Antral Wall Research Articles

S2230 Atypical Endoscopic Appearance of Duodenal Mucosa in Whipple’s Disease: An Incidental Finding in an African American Patient

Introduction: Whipple’s disease (WD) is an extremely rare disorder of European white males with an annual incidence reported as less than one case per million. It is a chronic infectious multisystem disorder caused by the bacterium Tropheryma whipplei. Esophagogastroduodenoscopy (EGD) is the gold standard for diagnosis which typically reveals alternating yellow shaggy and eroded erythematous small bowel mucosa. We report a biopsy-proven case of WD in an African American male with atypical endoscopic appearance of the duodenum revealing diffusely dispersed prominent white spots, swollen folds and mucosal nodularity. Case Description/Methods: A 45-year-old male presented with a 6-month history of watery diarrhea, anorexia, unintentional weight loss and exertional dyspnea. He had a history of seizures, recurrent pleural effusion of unknown etiology, vitamin D deficiency and iron deficiency anemia. Physical exam was remarkable for an underweight patient with pale conjunctivae, mild diffuse abdominal tenderness and decreased right sided breath sounds. Vital signs were stable. Patient was in no acute distress. Labs include Hb 10 mg/dL, albumin 2.1 g/dL, vitamin D 13.6 ng/mL, zinc 44 mcg/dL, ESR 45 mm and CRP 107 mg/dL. Stool was negative for ova/parasite, bacterial culture, C.difficile and AFB. Workup for celiac disease and neuroendocrine tumors also reported negative. CT imaging revealed gastric antral wall thickening, abdominal/pelvic ascites and right pleural effusion. Given these non-specific findings, malignancy workup was warranted. EGD revealed an unusual gross appearance of the second portion of duodenum with diffusely dispersed prominent white spots, swollen folds and mucosal nodularity (Fig. 1-a). Biopsy was consistent with WD (Fig. 1-b,c). Colonic and pleural biopsies were negative for malignancy. The patient showed significant clinical response to induction therapy with ceftriaxone followed by maintenance phase with TMP-SMX. Follow up is scheduled to assess endoscopic response to antibiotic therapy. Discussion: WD is a challenging diagnosis due to a constellation of symptoms that mimic other disorders. Whitish discoloration with mucosal nodularity is a rare but more specific endoscopic finding for WD, as reported in our case. Biopsy is required to confirm the diagnosis. This case is reported to draw gastroenterologists’ attention towards atypical endoscopic findings of WD. Early recognition of this debilitating and potentially fatal illness is the key before commencement of prolonged antibiotic therapy.Figure 1.: A. CT Chest with Pneumomediastinum B. Upper Endoscopy With Erythematous Posterior Oropharynx and an Extrinsic, Longitudinal Bulge in the Proximal Esophagus C. Intraoperative Photograph During Thoracotomy.

Detection of TNF-α as a cofactor in the pathogenesis of nasal polypi

Objectives To detect the site of attachment of the antral part of the polyp and the prevalence of coexisting sinonasal anatomical variations in the antrochoanal polyp (ACP) side. Patients and methods A retrospective study of 57 patients treated for ACP was conducted between 2018 and 2020 in the Department of Otolaryngology of Kasr Alainy Hospital, Cairo University. All patients underwent a complete history, head and neck examination, nasal endoscopy, and computed tomography. Factors, including age, gender, associated symptoms, imaging findings, surgical approach, and the site of attachment of the antral part of the polyp, were recorded. Results This study included a total of 57 patients (33 males and 24 females). The mean age of the patient was 22±12.9 (range, 9–59) years. Mean age was 21.8 years for males and 23.6 for females. The major symptoms seen were constant and unilateral nasal obstruction in 34 (59.6%) patients. The exact origins of the polyps were located in different positions within the maxillary sinus and were able to be detected in 39 sides. It was detected in the anteroinferior antral wall on 16 sides, in the inferior antral wall on six sides, in the medial antral wall on six sides, in the lateral antral wall on six sides, and in the posterior antral wall on five sides. Conclusion Endoscopic approach for complete removal of the choanal polyps is an extremely safe and effective procedure. Despite the different approaches of ACP excision, the recurrence rates are still high. Keywords: antrochoanal polyp, computed tomography, endoscopic, recurrence.

Distribution and morphology of P2X3-immunoreactive subserosal afferent nerve endings in the rat gastric antrum.

The present study investigated the morphological characteristics of subserosal afferent nerve endings with immunoreactivity for the P2X3 purinoceptor (P2X3) in the rat stomach by immunohistochemistry of whole-mount preparations using confocal scanning laser microscopy. P2X3 immunoreactivity was observed in subserosal nerve endings proximal and lateral to the gastric sling muscles in the distal antrum of the lesser curvature. Parent axons ramified into several lamellar processes to form net-like complex structures that extended two-dimensionally in every direction on the surface of the longitudinal smooth muscle layer. The axon terminals in the periphery of P2X3-immunoreactive net-like structures were flat and looped or leaf-like in shape. Some net-like lamellar structures and their axon terminals with P2X3 immunoreactivity were also immunoreactive for P2X2. P2X3-immunoreactive nerve fibers forming net-like terminal structures were closely surrounded by S100B-immunoreactive terminal Schwann cells, whereas axon terminals twined around these cells and extended club-, knob-, or thread-like protrusions in the surrounding tissues. Furthermore, a retrograde tracing method using fast blue dye indicated that most of these nerve endings originated from the nodose ganglia of the vagus nerve. These results suggest that P2X3-immunoreactive subserosal nerve endings have morphological characteristics of mechanoreceptors and contribute to sensation of a mechanical deformation of the distal antral wall associated with antral peristalsis.

