Inflammatory colitis associated with Teriflunomide.

Teriflunomide is an oral disease modifying therapy for relapsing-remitting multiple sclerosis (RRMS). Gastrointestinal (GI) side effects occurred in 15-17.9% of patients in the clinical trials and usually were mild and self-limiting. Few cases of inflammatory colitis related to teriflunomide and leflunomide, a prodrug which converts to teriflunomide and is used in the treatment of rheumatoid arthritis, have been reported but no clinical data is available except for a single case of lymphocytic colitis. We here report a 49-year-old man with RRMS who developed severe diarrhea and weight loss six months after starting teriflunomide and eventually was found to have multiple ulcers and inflammatory changes consistent with Crohn's disease. After stopping teriflunomide and chelation therapy, he was started on immunotherapy for Crohn's given the highly inflammatory degree of GI symptoms and histology findings.

Utility of serum CA19-9 levels in the diagnosis of pancreatic ductal adenocarcinoma in an endoscopic ultrasound referral population.

PURPOSE: Recent data suggest the use of carbohydrate antigen (CA) 19-9 as a potential marker in the early detection of pancreatic ductal adenocarcinoma (PDAC) when used in the appropriate clinical setting. Here, we assess the utility of CA19-9 in PDAC detection in a select population of pancreatic endoscopic ultrasound (EUS) referrals. METHODS: Retrospective review of an institutional EUS Pancreas Registry containing cases referred from November 2002 to November 2011 was completed for categorical analyses with CA19-9 level. A separate case-control study for the subset of non-elevated CA19-9 PDAC population was also performed to characterize the clinical features in this unique group of patients. RESULTS: Two hundred eighty-three patients had available CA19-9 data in the registry and were included in the study. Compared to the typical PDAC distribution, the proportion of patients with stage I disease was significantly higher in our registry population (P < 0.0001). Elevated CA19-9 levels most often reflected a diagnosis of PDAC relative to other pancreaticobiliary diagnoses. However, we observed that 15 % of patients with PDAC had normal CA19-9 levels. Clinical characteristics for this false-negative PDAC group compared to the true-positive group demonstrated a predilection for detection of cancer in the body/tail of the pancreas (P = 0.03), increased likelihood of lymph node metastases (P = 0.03), and initial presentation with vague abdominal pain or pancreatic mass as an incidental finding on imaging studies (P = 0.01). CONCLUSIONS: Elevated CA19-9 demonstrated a greater likelihood of PDAC diagnosis relative to benign pancreatic pathology, and higher levels of CA19-9 were in line with worse PDAC stage. Patients with normal CA19-9 PDAC may represent a unique subclass of patients, presenting with atypical clinical features, and possibly more advanced stage disease at the time of diagnosis. These patients may benefit from more diligent EUS examination or perhaps closer follow-up management.

First Case of Small Bowel Sarcomatoid Carcinoma Found by Video Capsule Endoscopy.

Sarcomatoid carcinoma of the small bowel is extremely rare. We report the first case of sarcomatoid carcinoma identified by video capsule endoscopy in a patient referred for obscure gastrointestinal bleeding. Computed tomography and small bowel follow through failed to identify the tumor. The tumor was visualized initially on video capsule endoscopy examination and a 6 x 3 cm polypoid, fungating mass with irregular borders was retrieved on surgical resection. Microscopic examination showed sheets of pleomorphic spindled to epitheliod cells staining positive for cytokeritin and vimentin, indicative of sarcomatoid carcinoma. Forty-one months after surgical resection the patient continued to be free of metastatic disease.

Improved diagnostic yield with severity of bleeding.

OBJECTIVE: Video capsule endoscopy (VCE) is an important tool for non-invasive imaging of the small bowel. Whether there is a dose-related effect of anemia severity on the diagnostic yield of VCE is unknown. The aim of this study was to determine the influence of anemia severity on VCE outcome measures. METHODS: VCE studies from the Sacramento Veterans Affairs Medical Center for 300 consecutive patients were retrospectively screened. Those with anemia were selected. Patients were grouped as mildly, moderately or severely bleeding. Outcomes data including completion of study, diagnostic yield and further intervention were compared. RESULTS: Of the 300 patients, 210 (70%) were found to have anemia. Overall 32 (15.24%) patients were mildly, 145 (69.05%) were moderately and 33 (15.71%) were severely bleeding. The diagnostic yield was significantly higher in severe (72.73%) relative to moderate (32.41%) and mild bleeding (12.50%); P = 0.0001. Significantly more angioectasias were detected in severely bleeding patients (42.42%) than in those bleeding moderately (14.48%) and mildly (0.00%), P = 0.0001. The ability of VCE to guide further intervention was significantly higher in patients bleeding severely (69.70%, P = 0.006). CONCLUSIONS: Our data showed a significant increase in diagnostic yield with the increasing degree of anemia. Relative difference in hemoglobin rather than absolute values may be a better predictor. The ability of VCE to guide further intervention reached significance in severely bleeding patients. The hypothesis that use of VCE prior to esophagogastroduodenoscopy or colonoscopy in the severely bleeding group deserves to be evaluated.

