Isolated papillary muscle rupture with nonobstructive coronary artery disease, minimal myocardial infarction, and normal wall motion.

Papillary muscle (PM) rupture can usually complicate inferior or posterior myocardial infarctions, but selective PM infarction is extremely rare, and the exact underlying pathophysiological mechanism is not entirely clear. We present a case of PM rupture due to isolated PM infarction in a patient with unobstructed coronary arteries, which could be misdiagnosed as a vegetation or other mass given the absence of regional wall motion abnormalities (RWMAs) on transthoracic echocardiogram. Our case highlights that in patients with severe mitral regurgitation and associated mitral valve mass, the absence of RWMAs should not exclude ischemic PM rupture from differential diagnosis.

Ultrasound-histopathologic features of the utero-placental interface in placenta accreta spectrum.

INTRODUCTION: The objective of this study was to evaluate the relationship between utero-placental vascular changes on ultrasound imaging and histopathologic findings according to the grade of villous invasion in placenta accreta spectrum (PAS). METHODS: The ultrasound features of 31 patients with singleton pregnancies diagnosed prenatally with low-lying/placenta previa accreta were compared with histopathology findings following caesarean hysterectomy (n = 25) or partial myometrial resection (n = 6). The number and degree of transformation of arteries within the superficial layer of myometrium were recorded. Cytokeratin 7 (CK7) immunohistochemistry was used to complement H&E analysis. RESULTS: All 31 patients presented with loss of clear zone, myometrial thinning and placenta lacunae. Subplacental hypervascularity and lacunae feeder vessels were found in 25 and nine cases, respectively. Large recent intervillous thromboses were found in one case with adherent villi and 12 cases with invasive villi, and showed a significantly different distribution according to lacunae scores. Thick basal plate fibrinoid deposits were found in all the areas of abnormally adherent and invasive villous tissue There was no significant difference in the mean count of partially remodeled vessels or vessels completely lacking remodeling according to the lacunae score and grade of placental invasiveness. EVT cells were arranged in superficial confluent sheets or superficial irregular clusters, or were scattered deep below the basal plate. CONCLUSION: Placental ultrasound and histopathologic features associated with PAS are more pronounced in invasive cases suggesting that they are secondary to the haemodynamic effects of abnormally deep placentation and transformation of the radial and arcuate arteries.

A new methodologic approach for clinico-pathologic correlations in invasive placenta previa accreta.

BACKGROUND: The development of new management strategies for women presenting with placenta accreta spectrum requires quality epidemiology data, which have so far been limited by the high variability in clinical and histopathologic data confirming the diagnosis at birth. OBJECTIVE: To evaluate the role of a new methodologic approach for the correlation of clinical and pathological data for women with a history of prior cesarean delivery diagnosed prenatally with placenta previa accreta. MATERIALS AND METHODS: A modified pathologic technique for gross examination of hysterectomy specimens with placenta in situ consisting of intraoperative examination, immediate postoperative examination, and guided histologic sampling was used prospectively in a cohort of 24 patients with singleton pregnancies complicated by placenta low-lying/placenta previa accreta. Maternal characteristics, detailed ultrasound findings, surgical outcomes, and histopathologic examination were compared with those of a group of 24 patients with similar clinical characteristics and in whom a standard pathologic examination method was used. RESULTS: The median reporting time for obtaining the complete histopathology results including the microscopic examination was significantly shorter (7 versus 15 days; P < .001) and the median number of samples taken for histologic examination significantly lower (4 versus 14 samples; P < .001) in the study group than in the controls. The number of histologic slides showing villous invasion was significantly higher (2 versus 1 slide; P = .002), and the ratio of the number of samples taken to the numbers of slides confirming villous invasion was significantly lower (2 versus 9; P < .001) in the study group than in the controls. In all cases in the study group, intraoperative examination identified a dense tangled bed of vessels or multiple vessels running laterally and cranio-caudally in the uterine serosa above the placental insertion that were no longer visible during immediate gross postoperative examination of the hysterectomy specimens. Immediate postoperative dissection enables the differential diagnosis between focal and large increta areas, and between abnormally adherent placenta and invasive placenta accreta. CONCLUSION: Valuable clinical information on the serosal vascularity, uterine dehiscence, and extension of the accreta area is added with the description of the macroscopic examination during the surgical procedure and immediate dissection of the specimen. This methodological approach is cost-effective and increases the quality of the histologic sampling. It thus provides more accurate correlations with the clinical data and more accurate epidemiologic data collection. Perinatal pathologists should be part of multidisciplinary teams involved the management placenta accreta spectrum disorders.