S2942 Rare Case of Primary Gastric Small Cell Carcinoma in a Renal Transplant Recipient

INTRODUCTION: Small cell carcinoma is a rapidly progressive, poorly differentiated neuroendocrine cancer that most often originates in the lungs; however, an estimated 2.5-5% of cases originate elsewhere. Extrapulmonary small cell carcinoma (ESCC) arising from the stomach is rare. Cases occurring in renal transplant recipients are even more uncommon. Here we present a case of metastatic ESCC from a gastric primary in a renal transplant recipient. CASE DESCRIPTION/METHODS: A 52-year-old Vietnamese male presented with 1 week of epigastric pain. He had a history two renal transplantations requiring multiple thymoglobulin inductions and long-term immunosuppression. Vital signs were normal. Physical exam revealed hepatomegaly. Labs were significant for Hgb 10.0 g/dL, ALP 155 U/L, AST 71 U/L, ALT 21 U/L. CT scan of the abdomen revealed hepatomegaly, innumerable hepatic masses up to 9 cm in diameter, retroperitoneal and portal lymphadenopathy and splenic and portal varices. MRI of the abdomen revealed suspicious circumferential gastric antral wall thickening up to 2.4 cm with adjacent nodularity (Figure A). Liver core biopsy was diagnostic for metastatic small cell carcinoma. Subsequent EGD revealed a large circumferential, infiltrative, fungating and ulcerated mass in the gastric antrum (Figure B) with biopsy confirming the diagnosis of primary gastric small cell carcinoma (GSCC). The patient completed 4 cycles of palliative chemotherapy and transitioned to hospice due to lack of significant response and severe neutropenic complications. DISCUSSION: Primary GSCC are rare, representing 0.1% of extrapulmonary small cell cancers and < 0.1% of all gastric cancers. These often present with early, widespread metastasis with a 5-year survival rate of 13-20%. An increased risk of de novo cancer and gastric cancers in renal transplant recipients has been well-described, however the overwhelming majority presenting as gastric adenocarcinomas. Extrapulmonary small cell carcinomas in renal transplant patients are also rare with most cases arising from genitourinary primaries, often from the donor kidney. There are reported cases of gastrointestinal primaries from the rectum, appendix, and duodenum. To our knowledge, this represents the first reported case of metastatic GSCC in a renal transplant patient that sheds a light on the association between immunosuppression and cancer risk. The absence of well-established epidemiological data, prognostic factors and treatment guidelines necessitates reporting these rare GSCC cases.Figure 1.: Hepatic masses with 2.4cm circumferential gastric antral wall thickening (red arrow).Figure 2.: Gastric antral mass.

S2662 An Unexpected Cause of Refractory Liver Abscesses

INTRODUCTION: We report a case of multifocal liver abscesses with recurrent fevers refractory to prolonged antibiotic therapy and catheter drainage due to penetration of a toothpick into the portal vein. CASE DESCRIPTION/METHODS: A 72-year-old male with type II diabetes presented with fever, confusion, and right upper quadrant pain associated with malaise and unintentional weight loss. Objective findings were consistent with septic shock and acute liver injury. Computed tomography (CT) and Magnetic Resonance Imaging (MRI) showed a 6.9 × 8.0 × 5. hepatic abscess and several scattered fluid collections (Figure 1). Immediate broad-spectrum antibiotics and percutaneous catheter drainage resulted in clinical improvement. Abscess fluid and blood cultures grew actinomyces odontolyticus and streptococcus viridans, respectively. Amebic serology was negative. Transition to appropriate outpatient antibiotics resulted in two readmissions for recurrent fevers with persistent drainage output for weeks. A repeat CT showed a shrunken abscess and a 4.6 cm radio-opaque linear foreign body penetrating through the gastric antrum into a branch of the left portal vein (Figure 2). Review of previous imaging confirmed the foreign body was present since first admission. Upper endoscopy showed a patch of erythematous mucosa in the antrum encircling a pinpoint opening to a fistulous tract and exuding purulent fluid (Figure 3). Exploratory laparotomy revealed a 4.5 cm wooden toothpick in the portal vein surrounded by a dense fibrotic scar. Foreign body removal and porto-enteric fistula repair were performed. Follow up CT showed complete resolution of the abscess. DISCUSSION: Penetrating foreign body is a rare cause of liver abscess. To our knowledge, penetration of a foreign body into the portal vein resulting in liver abscesses has never been reported. Discovery of foreign body requires a high index of suspicion as patients rarely remember ingesting the object, and it can be easily missed on CT. When suspected, a non-contrast CT is recommended with attention to coronal/sagittal views with signs such as thickened antral wall and fistulous tract. Non-specific clinical features such as hematemesis, subacute/chronic abdominal pain, and failure of antibiotic therapy can be suggestive. In the setting of any of these findings, foreign body should be considered in patients with unexplained liver abscess.Figure 1.: A large dominant hepatic abscess measuring 6.9 × 8.0 × 5.3cm, involving segments 4A and 4B of the liver, extending to and involving the anterior wall of the gallbladder, as well as several scattered small fluid collections (MRI of liver without contrast).Figure 2.: A 4.6cm radio-opaque linear foreign body penetrating through the gastric antrum into a branch of the left portal vein (CT of abdomen and pelvis without contrast).Figure 3.: A patch of erythematous mucosa in the pre-pyloric antrum encircling a pinpoint opening to a fistulous tract and scant purulent liquid; the foreign body was not visible (upper endoscopy).