Retrospective analysis showing the water method increased adenoma detection rate - a hypothesis generating observation.

BACKGROUND: A water method developed to attenuate discomfort during colonoscopy enhanced cecal intubation in unsedated patients. Serendipitously a numerically increased adenoma detection rate (ADR) was noted. OBJECTIVE: To explore databases of sedated patients examined by the air and water methods to identify hypothesis-generating findings. DESIGN: Retrospective analysis. SETTING: VA endoscopy center. PATIENTS: creening colonoscopy. INTERVENTIONS: From 1/2000-6/2006 the air method was used - judicious air insufflation to permit visualization of the lumen to aid colonoscope insertion and water spray for washing mucosal surfaces. From 6/2006-11/2009 the water method was adopted - warm water infusion in lieu of air insufflation and suction removal of residual air to aid colonoscope insertion. During colonoscope withdrawal adequate air was insufflated to distend the colonic lumen for inspection, biopsy and polypectomy in a similar fashion in both periods. Main outcome measurements: ADR. RESULTS: The air (n=683) vs. water (n=495) method comparisons revealed significant differences in overall ADR 26.8% (183 of 683) vs. 34.9% (173 of 495) and ADR of adenomas >9 mm, 7.2% vs. 13.7%, respectively (both P<0.05, Fisher's exact test). LIMITATIONS: Non-randomized data susceptible to bias by unmeasured parameters unrelated to the methods. CONCLUSION: Confirmation of the serendipitous observation of an impact of the water method on ADR provides impetus to call for randomized controlled trials to test hypotheses related to the water method as an approach to improving adenoma detection. Because of recent concerns over missed lesions during colonoscopy, the provocative hypothesis-generating observations warrant presentation.

Incomplete capsule endoscopy examinations after Roux-en-Y gastric bypass.

BACKGROUND: Video capsule endoscopy is an important tool for minimally invasive evaluation of the small bowel. Optimization of this imaging modality has focused on minimizing the rate of incomplete studies through appropriate patient selection. Recent data have shown an increased incidence of incomplete examinations in those with surgically altered gastrointestinal anatomy. METHODS: We present 4 consecutive cases of post Roux-en-Y gastric bypass patients undergoing video capsule endoscopy. RESULTS: Three patients were referred for obscure gastrointestinal bleeding and one for diagnosis of Crohn's disease; all 4 patients had incomplete studies. One patient experienced capsule retention in the gastric pouch. Two patients had repeated poor small bowel preparation despite compliance with preparatory methods. The fourth patient experienced delayed gastrointestinal transit despite satisfactory small bowel preparation. CONCLUSION: Patients with a history of Roux-en-Y surgery appear to be at increased risk for incomplete examination due to capsule retention and delayed gastric transit. Endoscopists may consider additional precursory testing or the use of alternative imaging methods in this population.

Lemierre syndrome: a pediatric case series and review of literature.

BACKGROUND: Lemierre syndrome is a rare disease of the head and neck often affecting adolescents and young adults. Classically, infection begins in the oropharynx with thrombosis of the tonsillar veins followed by involvement of the parapharyngeal space and the internal jugular vein. Septicemia and pulmonary lesions develop as infection spreads via septic emboli. Although a rare entity in modern times, Lemierre syndrome remains a disease of considerable morbidity and potential mortality. METHODS: This was a retrospective review of 3 cases and associated literature. RESULTS: A common 1- to 2-week history of fever, sore throat, neck pain, and fatigue was observed in all patients. Patient 1 developed right facial swelling, neck tenderness, trismus, and tonsillar exudate. Patient 2 displayed right tonsillar erythema and enlargement with right neck tenderness. Patient 3 revealed bilateral tonsillar enlargement with exudate and left neck tenderness. Subsequent studies included blood cultures and computed tomography, after which empiric antibiotic therapy was started. Patient 1 underwent drainage of a right peritonsillar abscess, right pressure equalization tube placement, and ligation of the right external jugular vein. He subsequently developed subdural empyemas, cavernous sinus thrombosis, and carotid artery narrowing and required 9 weeks of antibiotic therapy. Patients 2 and 3 developed pulmonary lesions and received 6 weeks of antibiotic therapy. Timing was crucial in all cases. CONCLUSIONS: Lemierre syndrome is a rare but severe opportunistic infection with poor prognostic outcomes if left untreated. Early diagnosis and treatment is essential. Aggressive antibiotic therapy coupled with surgical intervention, when necessary, provides excellent outcomes.

