Endoscopic Photographs Research Articles

Short-term endoscopic alterations of early gastric cancer after successful eradication of Helicobacter pylori

BackgroundDetecting and demarcating early gastric cancers (EGC) after eradication therapy of Helicobacter pylori (H. pylori) is a challenging task due to the fact that the lesion’s surface is covered with gastritis-like tissue (non-neoplastic epithelium covering the cancerous tissue). However, our study aimed to investigate the endoscopic alterations of EGC within 3 months after eradication, which has not been reported clearly yet.MethodsConsecutive EGC patients who underwent two gastroscopies (one with H. pylori infection and another within 3 months after successful H. pylori eradication) were enrolled. The endoscopic photographs were evaluated for the endoscopic features and confidence level of demarcation line (DL), invasion depth, and histopathological classification by three highly experienced endoscopists. The DL estimated by endoscopy was compared with that of postoperative pathological examination.Results45 pairs of EGC cases before and after eradication were enrolled. All the confidence level of DL (High confidence: 15.6% vs. 93.3%, p value = 0.000) and invasion depth (High confidence: 37.8% vs. 80.0%, p value = 0.000) and histopathological classification (High confidence: 31.1% vs. 91.1%, p value = 0.000) were significantly improved after eradication. A higher confidence level of DL before eradication was correlated with severe atrophy score (p value = 0.036). The inter-observer agreements for DL, invasion depth, and histopathological classification were 0.85 and 0.75 and 0.78, respectively.ConclusionsDL of EGC becomes much more apparent after eradication in the short-term. Eradication therapy is necessary even shortly prior to the procedure of endoscopic submucosal dissection (ESD) to help precise pre-procedure diagnosis and avoid incomplete resection.

Choice of suture technique may mitigate figure-of-8 deformity in slide tracheoplasty

ObjectivesTo demonstrate varying degrees of immediate postoperative figure of 8 deformity following three different methods of tracheal suturing. Study designComparative ex-vivo study. MethodsA fresh, unfixed rabbit trachea was harvested and bisected at its midpoint. The posterior membranous trachea was excised from both segments to mimic the anatomy of complete tracheal rings following longitudinal release. A slide tracheoplasty was performed on the same tracheal segments as an internal control, using three different methods of closure: simple running, running horizontal mattress, and a modified baseball stitch. Endoscopic and external photographs were taken immediately following repair to document the effect of closure technique on external and endoluminal anatomy. ResultsA simple running closure, in which traveling occurs between needle passes, showed the greatest degree of postoperative figure of 8 deformity. A running horizontal mattress suture closure showed less deformity and a modified running closure, in which traveling occurs within needle passes, showed the least deformity. ConclusionsOur study suggests that a minor modification of standard running closure techniques may help limit the common figure-of-8 deformity often noted following slide tracheoplasty. Lay SummaryFigure of-8 deformity is a problem that can occur when repairing a narrow trachea referred to as tracheal stenosis. This deformity may be prevented using particular suture techniques which may decrease the likelihood that the trachea becomes blocked again following repair.

Actinomycosis Confined to the Nasal Septum.

Actinomycosis is common in the head and neck region but rarely occurs in the nasal septum. A 75-year-old male patient with an edentulous maxilla, hypertension, and diabetes developed actinomycosis confined to the nasal septum and showed mucosal necrosis and septal bony sequestration. The patient underwent surgery and medication therapy; this case was reported using endoscopic photographs and radiographs and a literature review was conducted to provide further context and understanding of the condition of the patient.

Comparison of healing of acute total tympanic membrane perforation between rats with and without excision of the mallear handle.