Recurrent small bowel obstruction caused by Burkitt lymphoma in an elderly man: a case report and review of the\xa0literature

BackgroundAcute small bowel obstruction is a common surgical emergency usually caused by abdominal adhesions, followed by intraluminal tumors from metastatic disease. Although lymphomas have been known to cause bowel obstruction, Burkitt lymphoma is seldom reported to induce an obstruction in the adult population.Case presentationA 78-year-old Hispanic man with a history of abdominal interventions presented to our hospital with abdominal pain. Computed tomography revealed a partial small bowel obstruction attributed to local inflammation or adhesions. Medical management with bowel rest and nasogastric decompression resulted in resolution of symptoms and quick discharge. He returned 2 days later with worsening abdominal pain. Repeat imaging showed progression of the partial small bowel obstruction, but with an additional 1.6-cm nodular density abutting the anterior aspect of the gastric antrum and lobulated anterior gastric antral wall thickening. He was taken to the operating room, where several masses were found. Intraoperative frozen sections were consistent with lymphoma, and pathology later revealed Burkitt lymphoma. Disease was found on both sides of the diaphragm by positron emission tomography. After the initial resection and adjuvant chemotherapy, the patient is alive and well about 14 months after resection.ConclusionsSmall bowel obstruction is uncommonly due to Burkitt lymphoma in the geriatric population and is more frequently seen in the pediatric and young adult populations. Burkitt lymphoma is very aggressive with rapid cell turnover leading to significant morbidity. The rapid recurrence of an acute abdominal process should prompt an investigation for a more sinister cause such as malignancy.

The Assessment of Gastric Antral Wall Thickness in Helicobacter pylori gastritis by Abdominal Ultrasonography, Case-Control Study (2016-2018)

Background and Aim: Abdominal ultrasonography is effective in the visualization of gastric wall layers and measuring its thickness. The study aimed to assess gastric antral wall thickness in patients with H. pylori gastritis by abdominal ultrasonography and to study its predictive value in detecting H. pylori gastritis. Materials and Methods: The study included ninety adult individuals, sixty of them had dyspepsia and/or upper abdominal pain and histologically confirmed gastritis, were distributed equally according to the H. pylori infection status into group A (H. pylori gastritis) or B (non-H. pylori gastritis), while, group C included thirty asymptomatic participants with negative H. pylori screening. The participants were subjected to abdominal sonography for measuring the antral wall thickness (AWT), mucosal wall thickness (MLT) and mucosal-to-antral wall thickness ratio (MLT/AWT ratio). Results: The AWT, MLT and MLT/AWT ratio were significantly greater in H. pylori gastritis group (5.65 ± 0.58, 3.02 ± 0.43, 0.53 ± 0.04 respectively) than non-H. pylori gastritis group (4.57± 0.82, 2.07± 0.41, 0.45 ± 0.02 respectively) and control group (3.93 ± 0.52, 1.49 ± 0.2, 20.37± 0.03 respectively). The optimal cut off values of AWT, MLT and MLT/AWT ratio for detecting the of H. pylori infection among symptomatic gastritis patients were > 4.94 mm, > 2.46 mm and > 0.48 mm respectively. Conclusion: Ultrasonography of the gastric antrum is considered beneficial in evaluating patients with presumed gastritis. The increase of AWT > 4.94 mm, MLT > 2.46 mm, and MLT/AWT ratio > 0.48 mm in patients with gastritis is suggestive of H. pylori infection.

Percutaneous endoscopic gastrostomy with jejunal extension for a post-esophagectomy gastric conduit.

Percutaneous endoscopic gastrostomy (PEG) is a minimally invasive procedure providing nutritional benefits to malnourished patients. Although a past history of celiotomy is not a contradiction for PEG construction, this procedure is rarely undertaken in post-esophagectomy patients, for two reasons: anatomically limited gastric spaces and high susceptibility to pulmonary aspiration. To overcome these limitations, we developed an original method of introducing PEG with jejunal extension for esophagectomized patients with retrosternal gastric pull-up reconstruction. The procedures were as follows: (1) confirmation of endoscopic transillumination of the antrum; (2) test puncture of the antral wall and subsequent gastropexy using a double-needle device; (3) insertion of a needle jejunostomy catheter into the antrum; (4) direct catheter cannulation to the pylorus and introduction of a feeding tube into the jejunum. We successfully carried out this procedure in three male patients (70-78years old): two suffering from repetitive aspiration pneumonia and one with extensive recurrence of esophageal carcinoma. The operative times ranged 15-50min. There were no PEG-associated complications. Of note, none of the patients experienced aspiration pneumonia after PEG construction. Our novel method appears to be a promising approach to managing esophagectomized patients because of its feasibility and the potential to prevent postoperative pulmonary aspiration.

