Gastrointestinal Endoscopic Biopsy Research Articles

The clinicopathological features of lower gastrointestinal tract endoscopic biopsies in Benin City, Nigeria

Background: Despite the increasing incidence of colorectal cancer in Nigeria, there is no established colorectal screening program in Nigeria and only a few studies have been done on the pathologic features of colonoscopic biopsies in Nigeria. Materials and Methods: The lower gastrointestinal tract biopsy specimens were assessed in the histopathology surgical day books. The demographic information on the age and sex and the clinical information, presenting complaints and endoscopic findings were obtained from the original request cards. All of the archival slides were retrieved and reviewed with the diagnosis confirmed. Also, all available formalin fixed and paraffin embedded tissue blocks of lower gastrointestinal colonoscopic biopsies were sectioned at 3-5μm and stained with haematoxylin and eosin. Each lesion was diagnosed based on specific pathologic findings, clinical history and endoscopic findings as a guide. Neoplastic lesions were classified using the World Health Organization classification (2010]. Study Design: The study aims to describe the common lesions diagnosed on lower gastrointestinal (GI) endoscopy. The clinical history, endoscopic findings, slides, and paraffin-embedded blocks of all endoscopic biopsies of the lower GI tract seen from 2008 to 2012 were studied, and data obtained were analyzed using the SPSS version 16 software. Results: Two hundred and forty-nine specimens were studied. Fifty-seven (22.9%) of these biopsies were normal colonic mucosa and 192 (77.1%) of these biopsies had remarkable pathologies. The most common clinical indication for colonoscopy in this study was hematochezia and over half of these patients (48.6%) had malignant lesions. The most common lesions seen on endoscopy were polyps which were seen in 18.5% of cases. Seventy (36.5%) of these lesions were malignant, with epithelial cancers 67 (95.7%) being the vast majority. Thirty-five (18.2%) of the lesions were benign neoplastic lesions, 52 (27.1%) were inflammatory lesions, 18 (9.4%) were inflammatory bowel disease, 10 (5.2%) were hyperplastic polyps, and 7 (3.6%) were vascular lesions. Conclusion: A wide spectrum of lesions was diagnosed in this study with the predominant lesion diagnosed being malignant neoplastic lesions. The most common clinical indication for endoscopy was hematochezia with over half of these patients having a malignant lesion.

Gastric Mucosal Calcinosis

Background: Gastric mucosal calcinosis (GMC) is a rarely encountered disease characterized by calcific deposition in the gastric mucosa which was known to be associated with organ transplantation, end-stage renal disease, hypercalcemia, hyperphosphatemia, gastric neoplasia, medications such as antacids containing aluminum, sucralfate and bismuth, and so on. We describe incidentally found 23 cases of GMC. Methods: We identified 23 cases of GMC from July 2004 to June 2011 from pathology department records. All available inpatient and outpatient medical records including laboratory data were reviewed. Results: 23 cases (9 male and 14 femal: median age of 65.2, range 34-85) were found incidentally by upper gastrointestinal endoscopic biopsy. The microscopic examination showed multifocal basophilic calcific material just beneath the surface epithelium. 14 patients (60.9%) were taking tripotassium dicitrato bismuthate in variable duration from one week to four years, 5 patients (21.7%) were taking aluminum containing antacid and 2 patient (8.7%) were taking both of them. 1 patient (4.3%) showed hypercalcemia with increased parathyroid hormone. The patients had no history of renal insufficiency, organ transplantation or gastric malignancy and had variable symptoms according to other comorbid gastrointestinal diseases, in example, gastritis, gastroesophageal reflux disease, and functional dyspepsia. The endoscopic findings were hyperemia, edema, chalky or salty-white plaque in common and other frequently accompanying feature was spontaneous bleeding. However, endoscopic finding of 2 pateints (8.7%) showed gastric polyp which confirmed GMC pathologically. There was no difference of endoscopic findings between different etiologies. Follow up endoscopy which was available in 8 patients (34.8%) from two months to two years after stopping offending medication showed disappearance of previous noted GMC. Conclusion: Gastric mucosal calcinosis can develop in normal tissue because of altered serum or mucosal biochemical environment associated with therapeutic measures and can be reversed after abstinence of the offending medication.

Bleeding Risk Related to Upper Gastrointestinal Endoscopic Biopsy in Patients Receiving Antithrombotic Therapy: A Multicenter Prospective Observational Study

BackgroundAlthough antithrombotic agents are widely used for cardiac and cerebrovascular disease prevention, they increase the risk of gastrointestinal (GI) bleeding. ObjectiveTo examine GI bleeding risk in association with an esophagogastroduodenoscopy (EGD) biopsy performed in patients without cessation of antithrombotic therapy. MethodsThis study was prospectively conducted at 14 centers. EGD biopsies were performed in patients receiving antithrombotic agents without cessation, as well as age- and sex-matched controls not receiving antithrombotic therapy. Patients treated with warfarin before the biopsy had a prothrombin time-international normalized ratio level <3.0. The proportion of GI bleeding events was compared between the groups. ResultsThe patient group (n = 277) underwent a total of 560 biopsies while continuing antithrombotic therapy, of whom 24 were receiving multiple antiplatelet drugs, and 9 were receiving both antiplatelet and anticoagulant agents. The control patients (n = 263) underwent 557 biopsies. The upper-GI bleeding rate within 30 days after the EGD biopsy did not increase in patients without cessation of antithrombotic treatment, regardless of receiving single or multiple antithrombotic agents. ConclusionsWe found no significant increase in upper-GI bleeding risk following an EGD biopsy in patients taking antithrombotic agents, suggesting its safety without the need for antithrombotic treatment interruption.