We compared the histological changes and hearing restoration during the healing of acute total tympanic membrane (TM) perforations between Sprague-Dawley (SD) rats with and without excision of the mallear handle. Bilateral, acute, and total TM perforations were created in 36 male SD rats. The mallear handle was preserved in the left ear (handle-preserved ear [HPE]) and excised from the right ear (handle-excised ear [HEE]). Endoscopical examination, auditory brainstem response (ABR) thresholds, histopathological, and scanning electron microscope (SEM) analysis were performed. Endoscopic photographs showed that all perforations in the 18 SD rats were closed. The mean closure times were 6.83 ± 0.85 and 8.50 ± 0.71 days in the HPE and HEE groups, respectively (p < .001). SEM images showed radial arrangement of fiber bundles in a single direction in HPEs, although normal arrangement was not achieved. In contrast, HEEs showed disorganized arrangement. At 1 month after perforation closure, the ABR thresholds at high frequencies were significantly higher in the HEE group than in the HPE group (p = .029 and p = .017 for 16 and 32 kHz, respectively). Additionally, the changes in ABR threshold were significantly different at high frequencies (p = .011 and p = .017 for 16 and 32 kHz, respectively) before and 1 month after perforation closure between the HPE and HEE groups, although the differences were not statistically significant at the remaining frequencies. Although the malleus handle may not affect the closure of total perforation in SD rats, it contributes to accelerate the perforation closure by possible guide the migration of proliferative epithelial cell on the upper halves of the annulus. Additionally, resection of the malleus handle impairs high frequency hearing recovery following spontaneous closure of the TM.

Effect of Oral Prednisolone on Recovery after Tonsillectomy: A Quasi-Experimental Study

Background: Post-operative morbidities following tonsillectomy still remain a significant problem. Glucocorticoids might help to lessen these morbidities by decreasing inflammation at the sites of injury. The objective of this study was to assess the effect of oral prednisolone on recovery of patients after tonsillectomy. Methods: A quasi-experimental study was conducted from August 2015 to July 2016 among 70 patients aged four years or older scheduled for elective tonsillectomy by cold steel dissection method. The experimental group received a postoperative course of prednisolone 0.5 mg/ kg/ day over seven days whereas the control group received the standard of care only. Postoperatively, all participants were assessed for pain, type of diet and activity, presence of nausea and/ or vomiting and bleeding on 1st , 2nd , 3rd, 7th and 14th day, and healing process in the tonsillectomy bed measured through the use of endoscopic photograph on 7th and 14th day. Results: Significant reduction in pain was found in prednisolone group compared to the control group on 7 th day (mean score 1.41 and 2.51 respectively, p = 0.006) and on 14 th day (mean score 0.25 and 1.06 respectively, p = 0.005). Earlier return to normal diet was found on 7th day (p = 0.005) and 14th day (p = 0.02). No significant difference was found in rate of healing and other secondary outcomes. No adverse effects of prednisolone were noted. Conclusion: Use of oral prednisolone in post-tonsillectomy patients may offer significant benefits in relieving pain and earlier returning to normal diet without any serious adverse effects.

S2350 Mind the Steroids: Herpes Esophagitis in an Immunocompetent Patient After Steroid Therapy

Introduction: Infective esophagitis (IE) is rare, but well known to complicate the immunosuppressed state; particularly the HIV infected, transplant recipient, cancer patient and those treated with chronic corticosteroids or immunomodulators. Common infections include candida, cytomegalovirus, and herpes simplex virus (HSV). Steroids have been used for symptomatic relief of an acute sore throat. Short courses are considered benign with low risk of infectious complications. We report an immunocompetent patient found to have herpes esophagitis after a short course of corticosteroids. Case Description/Methods: A 41-year-old African American male with history of hypertension presented with worsening sore throat and odynophagia restricting oral intake. Prior to presentation, he had a 10-day history of sore throat. He was diagnosed with streptococcal pharyngitis and was on antibiotics and steroids 7 days ago. Given persistent symptoms he underwent laryngoscopy which demonstrated bilateral tonsillar exudates and normal pharyngeal mucosa, prompting admission and initiation of IV antibiotics and dexamethasone. He had modest improvement of pain, however 8 days later expressed worsening burning retrosternal chest pain and progressed oral intolerance. He underwent upper endoscopy revealing multiple circumferential erosions and Los Angeles grade D esophagitis of the lower third of the esophagus (Figure A). Biopsies demonstrated viral intranuclear inclusions that stained positive for HSV1/HSV2 (Figure B, C). His symptoms abated while on IV acyclovir allowing transition to oral valacyclovir. Discussion: Corticosteroids are well known for their anti-inflammatory effect but immunosuppression with short courses may be underestimated. Infectious sequalae such as herpetic esophagitis may complicate steroid use even when therapy duration is short. This patient was found to have progressive odynophagia while on corticosteroids administered for analgesia and had significant improvement after antiviral therapy. It is easy to overlook IE as a cause of odynophagia in the immunocompetent, however, with history of steroid use, a diagnosis of IE, especially HSV esophagitis, should be considered in the differential. Therefore, one should have a low threshold for early endoscopy when evaluating these patients.Figure 1.: A: Endoscopic photograph displaying multiple circumferential erosions and Los Angeles grade D esophagitis of the lower third of the esophagus. B: (x200): Photomicrograph of hematoxylin and eosin-stained section of the esophageal biopsy, showing multiple multinucleated epithelial cells. Cowdry type A is observed. C: (x200): IHC study using antibodies against HSV-1. Numerous intranuclear viral inclusions are positive with HSV-1 within the infected cells.