Hypoganglionosis in the gastric antrum causes delayed gastric emptying.

Enteric nervous system (ENS) abnormalities have been implicated in delayed gastric emptying but studies exploring potential treatment options are limited by the lack of an experimental animal model. We examined the ENS abnormalities in the mouse stomach associated with aging, developed a novel model of gastroparesis, and established a new approach to measure gastric emptying. A modified gastric emptying assay was developed, validated in nNOS -/- mice, and tested in mice at multiple ages. Age-related changes in ENS structure were analyzed by immunohistochemistry. Gastric aganglionosis was generated in Wnt1-iDTR mice using focal administration of diphtheria toxin (DT) into the anterior antral wall. Older mice (>5months) exhibit hypoganglionosis in the gastric antrum and a decreased proportion of nNOS neurons as compared to younger mice (age 5-7weeks). This was associated with a significant age-dependent decrease in liquid and solid gastric emptying. A novel model of gastric antrum hypoganglionosis was established using neural crest-specific expression of diphtheria toxin receptor. In this model, a significant reduction in liquid and solid gastric emptying is observed. Older mice exhibit delayed gastric emptying associated with hypoganglionosis and a reduction in nNOS-expressing neurons in the antrum. The causal relationship between antral hypoganglionosis and delayed gastric emptying was verified using a novel experimental model of ENS ablation. This study provides new information regarding the pathogenesis of delayed gastric emptying and provides a robust model system to study this disease and develop novel treatments.

Significance of Gastric Wall Thickening Detected in Abdominal CT Scan to Predict Gastric Malignancy.

Background Early diagnosis of gastric cancer is one of the most important parameters affecting the survival of the disease. In this study, we aimed to stress the importance of antrum wall thickness in CT examination. Method The study included 111 patients between ages of 18 and 95 who had antral wall thickening in computed tomography and also had endoscopic evaluation performed in the same clinic. The patients were divided into two groups as benign and malignant according to the pathology results. The thickness of the antrum wall in computed tomography, hemoglobin and albumin levels, and age was compared among these two groups. Parameters with significant differences were further analyzed by multivariate analysis using logistic regression analysis. Results Of the 111 patients included in the study, 57 were male and 54 were female. Mean age was 65 years. Fifty-one patients were classified as benign and 60 patients as malignant. Mean age of the malignant patients was 70, while that of benign patients was 59 (p < 0.05). Antrum wall thickness was 13.68 ± 3.27 mm in malignant patients and 9.22 ± 2.17 mm in benign patients (p < 0.05). Similarly, hemoglobin level was significantly different in malignant and benign patients (10.78 ± 1.57 g/dl and 12.64 ± 1.43 g/dl, respectively; p < 0.05). Albumin levels were 3.36 ± 0.57 mg/dl in malignant patients and 3.97 ± 0.57 mg/dl in benign patients (p < 0.05). Conclusion Evaluation of antrum wall thickness, age, hemoglobin, and albumin values together may contribute to distinguishing the benign and malignant pathologies involving this region in patients with suspected stomach wall thickening in abdominal CT scan.

Quantitative and qualitative assessments of intraosseous neurovascular canals in dentate and posteriorly edentulous individuals in lateral maxillary sinus wall

ObjectiveKnowledge and evaluation of the blood supply within the maxillary sinus before sinus augmentation are vital to avoid surgical complications. The lateral maxilla is supplied by branches of the posterior superior alveolar artery and infraorbital artery forming intraosseous anastomoses (IA) within the bony lateral antral wall. This study was undertaken to (i) measure mean diameter of IA and its distance from the alveolar ridge within dentate and posteriorly edentulous subjects and, (ii) qualitatively display the relationship of IA throughout its course within the lateral maxillary sinus in cone beam computed tomography (CBCT). MethodMaxillary CBCT images of two-hundred-and-fifty-seven consecutive patients (163 men, 94 women, mean age 42 years) were analyzed. Samples were later divided into dentate (n = 142) and posteriorly edentulous (n = 115) jaws. Using both alveolar ridge and tooth location as reference points, the distance and diameter of IA were assessed. ResultThe IA was seen in 63.7% of all sinuses with 68.2% in dentate and 62.4% in edentulous. Mean distance and diameter of IA across the posterior tooth locations were 17.9 ± 3.0 mm and 1.4 ± 0.5 mm (dentate) and 15.1 ± 3.0 mm and 1.0 ± 0.5 mm (posteriorly edentulous), respectively. In each sample, there were no significant differences in distance-alveolar ridge and no significant correlations in diameter-tooth location. A statistically significant Pearson coefficient correlation between diameter and distance in dentate state was observed (r = −0.6). ConclusionThis study reveals that dentate maxillary jaws present larger diameters as compared to posteriorly edentulous jaws, although the IA course remains the same. As these canal structures contain neurovascular bundles with diameters that may be large enough to cause clinically substantial complications, a thorough pre-surgical planning is therefore highly advisable.