Preoperative liver shrinking diet for bariatric surgery may impact wound healing: a randomized controlled trial.

BACKGROUND: In bariatric surgery, preoperative very low-calorie diets (VLCD) may better meet the technical demands of surgery by shrinking the liver. However, diets may affect tissue healing and influence bowel anastomosis in an as-yet-undefined manner. OBJECTIVE: This randomized controlled trial aimed to examine the effect on collagen deposition in wounds in patients on a 4-week VLCD before laparoscopic gastric bypass. SETTING: University hospital. METHODS: The trial was undertaken in patients undergoing laparoscopic Roux-en-Y gastric bypass, with a control group (n = 10) on normal diet and an intervention group (n = 10) on VLCD (800 kcal) for 4 weeks. The primary outcome measured was expression of collagen I and III in skin wounds, with biopsies taken before and after the diet and 7 days postoperatively as a surrogate of anastomotic healing. Secondary outcome measures included liver volume and fibrosis score, body composition, operating time, blood loss, hospital stay, and complications. RESULTS: Patients in both groups were similar in age, sex, body mass index (53.4 versus 52.8 kg/m2), co-morbidities, liver volume, and body composition. Expression of mature collagen type I was significantly decreased in diet patients compared with controls after 4 weeks of diet and 7 days after surgery. This was significant decrease in liver volume (23% versus 2%, P = .03) but no difference in operating times (129 versus 139 min, P = .16), blood loss, length of stay, or incidence of complications. CONCLUSIONS: Preoperative diets shrink liver volume and decrease expression of mature collagen in wounds after surgery. Whether the latter has a detrimental effect on clinical outcomes requires further evaluation.

Interobserver agreement on standardized ultrasound and histopathologic signs for the prenatal diagnosis of placenta accreta spectrum disorders.

OBJECTIVE: To evaluate interobserver agreement in assessment of ultrasound signs and histopathologic findings associated with placenta accreta spectrum (PAS) disorders. METHODS: A retrospective study was conducted using data for patients prenatally diagnosed with PAS disorders at a UK hospital between January 31, 2012, and March 30, 2017. Ultrasound images (including gray-scale and color Doppler imaging [CDI] parameters) and histopathologic slides were reviewed by two observers; the level of agreement was calculated. RESULTS: Among 25 patients, 11 had placenta creta, 10 had placenta increta, and four had placenta percreta. Interobserver agreement for ultrasound imaging in the second and third trimesters and histopathologic diagnosis of PAS was rated as good-to-excellent. The highest level of interobserver agreement for ultrasound signs was found for loss of clear zone (100%) and substantial myometrial thinning (96%-100%) on gray-scale imaging, the presence of lacunar feeder vessels (100%) on two-dimensional CDI, and crossing vessels and lacunae (92%-95%) on three-dimensional CDI. CONCLUSION: Standardized ultrasound signs might prove useful for prenatal screening of women at risk of PAS disorders and should enable remote evaluation of images when PAS is suspected.

Contrasting Pattern of Chronic Inflammatory Bowel Disease in Primary and Autoimmune Sclerosing Cholangitis.