Secondary syphilis of the oropharynx and cervical lymph nodes: a case report.

Secondary syphilis rarely affects the head and neck including the oropharynx and cervical lymph nodes. These patients present with throat pain, cystic/necrotic lymphadenopathy, and mucosal swelling. Sometimes this constellation of symptoms can be mistaken for head and neck cancer. We report a case of an enlarging throat and painless cystic neck mass in a transgender woman in her forties who was initially suspected to have oropharyngeal squamous cell carcinoma. A subsequent workup revealed the presence of spirochetes without cellular atypia consistent with secondary syphilis. We include the ultrasonography images as well as an endoscopic photograph of the oropharyngeal manifestation in this report.

Exploring the art of medical photography - an otolaryngologist's perspective.

Modern day otolaryngology has expanded beyond the ear, nose and throat to include head and neck surgery and aesthetic facial procedures. Photographic documentation is important within this expanded horizon. The spectrum of clinical photography includes photomicrographs, endoscopic photographs, peri-operative photography and medical social photography. This article aimed to review the standard guidelines essential to obtain, store and disseminate photographs and looked at setting up a small clinic with minimal gadgets to suit clinical photography requirements. Elaboration of basic photography techniques in otolaryngology was reviewed, with examples of photographs taken in a clinic by a clinician. Advances and innovation in clinical photography, in the form of smartphone photography, artificial intelligence, device editing and newer hardware and software in otorhinolaryngology was reviewed. Having a professional photographer to aid a clinician is a luxury. Simple knowledge and regular practice of basic photography guidelines by a clinician is imperative.

Endoscopic findings of Helicobacter pylori gastritis in children and young adults based on the Kyoto classification of gastritis and age-associated changes.

Background and AimWe aimed to evaluate endoscopic findings of Helicobacter pylori (H. pylori)‐positive children and young adults based on the Kyoto classification, and to examine if there are age‐associated changes in H. pylori‐positive gastritis.MethodsH. pylori‐positive patients under 40 years old who underwent upper gastrointestinal endoscopy from 1 April 2009 to 15 February 2017 were included. Subjects were classified into the Pediatric (<20 years) and Young adult groups (20–39 years). The patients' endoscopic photographs were retrospectively re‐evaluated based on the Kyoto classification. We compared endoscopic findings between the two groups and examined alterations in the findings of H. pylori‐associated gastritis in 5‐year age groups.ResultsForty‐three and 163 subjects were classified into the Pediatric and Young adult groups, respectively. In the Pediatric group, nodularity was seen in the majority (93.0%); other endoscopic findings in order of decreasing frequency included mucosal swelling (32.6%), spotty redness (25.6%), diffuse redness (18.6%), and atrophy (9.3%). In the Young adult group, endoscopic findings included atrophy (66.9%), mucosal swelling (49.7%), spotty redness (39.3%), nodularity (31.9%), and diffuse redness (30.3%). The difference in prevalence of nodularity or atrophy between the two groups reached statistical significance (P < 0.0001 each). The rate of nodularity decreased with increasing age in the Young adult group. The rate of atrophy was 33% in young adult patients aged 20–24, and the rate increased to >65% in patients over age 25.ConclusionH. pylori‐positive children had endoscopic findings besides nodularity based on the Kyoto classification. The prevalence of atrophy increased in patients over age 20.

Presyncope Leading to the Diagnosis of Gastrointestinal Stromal Tumor in a Pediatric Patient.