PUNCTURE FROM A TOOTHPICK: AN ATYPICAL PRESENTATION OF PYLEPHLEBITIS

SESSION TITLE: Wednesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Septic thrombophlebitis comprises of a spectrum of venous thrombi arising as a sequelae of inflammation in the setting of bacteremia. Pylephlebitis describes a septic thrombophlebitis involving the portal vein. We report a unique case of pylephlebitis resulting from endovascular foreign body perforation of the gastric wall. CASE PRESENTATION: A 69 year old female presented to our Emergency Department with 1 week of progressive abdominal pain, bloating and anorexia complaining of dark stools. She was noted to have sepsis and was started on broad spectrum antibiotics. Workup for sepsis revealed gastric antral thickening (Figure 1). Subsequent esophagogastroduodenoscopy (EGD) showed a toothpick perforating the gastric antral wall (Figure 2). Despite of removal, she continued to have abdominal pain and fever, prompting repeat CT abdomen. It showed infected portal venous, superior mesenteric venous (SMV) thrombus and portal venous gas (Figure 3). Blood cultures grew Streptococcus anginosus and Rothia mucilaginosa. Despite appropriate antibiotics, she developed septic shock and DIC, prompting another CT abdomen revealing a 1.4 cm abscess adjacent to the left anterolateral aspect of the SMV, thrombosis of the left portal vein with extensive portal venous air in the left lobe consistent with septic thrombophlebitis of the superior mesenteric vein and portal venous system (Figure 4). She was taken to OR for exploratory laparotomy, repair of gastric perforation, abdominal abscess drainage, portal vein thrombolysis. She was started on anticoagulation and was given extended course of antibiotic therapy at discharge. DISCUSSION: Pylephlebitis describes a septic thrombophlebitis involving the portal vein. The etiology of pylephlebitis is the pathophysiologic development of localized pockets of inflammation as an humoral immune response to an infection. Thrombophlebitis in small veins either embolize or extend into larger downstream veins, coalescing into the apogee of a portal vein thrombosis. While most cases involve thrombosis involving the SMV (42%), involvement of intrahepatic branches of the portal vein (39%) and the splenic vein (12%) is common. Pylephlebitis may arise from intra-abdominal or pelvic infection through direct downstream sequelae caught in the portal system. While of cases of pylephlebitis occur more commonly in the setting of diverticulitis, pylephlebitis remains a rare complication. Due to the paucity of data regarding pylephlebitis, it is difficult to assert that there is any greater association with extragastric complications when compared to other abdominal disease states. Gastric perforation from tooth pick with secondary pylephlebitis is a very unique clinical presentation. On review of available literature, only one case similar case was found. CONCLUSIONS: Physicians should have a high index of suspicion in cases of intra-abdominal pathology who remain unstable. Reference #1: Kanellopoulou T, Alexopoulou A, Theodossiades G, et al. Pylephlebitis: an overview of non-cirrhotic cases and factors related to outcome. Scand J Infect Dis 2010; 42:804. Reference #2: Plemmons RM, Dooley DP, Longfield RN. Septic thrombophlebitis of the portal vein (pylephlebitis): diagnosis and management in the modern era. Clin Infect Dis 1995; 21:1114. Reference #3: Peters, Thomas G., et al. “Suppurative Pylephlebitis Caused by Toothpick Perforation.” Southern Medical Journal 1988; 81:414-415. https://doi.org/10.1097/00007611-198803000-00034. DISCLOSURES: No relevant relationships by Krishna Akella, source=Web Response No relevant relationships by Brian Boden, source=Web Response No relevant relationships by Rajeev Fernando, source=Admin input No relevant relationships by Steve Georgopoulos, source=Admin input No relevant relationships by Kashif Hussain, source=Web Response No relevant relationships by Najia Hussain, source=Web Response No relevant relationships by Samer Ibrahim, source=Web Response No relevant relationships by ahsan khan, source=Web Response No relevant relationships by Paul Poidomani, source=Web Response No relevant relationships by Richard Ricca, source=Web Response No relevant relationships by Howard Sklarek, source=Web Response No relevant relationships by Amanda Stashin, source=Web Response

Transition to the ovulatory season in mares: An investigation of antral follicle receptor gene expression in vivo.

The inability to obtain in vivo samples of antral follicle wall layers without removing the ovaries or sacrificing the animals has limited more in-depth studies on folliculogenesis. In this study, a novel ultrasound-guided follicle wall biopsy (FWB) technique was used to obtain in vivo follicle wall layers and follicular fluid samples of growing antral follicles. The expression of proliferative, hormonal, angiogenic, and pro-/antiapoptotic receptors and proteins in the follicular wall among three follicle classes were compared during the spring transitional anovulatory (SAN) and spring ovulatory (SOV) seasons in mares. The main findings observed in the granulosa, theca interna, and/or all follicle layers during the SOV season compared with the SAN season were (a) small-sized follicles (10-14 mm) had greater epidermal growth factor receptor (EGFR) and Bcl-2 expression; (b) medium-sized follicles during the expected deviation/selection diameter (20-24 mm) had greater expression of EGFR, Ki-67, luteinizing hormone receptor (LHR), and Bcl-2; and (c) dominant follicles (30-34 mm) had greater EGFR, Ki-67, vascular endothelial growth factor, LHR, and Bcl-2 expression. Estradiol related receptor alpha expression and intrafollicular estradiol concentration increased, along with an increase in follicle diameter in both seasons. In this study, the application of the FWB technique allowed a direct comparison of different receptors' expression among follicles in different stages of development and between two seasons using the same individuals, without jeopardizing their ovarian function. The successful utilization of the FWB technique and the mare as an experimental animal offer a great combination for future folliculogenesis studies on mechanisms of follicle selection, development, and ovulation in different species, including women.