Recent experience with abdominal perineal resection with vertical rectus abdominis myocutaneous flap reconstruction after preoperative pelvic radiation.

Abdominoperineal resection (APR) after pelvic radiation can be complicated by an increased rate of difficult to treat perineal wound complications. In an effort to improve postoperative morbidity after APR, myocutaneous flap reconstructions have been used. We review our recent experience with APR with vertical rectus abdominis myocutaneous flap reconstruction (VRAM) after preoperative pelvic radiation. A retrospective review of patients who underwent APR with VRAM reconstruction after pelvic radiation from December 2004 to July 2008 was conducted. Outcome measures included demographics, comorbidities, length of stay, wound complications, and morbidity and mortality. Fifteen patients with a mean age of 61 +/- 9 years underwent APR with VRAM reconstruction. Five patients also required posterior vaginectomy with the APR. Indications for APR were rectal cancer (n = 14, 93%) and anal canal cancer (n = 1, 7%). There were no intraoperative complications. Mean estimated blood loss was 635 +/- 446 mL and mean intraoperative blood transfusion requirements were 1 +/- 2 units. Mean length of hospital stay was 11 +/- 4 days. Six (40%) patients had minor perineal wound complications. One (7%) patient had a perineal wound infection requiring reoperation with washout and reapproximation. There was no 30-day or in-hospital mortality. All VRAM flaps remained viable through follow-up. APR with VRAM flap reconstruction after preoperative pelvic radiation can be performed safely with limited wound complications and no mortality.

Acute small bowel perforation after wireless capsule endoscopy in a patient with Crohn's disease: a case report.

INTRODUCTION: Wireless capsule endoscopy is an important tool for minimally invasive evaluation of the small bowel, allowing improved diagnostic yield with low complication rates relative to traditional modalities. Recently however, reports on small bowel perforation after wireless capsule endoscopy have surfaced. Here we present the first case of acute small bowel perforation in a middle-aged male in the United States. CASE PRESENTATION: A 58-year-old male with a presumed quiescent history of Crohn's Disease presented to the Emergency Department in a septic state 48 hours after a wireless capsule endoscopy procedure complaining of abdominal pain, distension, and frequent emesis. A computed tomography scan of the abdomen was suggestive of small bowel perforation and ischemic enteritis. The patient was adequately resuscitated and taken to the operating room for an ileocecectomy and extensive resection of the small bowel. Pathology of the resected specimen revealed an ileal stricture and associated necrotizing ileitis, and a perforation just proximal to the stricture. CONCLUSION: Wireless capsule endoscopy remains the preferred endoscopic imaging method of the small bowel. This case illustrates the importance of appropriate patient selection and evaluation of functional patency of the small bowel prior to wireless capsule endoscopy, especially with the growing role of this procedure in the evaluation of inflammatory bowel disease.

National trends in use and outcome of laparoscopic adjustable gastric banding.

BACKGROUND: Laparoscopic adjustable gastric banding is gaining popularity in the United States. Our objective was to examine the use and outcomes of laparoscopic adjustable gastric banding at academic medical centers. METHODS: Using the "International Classification of Diseases, Ninth Revision" diagnosis and procedure codes, data were obtained from the University Health System Consortium Clinical Database for all laparoscopic adjustable gastric banding and gastric bypass procedures performed from 2004 to 2007. Quartile trends in the use of all procedures were determined, and a comparison of in-hospital morbidity and mortality between laparoscopic adjustable gastric banding and laparoscopic gastric bypass was performed. RESULTS: A total of 31,333 bariatric surgery procedures were performed from 2004 to 2007. During this period, the use of laparoscopic adjustable gastric banding and gastric bypass procedures increased from 7% to 23% and 53% to 66%, respectively. A concurrent decrease occurred in the use of open gastric bypass procedures from 40% to 11%. Compared with laparoscopic gastric bypass, laparoscopic adjustable gastric banding was associated with a significantly shorter length of stay (1.3 versus 2.7 d, P<.01), lower morbidity (2.8% versus 7.5%, P<.01), lower 30-day readmission rate (.7% versus 2.5%, P<.01), lower in-hospital mortality (.02% versus .08%, P<.01), and lower hospital cost ($8689 versus 14,386, P<.01). CONCLUSION: From 2004 to 2007, significant growth occurred in the number of laparoscopic adjustable gastric banding (+329%) and laparoscopic gastric bypass (+125%) procedures, with a precipitous decrease in the number of open gastric bypass (-73%) procedures. The increasing popularity of the laparoscopic adjustable gastric band procedure could in part be related to the lower cost and lower morbidity compared with laparoscopic gastric bypass.