A 16-year-old African American girl presented after a presyncopal event. Initial evaluation revealed anemia (hemoglobin 5.2 mmol/L) and positive stool hemoccult. Esophagogastroduodenoscopy revealed an ulcerated, bleeding, submucosal mass (Fig. 1). Bleeding was controlled with argon plasma coagulation. Abdominal computed tomography showed a heterogenous 6.8 cm mass at the serosal surface of the lesser curvature. Neck and thorax computed tomography did not show metastases. Endoscopic ultrasound with fine needle biopsy (Fig. 2) revealed histology consistent with a gastrointestinal stromal tumor (GIST). Laparotomy was performed with complete resection of the mass. Pediatric GISTs are rare and they account for about 1% of all GISTs (1). When suspected, endoscopic biopsy, either core needle or forceps biopsy, is the preferred method to prevent tumor spillage which is highly associated with GIST recurrence (2). Pediatric GISTs usually lack KIT or PDGFRA gene mutations, making them wild-type GISTs (3). In this case, genetic testing revealed associations with hereditary paraganglioma-pheochromocytoma syndromes (4). Prognosis is based on the mitotic rate, tumor size, and tumor site; gastric site being the most favorable (5). MRI after surgery showed no residual tumor. The patient will continue close monitoring via annual MRI, which is the preferred modality for surveillance (6).FIGURE 1: Endoscopic photograph showing a bleeding submucosal mass.FIGURE 2: Endoscopic ultrasound of the mass while obtaining fine needle biopsy.

S2158 Fundic Gland Polyp Causes Massive Melena During Induction Chemotherapy With R-EPOCH for DLBCL

INTRODUCTION: Fundic Gland Polyps (FGPs) are hamartomatous cystic lesions in the gastric mucosa, and mostly occur sporadically. Bleeding from an FGP is very rare but has been reported in the setting of long-term PPI use and rare hematologic conditions. Overall, these polyps are considered quite benign. CASE DESCRIPTION/METHODS: A 71-year-old gentleman presented to the hospital in active tumor lysis and was subsequently diagnosed with Diffuse Large B Cell Lymphoma of the non-germinal center type, in a background of 3B follicular lymphoma. He was started on induction chemotherapy with the R-EPOCH regimen (without rituximab given unknown HBV status) and a day later, developed massive melena resulting in hemorrhagic shock. His chemotherapy regimen was stopped and he was resuscitated, requiring multiple transfusions. Once in stable condition, an EGD was performed which found only a benign FGP in a background of chronic atrophic gastritis as a source of the bleed (Figure 1). The pathology revealed pyloric and intestinal metaplasia, consistent with autoimmune gastritis (Figure 2), with no evidence of dysplasia or malignancy. Mesenteric angiography was subsequently performed to identify any other source of GI bleed for IR embolization, but no contrast extravasation was observed to suggest one. The patient's clinical status improved during the procedure, suggesting that the hemorrhage had ceased. DISCUSSION: The development of FGPs is a rare phenomenon. When they do form, they may form sporadically, or may be associated with hypergastrinemia seen in patients taking proton pump inhibitors, in those with Zollinger-Elison syndrome, and in those with autoimmune metaplastic atrophic gastritis (AMAU). Interestingly, our patient was found to have AMAU on pathology and there have been multiple reports of a bidirectional association between lymphocytic malignancies, like DLBCL, and autoimmune manifestations. Our patient's GI bleed was likely the result of a combination of factors, including his AMAU and his DVT prophylaxis (enoxaparin), but the most significant of these factors is the gastrointestinal side effects of his chemotherapeutic R-EPOCH (Rituximab, Etoposide, Prednisone, Oncovin, Cyclophosphamide and Doxorubicin Hydrochloride) regimen. Many of the drugs used in this regimen are known to cause mucositis, and prednisone in particular has been historically associated with GI bleeds due to mechanisms such as impaired wound healing. As seen in this case, when his chemotherapeutic regimen was stopped, his bleeding also ceased.Figure 1.: Endoscopic photograph of the fundic gland polyp.Figure 2.: The biopsy of the fundic gland polyp demonstrates cystically dilated glands arising in oxyntic-type mucosa.Figure 3.: The biopsy of the background fundic mucosa shows atrophic mucosa with loss of oxyntic glands, pseudopyloric metaplasia, and chronic inflammation in the lamina propria, compatible with autoimmune gastritis.