The Effect of the Change in the Volume and the Wall Thickness of Stomach by Adjusting Dosage of Water According to Gender and Weight in Stomach CT.

목적: 위 CT검사에서 경구 조영제인 물을 성별 및 체중에 따라 복용량을 조절하여 위 체적 및 위벽 두께 변화에 미치는 영향에 대해 연구하고자 하였다. 대상 및 방법: 실험에 사용한 장비는 Philips 사의 Brilliance CT 64 scanner (64 MDCT)와 Terarecon 사의 Aquarius iNtuition edition (iNtuition), Philips 사의 IntelliSpace Portal V9.0 (ISP V9.0)의 3D 워크스테이션을 사용하였다. 팬텀 연구를 통하여 생리식염수를 각각 100 mL, 150 mL, 200 mL 주입한 실린지를 스캔하고 3D 워크스테이션을 이용하여 각각의 실린지 볼륨을 측정하고 측정값의 정확도 및 재현성을 구하였다. 임상 연구에서는 기존 프로토콜대로 일정한 양의 물을 마시게 하여 위 CT검사를 시행한 대조군 211명과 성별 및 체중에 따라 물 복용량을 정량화한 프로토콜에 따라 복용을 한 실험군 194명을 위 내강의 물의 양을 3D 워크스테이션으로 재구성하여 볼륨양의 변화를 측정하고 위체부, 위전정부 두 곳에서의 두께를 정량적으로 평가하였고 복부 판독의 2명이 4점 척도로 위 내강의 팽창이 진단학적으로 적절한지 정성적으로 평가하였다. 결과: 팬텀 연구에서 100mL, 150 mL, 200 mL 실린지에서 오차율이 각각 0.007%, 0.004%, 0.01%로 모두 기준 허용범위인 ±5 %을 만족하였다. 임상 연구에서 실험군 남성 60-70 kg, 70-80 kg, 80 kg이상 그룹에서 위 내강의 물의 양이 대조군과 비교하여 평균 7.5%, 37.9%, 38% 증가하였고, 같은 그룹에서 위벽 두께 또한 대조군과 비교하여 평균 0.27±0.01 mm, 0.20±1.30 mm, 0.09±0.35 mm 얇게 측정되어 정량적 평가에서 우수하였다. 위 내강의 팽창에 관한 정성적 평가 별 분포에 3점 척도 이상에서 평가자 1은 대조군 44.6%, 실험군 58.8%로 나타났고, 평가자 2는 대조군 44.1%, 실험군 61.9 %로 나타나 두 평가자 모두 실험군에 높은 점수를 주었다. 결론: 위 CT 검사 시 성별 및 체중별로 물의 양을 정량화하여 마시는 경우 환자에게는 물 복용에 대한 부담감을 최소화하여 환자의 편의성을 높이고 동시에 진단하는데 있어 충분한 영상학적 정보를 얻을 수 있다.Purpose: We tried to compare the changes of stomach volume size and wall thickness by changes of water amount, as an oral contrast agent, depending on each patient’s gender and weight in stomach CT for pre-operative evaluation of early gastric cancer. Materials and Methods: In phantom study, three syringe phantoms(100 mL, 150 mL, 200 mL) filled with normal saline were scanned 10 times. Volumes of three phantoms were measured by 3D workstation to determine the accuracy and reproducibility of the measured values. In clinical study, 211 control subjects who ingested the certain amount of water according to the existing protocol(drinking same amount of water), and 194 subjects who ingested the amount of water adjusted according to one’s gender and weight, the volumes of water in stomach of them were measured by reconstructing the workstation and assessed stomach body and antral wall as quantitative analysis. Two independent observers evaluated expansion of the gastric on a 4-point scale method as a qualitative analysis. Results: In phantom study, result of difference percentages of volume measurements were 0.007% (100 mL), 0.004% (150 mL) and 0.01% (200 mL). All phantom measurements were satisfied with standard tolerance ranges within ±5%. In clinical study, groups of male 60-70 kg, 70 to 80 kg and 80 kg or more in the experimental group, the amounts of remaining water in gastric were 7.5%, 37.9%, and 38 % increased more than the control group. The average thickness of the stomach walls in three groups were measured 0.27±0.01 mm, 0.20±1.30 mm, 0.09±0.35 mm thinner than the control group which shows better results for evaluate early gastric cancer. In qualitative analysis, points of 3 and 4 were increased in experimental group. Observer 1 gave 44.6% of points of 3 and 4 in the control group and 58.8% in the experimental group. Observer 2 gave 44.1% of points of 3 and 4 in the control group and 61.9% in the experiment group. Both evaluators gave high scores. Conclusions: Changing amount of water agent depending on each patient’s gender and weight shows not only sufficient of remaining water in stomach but it also distends stomach wall which is easy to distinguish between early gastric cancer and advanced gastric cancer. Additionally, this protocol reduces burdens of drinking water because we set the appropriate amount of water by gender and weight following anatomically and physiologically.

