbeAg) positive chronic hepatitis B. Our aim was to evaluate the long-term therapeutic efficacy of the combination of interferon alpha-2b and thymosin-alpha1 compared with lamivudine plus interferon alpha-2b and interferon alpha-2b alone. Fifty-two patients with HbeAg-negative chronic hepatitis B were assigned to three different groups in a nonrandomized manner. Group 1 (n = 27) received thymosin-alpha1 [1.6 mg subcutaneously (sc), twice a week] and interferon alpha-2b (10 MIU sc, three times per week) for 26 weeks, subsequently followed by interferon alpha-2b monotherapy at the same dosage for an additional 26 weeks. Group 2 (n = 10) received interferon alpha-2b (10 MIU sc, three times per week) for 52 weeks. Group 3 (n = 15) received interferon alpha-2b (10 MIU sc, three times per week) and lamivudine [100 mg orally (po), q.d.] for 52 weeks, followed by continuous lamivudine (100 mg po, q.d.) therapy. By the end of 78 weeks, a sustained response (SR-6 mo) was seen in 74% (20/27) of the patients within Group 1. On the contrary, Groups 2 and 3 had sustained response rates of 40 (4/10) and 53.3% (8/15), respectively (p = 0.13). At the end of 12 months post-treatment in Group 1, a virological and biochemical response rate was seen in 70.3% of patients (19/27); in contrast, Groups 2 and 3 had response rates of 20 (2/10) and 26.6% (4/15), respectively (p = 0036). At the end of the 18-month post-treatment follow-up period, 71.4% (19/27) of patients in Group 1, 10% of patients in Group 2 (1/10), and 20% of patients in Group 3(3/15) preserved their sustained response (p = 0.0003). Interferon alpha-2b and thymosin-alpha1 combination therapy results in significant virological and biochemical response rates compared with standard therapeutic regimens and is well tolerated.

Gallbladder ejection fraction and symptom outcome in patients with acalculous biliary-like pain.

Patients with acalculous biliary-like pain present a difficult clinical challenge. Our aim was to evaluate the outcome of patients with recurrent biliary-like pain without gallstones who underwent testing of gallbladder ejection fraction (GBEF) by cholecystokinin-cholescintigraphy (CCK-CS) in order to determine clinical factors that may predict symptom resolution. We reviewed the records of patients with recurrent acalculous biliary-like pain who underwent CCK-CS from January 1995 to December 1999. For comparison, we also studied an age- and sex-matched group of patients who underwent cholecystectomy for symptomatic cholelithiasis. Outcome was obtained by telephone interview, using a scale from 0 to 3 where 0 = no improvement and 3 = clinical remission. Patient demographics, predominant symptom(s), method of management, gallbladder pathology, and response to treatment were recorded. One hundred twenty-nine patients underwent CCK-CS. Of 69 with an abnormal GBEF, 48 (70%) were available for interview. Forty patients underwent cholecystectomy. Twenty-seven patients reported symptom resolution after surgery while 4 nonsurgical patients reported the same (P = NS). Univariate analysis revealed no association between symptom outcome and presence of gastrointestinal symptom(s), severity and duration of abdominal pain, management, or gallbladder pathology. In addition, no GBEF cutoff level predicted symptom outcome. Of the remaining 60 patients with a normal GBEF, 30 (50%) were available for interview. Twenty-eight patients in this group were managed medically and 2 patients underwent cholecystectomy. Eighteen patients managed medically were asymptomatic, as were the 2 who underwent cholecystectomy. There was no difference in symptom outcome between patients who had GBEF >35% vs <35%. In conclusion, in a group of patients with recurrent acalculous biliary-like pain who underwent CCK-CS, we found a high rate of symptom resolution following cholecystectomy; however, this was not statistically different from a smaller cohort who did not undergo surgery. We were unable to determine any variable predictive of symptom resolution.

Increased cumulative incidence of prostate malignancies in colorectal cancer patients.

BACKGROUND: Identifying subjects at an increased risk of colorectal cancer (CRC) is of considerable importance in designing effective screening strategies. Malignancies that cosegregate with CRC provide important markers for higher-risk patients. CRC and prostate cancer share many similarities with regard to etiological factors. However, the previous reports on associations between these common malignancies are contradictory and confounded by a lack of rigorous controls. AIM OF THE STUDY: The aim of this study was to further elucidate the relationship between CRC and prostate cancer. METHODS: We performed a retrospective case-control study of subjects receiving medical care at the Omaha Veteran's Administration Medical Center between 1992 and 2002. Cases (patients with CRC) were obtained through the pathology records, whereas controls (patients with a negative colonoscopy during the same time period) were found through assessment of the endoscopy database. All subjects had the pathology database queried for other malignancies. The medical record also was assessed for confounding factors such as prostate cancer screening, radiation therapy status, and so on. RESULTS: We identified 149 male patients with CRC cases and 186 controls (age-matched male patients with a negative colonoscopy). The 10-yr cumulative incidence of prostate cancer was 10.7% of the cases but only 3.8% of the controls (p = 0.016). There were no significant differences between cases and controls among 11 other primary malignancies evaluated. The association between CRC and prostate cancer was unrelated to characteristics such as location in the colon and differentiation. Furthermore, confounding factors including frequency of prostate cancer screening and radiation therapy status did not explain the cosegregation between CRC and prostate. CONCLUSION: This preliminary report suggests that there is an association between CRC and prostate cancer. If replicated in other populations, this may have important implications for cancer screening strategies.

Hepatitis C and alcohol.

Patients infected with the hepatitis C virus (HCV) who drink heavily are likely to suffer more severe liver injury, promoting disease progression to cirrhosis and increasing their risk for liver cancer. Some research, although not conclusive, suggests that even moderate drinking may spur liver damage in HCV-infected patients. Research areas that have the greatest potential for developing more effective treatment options include HCV virology, immunology, animal models, and the mechanisms of liver injury.

The effect of perendoscopic sclerosing agent injection in Forrest's II ulcers -- a pilot study from Turkey.

BACKGROUND: We aimed to clarify the outcome of perendoscopic prophylactic injection of sclerosing agent in Forrest's II ulcers. MATERIAL/METHODS: Patients with upper gastrointestinal bleeding in last 6 hours were performed emergency endoscopy and were enrolled. The patients in group-1 were performed prophylactic injection therapy with 1% aethoxysclerol and then given medical treatment with intravenous 40 mg omeprazole twice a day and somatostatin infusion at the dose of 6 mg/day during 3 days. Group-2 patients were only given medical treatment with same agents and at same doses without having any perendoscopic therapy. RESULTS: There were 32 patients in group-1 and 20 in group-2. In emergency endoscopy, 20 (62.5%) patients had IIa ulcers and 12 (37.5%) patients had IIb ulcers in group-1. These patients underwent prophylactic perendoscopic hemostasis by 1% aethoxysclerol in addition to medical treatment. Early rebleeding occurred in 9 (28.1%) patients of group-1 and 3 (15%) in group-2 (p<0.001). At the endoscopic control after 48 hours 13 (40.6%) patients in the group-1 and 15 (75%) patients in group-2 showed improved local ulcer stigmata (p<0.001). The numbers of blood units transfused were lower in the group-2 (p=0.002). The hospital stay was longer in group-1 (p=0.01). In the group-1, more endoscopic intervention was needed. Any death and the need for surgical intervention did not occurred in any groups. CONCLUSIONS: According to our results; the indication of perendoscopic prophylactic injection of sclerosing agent in non-bleeding ulcers with high risk of rebleeding must be reviewed by large population based, prospective, randomized trials.