S3361 A Case of Metastatic Renal Cell Carcinoma to the Colon

INTRODUCTION: Renal cell carcinoma (RCC) originates in the renal cortex and constitutes 80-85% of primary renal malignancies in adults. Treatment of this condition ranges from partial or complete nephrectomy for isolated renal masses to chemotherapy for disseminated disease. In cases of metastatic disease, common sites include the lungs, lymph nodes, bone, liver and brain. The Gastrointestinal (GI) tract remains an uncommon site of metastasis of this malignancy. We present a rare case of RCC with colonic metastasis. CASE DESCRIPTION/METHODS: A 76 year-old-male with a past medical history of metastatic RCC treated with left radial nephrectomy (6 years prior) and chemotherapy (with Nivolumab) who presented with dyspnea on exertion. He was noted to have iron deficiency anemia; hemoglobin 5.6g/dl, MCV 65.9 A decision was made to perform colonoscopy and EGD. EGD was notable for gastric varices (IGV-1) and mild gastritis. Colonoscopy revealed a single, ulcerated, flat lesion 40 cm from the entry site that was biopsied. Remaining colon was unremarkable. Pathology of the lesion confirmed metastatic RCC to the Colon. Patient, underwent liver ultrasound that showed no lesions, left upper quadrant ultrasound with splenic vein visualized likely secondary to occlusion). Chest x-ray showed no acute cardiopulmonary abnormality._ Hematology and oncology was consulted and a plan for possible re-treatment with Nivolumab was made. DISCUSSION: RCC has been documented to metastasize to uncommon sites such as the cervix, pancreas and skin. Metastasis to the colon is exceedingly rare. Treatment typically involves nephrectomy or chemotherapy and patients usually undergo different with long term surveillance (e.g. BUN, Creatinine levels , CT/MRI head, abdomen pelvis) for recurrent disease depending on the stage. We feel that our study is important because it demonstrates a rare case of of secondary GI malignancy that may not be on the differential of many physicians. Keeping this diagnosis in mind when approaching future cases will likely allow for more prompt diagnosis and treatment of this condition.Figure 1.: Endoscopic photograph of flat, ulcerated polyp that was biopsied and eventually found to be metastatic prostate cancer.Figure 2.: Endoscopic photograph of the same flat, ulcerated polyp that was biopsied and eventually found to be metastatic prostate cancer.

Evaluation of Recurrent Maxillary Sinusitis due to Middle Meatal Antrostomy Site Stenosis.

This study was performed to evaluate the incidence, timing, and factors contributing to recurrent maxillary sinusitis due to middle meatal antrostomy (MMA) site stenosis after endoscopic sinus surgery (ESS). The medical records and endoscopic photographs of 288 patients with chronic rhinosinusitis who underwent ESS were evaluated. Patients visited the clinic with similar schedule after ESS; recurrent maxillary sinusitis due to MMA site stenosis was investigated, including in terms of the incidence and timing. The preoperative computed tomography (CT) scans, intraoperative findings, and possible factors contributing to MMA site stenosis were examined. Recurrent maxillary sinusitis due to MMA site stenosis occurred in 10 patients. Most had unilateral sinusitis and stenosis was observed within 6 months postoperatively. All patients had severe inflammation, pus retention, and thick mucosal hypertrophy in the maxillary sinus on preoperative CT; intraoperative findings confirmed these conditions. In most patients, extensive trimming of the hypertrophied mucosa was performed intraoperatively through canine fossa trephination. MMA site stenosis is a rare condition after ESS. We hypothesized that rapid shrinkage and fibrosis of the sinus mucosa after extensive trimming thereof may be the main causes of stenosis. Residual mucosal inflammation, granulation formation, and persistent sinus crust and debris may also be contributing factors. Therefore, conservative trimming, meticulous dressing, and removal of sinus crust and granulation tissue near the MMA site should be performed in patients with MMA site stenosis.