BACKGROUND: Primary sclerosing cholangitis (PSC) and autoimmune sclerosing cholangitis (AISC) are related, but distinct chronic liver diseases. PSC is associated with a high prevalence of ulcerative colitis while the intestinal inflammation associated with AISC is less well characterised. AIMS: To assess and contrast aspects of intestinal inflammation in patients with AISC and PSC and compare the clinical features with those of patients with ulcerative colitis and Crohn's disease. METHODS: 23 and 22 patients with AISC and PSC, respectively, underwent review of colonoscopy and biopsy findings, capsule enteroscopy and assessment of clinical and inflammatory (faecal calprotectin) disease activity, which was compared with that of patients with ulcerative colitis and Crohn's disease (n = 55 each). FINDINGS: Five and 6 patients with AISC and PSC, respectively, had normal colonoscopy and faecal calprotectin levels of 34.4 ± 8.3 and 39.7 ± 8.4 µg/g, respectively (normal < 50 µg/g), whereas 18 and 16, respectively, had identical variably severe, right sided colitis with frequent rectal sparing, consistent with ulcerative colitis. Mean (± SD) faecal calprotectin levels did not differ significantly (p > 0.05) between patients with intestinal inflammation in AISC (588 ± 549 µg/g), PSC (421 ± 351 µg/g), ulcerative colitis (501 ± 656 µg/g) or Crohn's disease (476 ± 571 µg/g). Capsule enteroscopy showed that 7 of 18 (39%) (p < 0.03) of those with AISC had small bowel mucosal breaks whereas no patient with PSC had these findings. INTERPRETATION: Collectively these findings lend support to the suggestion that the chronic inflammatory bowel disease associated with PSC and in particular AISC may represent a distinct nosologic entity different from classic ulcerative colitis and Crohn's disease.

An uncommon cause of life-threatening gastrointestinal bleeding: 2 synchronous Dieulafoy lesions.

Dieulafoy lesions are a rather uncommon cause of gastrointestinal bleeding that can be torrential and life-threatening. Extragastric location and pediatric cases are very rare. We report the first case of synchronous Dieulafoy lesions in the stomach and jejunum. This case is discussed in the light of the reported literature on this condition.

Strategy to reduce the risk of positive pancreatic resection margin at pancreatico-duodenectomy.

BACKGROUND: The accuracy of histological assessment of frozen section (FS) of the pancreatic resection margin (PRM) at pancreatico-duodenectomy can be improved by concurrent FS examination of a sample of the suspected pancreatic lesion. METHODS: A prospective trial was conducted using archived material. FS of all the PRM and suspected pancreatic lesion of 12 patients randomly selected from a historical group who underwent pancreatico-duodenectomy for suspected malignancy were examined by five histopathologists. They were asked to examine the PRM alone and alongside the suspected lesion. The diagnosis of the PRM was 'benign', 'malignant' or 'defer to paraffin section'. All the histopathologists were blinded to the paraffin section diagnosis. RESULTS: The main outcome measures were sensitivity, specificity and the incidence of deferring to paraffin section. In this respect examination of the PRM alone had a sensitivity of 70% and a specificity of 87.5%. Concurrent FS examination of PRM with the pancreatic lesion increased the sensitivity to 90% and the specificity to 92.5%. The incidence of deferring to paraffin section was reduced from 17 to 7% (P = 0.03). CONCLUSION: This policy is recommended because it improves the diagnostic accuracy of FS evaluation of the PRM resulting in a reduction of residual pancreatic cancer at the pancreatic transection line.

Role of rapid urease test and histopathology in the diagnosis of Helicobacter pylori infection in a developing country.