Chronic maxillary atelectasis (including silent sinus syndrome) can present bilaterally.

Chronic maxillary atelectasis is a rare and underdiagnosed condition in which there is a persistent and progressive decrease in maxillary sinus volume secondary to inward bowing of the antral walls. Chronic maxillary atelectasis is typically unilateral. Simultaneous bilateral chronic maxillary atelectasis is extremely uncommon. A retrospective review was performed of patient data collected by the senior clinician over a three-year period (2015-2018). A comprehensive literature search was conducted to locate all documented cases of chronic maxillary atelectasis in English-language literature. Abstracts and full-text articles were reviewed. Three patients presented with sinonasal symptoms. Imaging findings were consistent with bilateral chronic maxillary atelectasis. The literature review revealed at least nine other cases of bilateral chronic maxillary atelectasis. Management is typically via endoscopic middle meatus antrostomy. Chronic maxillary atelectasis was initially defined as a unilateral disorder, but this description has been challenged by reports of bilateral cases. Further investigation is required to determine the aetiology and pathophysiology of the disease.

Direct role of the C-C motif chemokine receptor 2/monocyte chemoattractant protein 1 system in the feline cumulus oocyte complex†.

Studies were designed to (a) evaluate the mRNA expression of the C-C motif chemokine receptor 2 (CCR2) and its chemokine ligands, as well as genes related to periovulatory events, within the cumulus oocyte complex (COC) and follicle wall after a luteinizing hormone (LH) stimulus in cultured feline antral follicles; (b) assess the immunolocalization of CCR2 and its main ligand (monocyte chemoattractant protein 1, MCP1) within the feline COC; and (c) examine the direct effects of exogenous recombinant MCP1 on mRNA expression of the CCR2 receptor and MCP1 as well as key periovulatory genes in the COC, using a feline COC culture system. Both culture systems were developed by our laboratory and exhibit physiological response to gonadotropin stimuli. In summary, this study demonstrated mRNA expression of CCR2 receptor and its assessed ligands (MCP1, MCP2, MCP3, and MCP4) within the feline COC and follicle antral wall, and a significant increase in CCR2 mRNA by LH within the COC. Also, CCR2 and MCP1 immunoreactivity was observed in the oocyte and cumulus cells of the feline COC. Remarkably, this is the first report, in any species, describing a direct effect of the recombinant MCP1 in the CCR2/MCP1 system within the COC, by increasing the mRNA levels of key genes involved in the ovulatory cascade, as well as its own receptor CCR2. Together, these data suggest that CCR2 receptor signaling in the COC may regulate events critical for promoting cumulus oocyte expansion and/or oocyte maturation.

Gastrointestinal Occurrence of a Glomus Tumor

Glomus tumors are benign subepithelial mesenchymal neoplasms generally found in the fingers. It is rare to find a glomus tumor in the gastrointestinal tract. This is a case of a gastric glomus tumor (GGT). It is important to understand the difference betwen a glomus tumor and a gastrointestinal stromal tumor (GIST), which is far more common. The patient is a 26 year old Caucasian female who, for the past one year, had been visiting the gastroenterology clinic with complaints of epigastric abdominal pain, constipation, diarrhea, and heartburn. She was a moderately built individual with no abnormal vitals or notable findings on physical examination. We decided to do an EGD, and a mass in the body of the stomach was discovered. CT abdomen revealed a high density nodular lesion. EUS showed a 2.5cm x 2.2cm submucosal mass with mixed echogenicity and cystic spaces, arising from the muscularis propria of the stomach wall. The biopsy was consistent with a neuroendocrine lesion. Neuroendocrine markers were negative. However, smooth muscle actin and vimentin were strongly immunoreactive. Serotonin levels were normal, and octreotide scan revealed a faint glow in the tumor. Surgery was consulted and laparoscopic partial gastrectomy was performed. Pathology of the wedge resection revealed a gastric glomus tumor 1.8cm in diameter with well-defined margins and no evidence of malignancy. Subepithelial tumors of the gastrointestinal tract include carcinoid tumors, lymphomas, glomus tumors, and GIST. GIST, being the most common, are thought to arise from the interstitial cells of Cajal of the autonomic nervous system of the intestine. Glomus tumors arise from the glomus body in the intramuscular layer, typically in the antrum of the stomach. Both appear on CT as well-circumscribed homogenous masses, and on EUS as hypoechoic masses. However, GGT can be distinguished from GIST based on immunohistochemisty. GIST is typically positive for c-kit (CD117), whereas GGT may test positive for smooth muscle actin, laminin, collagen type IV, desmin, and vimentin.2680_A Figure 1. MR Abdomen, showing a 2.2cm homogenously-enhancing subepithelial gastric antral wall mass.2680_B Figure 2. Microscopic examination, showing multiple blood vessels surrounded by round glomus cells.Even though EUS-FNA differentiates GTs from more aggressive gastric tumors with a 95.6% accuracy, surgery is still preferred. According to the National Comprehensive Cancer Network, if the GIST is >2cm it should be surgically resected. Even if there were any doubt between a GT or GIST, wedge resection is the therapeutic management of choice. This rare case taught us how to diagnose and treat a gastrointestinal glomus tumor.