Clinical and endoscopic characteristics of diffuse esophageal intramural pseudo-diverticulosis

IntroductionWith 250 published cases worldwide, diffuse esophageal intramural pseudo-diverticulosis (DEIPD) is a poorly understood disease. The aim of this study was to determine the prevalence of DEIPD in our own population, identify risk factors and clinical symptoms, and characterize its typical endoscopic signs.MethodsRetrospective search in our center’s endoscopic and clinical database. Reviewing of all cases by re-examining stored endoscopic photographs. Reviewing of all cases regarding age, sex, risk factors, comorbidities, histology, and clinical symptoms.ResultsIn a population of 150.000 we found 21 cases of DEIPD. Mean age was 56 ± 10 years. 86% were males, 76% had alcohol abuse, 57% had nicotine abuse, 38% had arteriosclerosis, 33% had COPD, 29% had malignancies, 24% had liver cirrhosis, 19% had impaired kidney function, and 15% had diabetes. Dysphagia was present in 62% and food bolus impaction (single or repeated) in 48%. Endoscopically, 95% of patients had multiple (> 4), small (0.25–2.5 mm) pseudodiverticle openings in the esophageal wall. In 62%, openings were aligned longitudinally. 86% showed edematous swelling of mucosa (“frosted glass look”), 76% showed a fine-grained pattern of small (10–100 µm) red dots (“faux uni pattern”), and 76% had a rigid, narrow lumen with multiple rings (“trachealization”).ConclusionWith a prevalence of approximately 5 to 50/100.000, DEIPD may be more frequent than previously estimated. It preferably affects middle-aged male alcoholics. Key symptoms are chronic dysphagia and food impaction. Typical endoscopic findings are multiple, small, longitudinally aligned pseudodiverticle openings, frosted glass look, faux uni pattern, and trachealization of the esophagus.

Improving exposure for transoral oropharyngeal surgery with the floor of mouth window: a cadaveric feasibility study

BackgroundTransoral robotic and laser surgery is rising in popularity due to the increasing incidence of Human Papilloma Virus (HPV) related oropharyngeal cancer. However, adequate exposure of the tongue base remains a major hurdle in many cases. This study introduces a novel surgical technique called the Floor of Mouth Window, which can be used to improve tongue base exposure at the time of transoral surgery.MethodsThis is a preclinical anatomic cadaver study. Seven fresh cadavers were used for this study. Exposure of the tongue base was compared between conventional mouth gags – the Feyh-Kastenbauer and McIvor – and our novel procedure, the Floor of Mouth Window. Exposure was compared subjectively using endoscopic and extracorporeal photographs, as well as objective measurements of inter-incisor distance, and oral cavity volume.ResultsThe exposure achieved by the Floor of Mouth Window technique was superior to the mouth gags. Inter-incisor distance and oral cavity volume measurements were all more favorable with the Floor of Mouth Window. This technique allowed for successful transoral laser tongue base and tonsil resection without the use of gags or scopes.ConclusionThe Floor of Mouth Window is an adjunctive procedure that simply and reliably improved exposure for transoral oropharyngeal surgery in this cadaveric feasibility study. This improved exposure may help increase the adoption of transoral surgery and reduce the number of aborted cases due to anatomic limitations.

Acute liver failure secondary to severe systemic disease from fatal hemophagocytic lymphohistiocytosis: Case report and systematic literature review.

AIMTo systematically review liver disease associated with hemophagocytic lymphohistiocytosis (HLH), propose reasonable contraindications for liver transplantation for liver failure in HLH, and report an illustrative case.METHODSSystematic review according to PRISMA guidelines of hepatic manifestations of HLH using computerized literature search via PubMed of articles published since 1980 with keywords (“hemophagocytic lymphohistiocytosis” or “HLH”) AND (“liver” or “hepatic”). Two authors independently performed literature search and incorporated articles into this review by consensus. Illustrative case report presented based on review of medical chart, and expert re-review of endoscopic photographs, radiologic images, and pathologic slides.RESULTSA 47-year-old Caucasian male, was hospitalized with high-grade pyrexia, rash, total bilirubin = 45 g/dL, moderately elevated hepatic transaminases, ferritin of 3300 ng/dL, leukopenia, and profound neutropenia (absolute neutrophil count < 100 cells/mm³). Viral serologies for hepatitis A, B, and C were negative. Abdominal computed tomography scan and magnetic resonance imaging revealed no hepatic or biliary abnormalities. Pathologic analysis of liver biopsy revealed relatively well-preserved hepatic parenchyma without lymphocytic infiltrates or macrophage invasion, except for sparse, focal hepatocyte necrosis. Bone marrow biopsy and aspirate revealed foamy macrophages engulfing mature and precursor erythrocytes, consistent with HLH. Interleukin-2 receptor (CD25) was highly elevated, confirming diagnosis of HLH according to Histiocytic Society criteria. Patient initially improved after high-dose prednisone therapy. Patient was judged not to be a liver transplant candidate despite model for end stage liver disease (MELD) score = 33 because liver failure was secondary to severe systemic disease from HLH, including septic shock, focal centrilobular hepatocyte necrosis from hypotension, bone marrow failure, and explosive immune activation from HLH. The patient eventually succumbed to overwhelming sepsis, progressive liver failure, and disseminated intravascular coagulopathy. Systematic review reveals liver injury is very common in HLH, and liver failure can sometimes occur. Data on liver transplantation for patients with HLH are very limited, and so far the results have shown a generally much worse prognosis than for other liver transplant indications. Liver transplantation should not be guided solely by MELD score, but should include liver biopsy results and determination whether liver failure is from intrinsic liver injury vs multisystem (extrahepatic) organ failure from HLH.CONCLUSIONThis case report illustrates that liver transplantation may not be warranted when liver failure associated with HLH is primarily from multisystem failure from HLH. Liver biopsy may be very helpful in determining the severity and pathophysiology of the liver disease.