Keloid banding using suture ligature: a novel technique and review of literature.

INTRODUCTION: Successful wound healing represents the coordinated response of cellular, cytokine, and growth factor mechanisms involved in tissue recovery. Disruptions in transforming growth factor-beta signaling, senescence/apoptosis, keratinocyte-fibroblast interactions, and other regulatory cascades can lead to the production of hypertrophic scar or keloid tissue formation. Current clinical investigations support surgical excision, meticulous closure, postoperative steroid injections, and postprocedural pressure dressings in the treatment of keloid tissue formation. Unfortunately, a universal approach in keloid therapy has yet to be identified. Here we offer a novel banding technique using suture ligature for the removal of these tissues. METHODS: Using a suture ligature, keloid tissues were banded along their base for a 5-week period. Tissue evaluation and additional suture banding was performed on a weekly basis until complete mummification and spontaneous removal of ligated tissues. No additional pressure dressings were placed after tissue removal as treated sites had essentially undergone pressure therapy from the banding treatment. RESULTS: Keloid tissues from multiple sites of the head and neck were effectively removed without complication using the suture banding technique. During a follow-up period of 12 months, no evidence of keloid tissue recurrence was observed. CONCLUSION: Keloid tissue formation remains a formidable challenge for the patient and physician alike. The application of a simple tissue banding technique holds promise in the direct and preventative treatment of keloid tissue formation whereas the end results merit further clinical and laboratory investigation.

Regulation of flowering time in Arabidopsis by K homology domain proteins.

The transition from vegetative growth to reproductive development in Arabidopsis is regulated by multiple floral induction pathways, including the photoperiodic, the autonomous, the vernalization, and the hormonal pathways. These pathways converge to regulate the expression of a small set of genes critical for floral initiation and different signal transduction pathways can interact to govern the time to flower. One important regulator of floral initiation is the MADS-box transcription factor FLC, which acts as a negative regulator of flowering in response to both endogenous and environmental signals. In this report, we describe a study of the flowering-time gene, FLK [flowering locus K homology (KH) domain] that encodes a putative RNA-binding protein with three KH domains. The flk mutations cause delayed flowering without a significant effect on the photoperiodic or vernalization responses. FLK functions primarily as a repressor of FLC expression, although it also modestly affects expression of genes associated with the photoperiodic pathway. In addition to FLK, the expression of two other KH domain genes are modestly affected by the flk mutation, suggesting a possible involvement of more than one KH domain protein in the regulation of flowering time in Arabidopsis.

Regulation of photoperiodic flowering by Arabidopsis photoreceptors.

Photoperiodism is a day-length-dependent seasonal change of physiological or developmental activities that is widely found in plants and animals. Photoperiodic flowering in plants is regulated by photosensory receptors including the red/far-red light-receptor phytochromes and the blue/UV-A light-receptor cryptochromes. However, the molecular mechanisms underlying the specific roles of individual photoreceptors have remained poorly understood. Here, we report a study of the day-length-dependent response of cryptochrome 2 (cry2) and phytochrome A (phyA) and their role as day-length sensors in Arabidopsis. The protein abundance of cry2 and phyA showed a diurnal rhythm in plants grown in short-day but not in plants grown in long-day. The short-day-specific diurnal rhythm of cry2 is determined primarily by blue light-dependent cry2 turnover. Consistent with a proposition that cry2 and phyA are the major day-length sensors in Arabidopsis, we show that phyA mediates far-red light promotion of flowering with modes of action similar to that of cry2. Based on these results and a finding that the photoperiodic responsiveness of plants depends on light quality, a model is proposed to explain how individual phytochromes and cryptochromes work together to confer photoperiodic responsiveness in Arabidopsis.