Gastric outlet obstruction caused by metastatic tumor of the stomach originating from primary breast cancer: A case report.

The most common sites of breast cancer metastasis are the bone, liver, lung and brain, while gastrointestinal metastasis from breast cancer is rare. We herein present the case of a 68-year-old woman who was admitted to our department with nausea and appetite loss. The patient's medical history included right mastectomy with sentinel lymph node biopsy 5 years earlier for invasive lobular carcinoma, measuring 6.2 cm in greatest diameter, without lymphovascular invasion. Two years after the surgery, the patient developed brain metastasis and underwent metastasectomy to control the neurological symptoms, including unsteadiness and asthenia. After the second surgery, the patient received systemic chemotherapy using S-1, followed by bevacizumab plus paclitaxel. However, due to bevacizumab-related cardiotoxicity, the treatment was switched to eribulin. On esophagogastroduodenoscopy, an elevated lesion was identified in the antrum, causing severe narrowing of the gastric outlet. Biopsy and histological examination of the tumor revealed infiltration of the gastric wall by undifferentiated neoplastic cells with poor adhesion, morphologically similar to invasive lobular carcinoma, and immunohistochemical staining was positive for estrogen receptor, mammaglobin and GATA3. Finally, 18F-2-deoxy-2-fluoro-D-glucose (FDG) positron emission tomography combined with computed tomography imaging revealed FDG uptake across the thickness of the antral wall. The patient was diagnosed with gastric metastasis from the original breast cancer and subsequently underwent endoscopic self-expandable metallic stent (SEMS) placement. There were no procedure-related adverse events, and the patient remained alive under best supportive care 4 months after SEMS placement. To the best of our knowledge, this is the first reported case of gastric outlet obstruction caused by metastatic breast carcinoma managed by SEMS placement. While such a diagnosis is rare, clinicians treating patients with gastric metastases should be aware of possible gastric outlet obstruction and SEMS placement as an effective palliative intervention.

In vivo antral follicle wall biopsy: a new research technique to study ovarian function at the cellular and molecular levels

BackgroundIn vivo studies involving molecular markers of the follicle wall associated with follicular fluid (FF) milieu are crucial for a better understanding of follicle dynamics. The inability to obtain in vivo samples of antral follicle wall (granulosa and theca cells) without jeopardizing ovarian function has restricted advancement in knowledge of folliculogenesis in several species. The purpose of this study in mares was to develop and validate a novel, minimally invasive in vivo technique for simultaneous collection of follicle wall biopsy (FWB) and FF samples, and repeated collection from the same individual, during different stages of antral follicle development. We hypothesized that the in vivo FWB technique provides samples that maintain the normal histological tissue structure of the follicle wall layers, offers sufficient material for various cellular and molecular techniques, and allows simultaneous retrieval of FF.MethodsIn Experiment 1 (ex vivo), each follicle was sampled using two techniques: biopsy forceps and scalpel blade (control). In Experiment 2 (in vivo), FWB and FF samples from 10-, 20-, and 30-mm follicles were repeatedly and simultaneously obtained through transvaginal ultrasound-guided technique.ResultsIn Experiment 1, the thickness of granulosa, theca interna, and theca externa layers was not influenced (P > 0.05) by the harvesting techniques. In Experiment 2, the overall recovery rates of FWB and FF samples were 97 and 100%, respectively. However, the success rate of obtaining samples with all layers of the follicle wall and clear FF varied according to follicle size. The expression of luteinizing hormone receptor (LHR) was mostly confined in the theca interna layer, with the estradiol-related receptor alpha (ERRα) in the granulosa and theca interna layers. The 30-mm follicle group had greater (P < 0.05) LHR expression in the theca interna and ERRα in the granulosa layer compared to the other groups. The overall expression of LHR and ERRα, and the intrafollicular estradiol were higher (P < 0.05 – P < 0.0001) in the 30-mm follicle group.ConclusionThe in vivo technique developed in this study can be repeatedly and simultaneously used to provide sufficient FWB and FF samples for various cellular and molecular studies without jeopardizing the ovarian function, and has the potential to be translated to other species, including humans.

Antral Wall Approach for Reconstruction of Orbital Floor Fractures Using Anterior Maxillary Sinus Bone Grafts

Isolated orbital wall fractures account for 4% to 16% of all facial fractures. Even a modest change in the position of the bony walls can have a significant impact on orbital volume and globe position. Alloplastic materials or autogenous bone grafts such as the antral maxillary wall can be used to reconstruct small- to medium-size orbital fractures. The main advantage of an antral wall graft is the intraoral approach with minimal morbidity. Nine patients underwent repair of orbital floor fractures using the extraoral and the intraoral antral wall approach. The patients underwent preoperative computed tomography imaging and a minimum of 1 year follow-up. The size of the defects ranged from 0.5 to 1.4 cm. Two patients experienced minor immediate postoperative complications; infraorbital hypoesthesia. On follow-ups, none of our patients suffered from ocular movement restrictions or complications regarding the maxillary antral wall approach. The use of harvested bone grafts from the anterolateral wall of the maxillary sinus is a promising approach for the reconstruction of small- to mid-size orbital floor defects with minimal complications and excellent cosmetic and functional results.