Incidence of re-deviated nasal septum after septoplasty in adolescent and adult patients

Background: Re-deviation of the nasal septum may occur after septoplasty. Because the cartilaginous septum grows until the age of 16–17 years, septoplasty is usually recommended thereafter. However, severely deviated septum may necessitate septoplasty in younger adolescents.Objectives: To compare the incidence of re-deviated nasal septum in patients who underwent septoplasty at ≤18 versus ≥19 years of age.Materials and methods: The medical records and endoscopic photographs of patients who underwent septoplasty between 2005 and 2015 were retrospectively reviewed. Re-deviation of the nasal septum was defined as >50% narrowing of one side of the nasal cavity compared to immediately after septoplasty.Results: The inclusion criteria were met by 52 adolescent patients and 549 adult patients. Re-deviation of the septum occurred in 11 (21.2%) and 39 (7.1%) patients, respectively; the difference was significant. Most patients had caudal and upper cartilaginous deviations. Four adolescent and 14 adult patients underwent revisional septoplasty.Conclusions and significance: Adolescent patients who underwent septoplasty had a significantly higher incidence of re-deviation of the nasal septum than adult patients. Therefore, when septoplasty is deemed necessary in adolescent patients, they and their parents should be informed about the possibility of re-deviation and the need for revisional septoplasty.

A 14-Year Study of 398 Esophageal Adenocarcinomas Diagnosed Among 156,256 EGDs Performed at Two Large Hospitals: An Inlet Patch Is Proposed as a Significant Risk Factor for Proximal Esophageal Adenocarcinoma.

An association between inlet patches and proximal esophageal adenocarcinomas is currently suspected because of numerous case reports of simultaneous occurrence of both diseases. To analyze whether inlet patches are significantly associated with proximal esophageal adenocarcinomas in a large population. Computerized search of pathology and EGD reports revealed 398 cases of esophageal adenocarcinomas among 156,236 EGDs (performed on 106,510 patients) diagnosed by histopathology performed at Royal Oak/Troy, William Beaumont Hospitals, 2003-2016. Adenocarcinomas localized as distal, middle, or proximal; and characterized as associated versus unassociated with inlet patches. Medical records were reviewed. Endoscopic photographs, radiologic images, and pathologic slides were re-reviewed. Two researchers independently performed systematic computerized literature searches; cases of simultaneous diseases identified by consensus. Adenocarcinoma locations included: distal-381, middle-14, and proximal esophagus-3. Five patients had inlet patches with esophageal adenocarcinomas located at: distal-2, middle-0, and proximal esophagus-3 (relative frequency of inlet patches with cancers of distal/middle esophagus=2/395 [.5%] vs. proximal esophagus=3/3 [100%], p<.000001, 95% OR CI>50.1, Fisher's exact test). Cases of proximal esophageal adenocarcinomas within inlet patches included: (1) Seventy-eight-year-old man presented with dysphagia. Neck CT showed proximal esophageal mass. EGD revealed semi-circumferential, multinodular, 3.0×1.5 cm mass within inlet patch. Histopathology of biopsies revealed moderately-to-poorly differentiated adenocarcinoma. Patient received chemoradiotherapy and expired 2years later. (2) Seventy-nine-year-old man presented with anorexia and weight loss. EGD demonstrated proximal esophageal mass within inlet patch. Histopathology of biopsies revealed poorly differentiated, signet ring cell adenocarcinoma. Chest CT revealed 3.4×2.1-cm-proximal esophageal mass. Patient expired 4months later. (3) Sixty-year-old man presented with dysphagia. EGD revealed 4-cm-long, semi-circumferential, proximal esophageal mass within inlet patch. Histopathology of biopsies revealed poorly differentiated adenocarcinoma. Patient underwent emergency esophagectomy for esophageal perforation 2weeks after initiating chemoradiotherapy, and died shortly thereafter. Literature review revealed 39 cases of simultaneous disease. Potential underreporting by endoscopists of inlet patches at EGD. Study supplements 39 previously reported cases of simultaneous disease, by adding three new cases, and by novel report of statistically significant association between these two entities, which has important implications in the pathophysiology of proximal esophageal adenocarcinoma.