BACKGROUND: The aim of this study was to determine the effect of commonly self-prescribed proton pump inhibitors (PPI) on the results of rapid urease test and histology for the diagnosis of H. pylori infection. METHODS: One hundred-nine consecutive patients with dyspeptic symptoms attending the endoscopy suite were enrolled in this study. Antrum biopsy specimens were collected at endoscopy for the rapid urease test (Pronto Dry, Medical Instrument Corp, France) and histopathology. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and like-hood ratio of a positive and negative of Pronto Dry test were compared against histology. The gold standard test for the diagnosis of H. pylori infection was histopathology. RESULTS: Sixty-one percent (66/109) patients were males with mean age of 43 +/- 14.1 years and age range 17-80 years. Fifty-two percent (57/109) were not on any medications while 48% (52/109) used PPI before presentation to the outpatients. Pronto Dry was positive in 40% (44/109) and negative in 60% (65/109). Histopathology was positive for H. pylori in 57% (62/109) and negative in 43% (47/109). The sensitivity, specificity, PPV, NPV and like-hood ratio of a positive and negative Pronto Dry test with and without PPI were 43.3%, 86.4%, 81.3%, 3.18, 0.656 and 52.8% vs 71.9%, 80%, 82.1%, 69%, 3.59 and 0.35. CONCLUSION: This study shows that the sensitivity, specificity, NPV and PPV of rapid urease test was reduced in patients who are on PPI. The exclusive use of the rapid urease test for the diagnosis of Helicobacter pylori cannot be recommended in patients with prior PPI use.

Prevalence of non-Helicobacter pylori duodenal ulcer in Karachi, Pakistan.

AIM: To determine the prevalence of non-Helicobacter pylori (H pylori)-related duodenal ulcer in patients with acid-peptic diseases. METHODS: Medical records of patients who attended the Gastroenterology Department at Aga Khan University Hospital from 1999 to 2001 and had endoscopic diagnosis of duodenal ulcers were reviewed. Duodenal ulcer associated with H pylori was diagnosed on the basis of endoscopy, rapid urease test and histopathology whereas histories of aspirin or other non-steroidal anti-inflammatory drugs (NSAIDs) related duodenal ulcers. Non-H pylori, non-NSAID duodenal ulcers were those without H pylori infection and history of NSAID intake. Co-morbid conditions associated were noted. RESULTS: Of 2 260 patients, 10% (217/2 260) had duodenal ulcer. Duodenal ulcer related to H pylori infection accounted for 53% (116/217), NSAID-related 10% (22/217), non-H pylori non-NSAID 29% (62/217), and 8% (17/217) had both H pylori infection and histories of NSAID intake. Fifteen percent (18/116) patients had past histories of peptic ulcer disease in H pylori infection, while 8% (5/62) in non-H pylori non-NSAID ulcer. Co-morbid conditions in H pylori infection were seen in 23% (27/116) and 34% (21/62) in non-H pylori non-NSAID ulcer. CONCLUSION: Incidence of H pylori infection related with duodenal ulcer is common. In the presence of co-morbids, non-H pylori and non-NSAID duodenal ulcer is likely to be present.

Giardiasis in patients with dyspeptic symptoms.

AIM: To investigate the prevalence of giardiasis in patients with dyspeptic symptoms. METHODS: Clinical records of consecutive patients who attended Gastroenterology Department at Aga Khan University Hospital from January 2000 to June 2003 and had esophagogastroduodenoscopy (EGD) with duodenal biopsies and international classification of diseases 9th revision with clinical modifications (ICD-9-CM) coded with giardiasis were studied. RESULTS: Two hundred and twenty patients fulfilled the above criteria. There were 44% (96/220) patients who were giardiasis positive, 72% (69/96) of them were males and 28% (27/96) of them were females. There were 65% (81/124) males and 35% (43/124) females who were giardiasis negative. The mean age of patients with giardiasis was 28+/-17 years, while that of giardiasis negative patients was 40+/-18 years (P<0.001). In patients with giardiasis, abdominal pain was present in 71% (68/96) of patients (P = 0.02) and diarrhea in 29% (28/96) (P = 0.005); duodenitis in 25% (24/96) on EGD (P = 0.006) and in 68% (65/96) on histopathology (P = 0.002). CONCLUSION: Giardiasis occurs significantly in young people with abdominal pain, while endoscopic duodenitis is seen in only 25% of giardiasis positive cases, which supports routine duodenal biopsy.