Can urologists accurately stage and grade urothelial bladder cancer by assessing endoscopic photographs?

Introduction Assessment of urothelial bladder cancer during cystoscopy or transurethral resection of bladder tumour has a significant impact on the urologist's decision-making: treatment with simple outpatient fulguration, required depth of resection, and need of immediate post-surgical intravesical therapy. These choices depend heavily on the urologist's ability to accurately assess pre-biopsy tumour stage and grade. The aim of the study was to determine whether evaluation of photographs taken during transurethral resection of bladder tumour can reliably characterize a tumour’s stage and grade. Methods Smartphone photographs of 50 urothelial bladder cancer cases were taken at the beginning of transurethral resection of bladder tumour and individually presented to seven senior urologists. All urologists were blinded to the final pathological report and to any other urological evaluation. Each one was asked to rate the tumour as low vs high grade and noninvasive Ta vs noninvasive T1 or muscle invasive. Results were compared with final pathology. Individual appraisal and the majority's opinion were evaluated. Results Urologists have correctly predicted tumour stage and grade in 63.5% of cases (222 of 350, average of 32 out of 50 accurate assessments). The final majority assessment was correct in 40 of 50 cases (80%). Sensitivity and specificity of the final results for the diagnosis of T1 or higher were 80% and 88.6%, respectively. Sensitivity and specificity for Ta low grade were 83.3% and 80%, respectively. Conclusions To the best of our knowledge, this is the first documented attempt to evaluate urologists' ability to assess urothelial bladder cancer stage and grade using endoscopic photographs. Urologists can usually identify stage and grade of urothelial bladder cancer but accuracy increases when multiple senior urologists examine the same photographs and achieve majority consensus. Presenting photographs of urothelial bladder cancer to a team of urologists may lead to an excellent decision regarding type and extent of surgical treatment and substantiate appropriate post-surgical management.

Gastric superficial neoplasia: high miss rate but slow progression.

Background and aims Gastric superficial neoplasia (GSN) is often overlooked at endoscopy because of difficulty in identifying it. The miss rate of GSN at endoscopy and the impact on clinical outcome of the missed GSN have not been fully elucidated. In this study, we investigated these issues. Methods Among 1462 endoscopically and pathologically diagnosed gastric cancers in our hospital from January 2011 to December 2014, previous records of esophagogastroduodenoscopy (EGD) were available for 198 lesions (index lesions) and were reviewed retrospectively. Among those, 157 lesions, which were diagnosed as GSN on the basis of their EGD findings at initial endoscopy, were analyzed. Progression was defined as advanced cancer in the index lesion. Results Among the 157 GSNs, 118 (75.2 %) had not been recorded in the previous EGD report but were evident upon review of endoscopic photographs for this study. Progression to advanced cancer was observed in only 13 (8.3 %) of the 157 GSNs during a mean interval of 41 months and as long as 96 months, and the rate of progression was similar in missed and not-missed lesions (8.5 % and 7.7 %, respectively). Cumulative incidence rates of progression of missed GSNs to advanced cancer were 0.8 %, 1.7 %, 4.2 %, and 7.6 % at 36, 48, 60, and 72 months after the initial EGD, respectively. Conclusions Our findings illustrate that GSNs are often missed at endoscopy but progress slowly in most cases. Even though the rate of progression to cancer is relatively low, rigorous attempts should be made to reduce the miss rate of GSNs at EGD.