Carcinoma of the Ampulla of Vater Associated with Annular Pancreas.

Carcinoma of the ampulla of Vater associated with annular pancreas is a rare entity. Only seven cases have been reported so far in the English literature. We herein report one such case in a 42-year-lady who presented with progressively increasing jaundice and pain in the upper abdomen for past 2months. A magnetic resonance cholangiopancreaticography (MRCP) and MRI revealed an annular pancreas with an ampullary mass and a dilated CBD. An upper gastrointestinal endoscopic biopsy from the ampullary mass revealed a moderately differentiated adenocarcinoma. She was diagnosed as having annular pancreas with periampullary cancer that was subsequently confirmed at laparotomy. Histological examination confirmed a complete annular pancreas with a 2cm×2cm moderately differentiated adenocarcinoma of the ampulla of Vater. The management, however, remains as in any case of periampullary malignancy. This highlights the importance that obstructive jaundice in an adult patient presenting with annular pancreas may be associated with a coexisting periampullary malignancy.

Evaluating Quality and Adequacy of Gastrointestinal Samples Collected using Reusable or Disposable Forceps.

BackgroundSample quality of gastrointestinal endoscopic biopsies is of paramount importance for accurate histological diagnosis. Many veterinary practices use reusable forceps as a result of perceived decreased cost. With reusable forceps, it remains unknown whether sample quality declines with repeated use and becomes inferior to single‐use forceps and is therefore more or less cost effective than single‐use forceps.Hypothesis/ObjectivesThe study hypothesis was that reusable forceps sample quality would deteriorate after repeated use as compared to single‐use forceps.AnimalsSixty‐five dogs undergoing gastrointestinal endoscopy for diagnostic investigations at the Hospital for Small Animals, Edinburgh University.MethodA prospective, pathologist‐blinded study comparing single‐use and reusable alligator standard cup biopsy forceps (Olympus 2.0 mm 1550 mm) with 5 randomized reusable forceps. Sample quality (stomach, duodenum, ileum, and colon) was assessed by a single pathologist using the WSAVA guidelines.ResultsThere was no difference in the adequacy, depth, villi number, or crush artifact in the 4 intestinal areas between forceps type with at least 10, and up to 15, repeated uses of the reusable forceps.Conclusions and clinical importanceThis study demonstrates that reusable cup biopsy forceps provide equivalent biopsy quality after repeated uses to single‐use forceps and are cost effective at 10‐case use.

Dual diagnosis of gastrointestinal stromal tumour and papillary renal cell carcinoma by upper gastrointestinal endoscopic ultrasound-guided fine-needle aspiration biopsy: A case report

Dual diagnosis of gastrointestinal stromal tumour and papillary renal cell carcinoma by upper gastrointestinal endoscopic ultrasound-guided fine-needle aspiration biopsy: A case report

Intestinal ganglioneuromatosis with peri-intestinal neurofibroma limited to the gastrointestinal tract mimicking Crohn’s disease

S S141 characteristic. As patients with TDT-negative T-ALL/LBL tend to show worse outcome, it is important to remember that lack of TDT expression is expected in subsets of T-ALL/LBL. This pitfall should not preclude a correct diagnosis. 71. INTESTINAL GANGLIONEUROMATOSIS WITH PERI-INTESTINAL NEUROFIBROMA LIMITED TO THE GASTROINTESTINAL TRACT MIMICKING CROHN’S DISEASE Sushmitha Malpe Gopal, Anuradha C.K. Rao, Ranjini Kudva, Rajgopal Shenoy 1Department of Pathology, Melaka Manipal Medical College, and 2Department of Pathology and Surgery, Kasturba Medical College, Manipal, Manipal University, Karnataka, India Introduction: Ganglioneuroma is a benign neurogenic tumor composed of ganglion cells, nerve fibers and Schwann cells. Intestinal ganglioneuromas are rare tumors more often identified in the adults as solitary polypoidganglioneuromas, ganglioneuromatous polyposis and diffuse ganglioneuromatosis, presenting with abdominal pain, diarrhoea, thickening of the bowel wall and stricture formation. Diffuse ganglioneuromatosis is typically associated with multiple endocrine neoplasia, neurofibromatosis type 1 and Cowden syndrome. In this case report, we describe a case of diffuse and poylpoidganglioneuromatosis along with peri-intestinal neurofibroma in a 30 year old female with no syndromic afflictions. Case report: 30 year old female was investigated for recurrent alternating episodes of constipation and diarrhoea since 15 days associated with abdominal distension and palpable mass per abdomen. On CECT abdomen and pelvis, multifocal strictures with subacute intestinal obstruction was noted with possibilities of Crohns disease or tuberculosis. Surgically resected terminal ileum and ascending colon showed multiple linear ulcers, pseudopolyps and cobblestone appearance. On histopathological examination of the resected specimen, diagnosis of intestinal ganglioneuromatosis (polypoid and diffuse) with suture granuloma and peri-intestinal neurofibroma was given. History elicited for similar prior complaints showed nonspecific ileocolitis on biopsy 2 years earlier. She also gave history of surgery for resection and anastomosis 6 years back. Conclusion: We report a patient with intestinal ganglioneuromatosis in whom clinical and radiological findings mimicked those of Crohn’s disease/tuberculosis. Despite its rarity, intestinal ganglioneuromatosis should be considered in patients with findings of Crohn’s disease/tuberculosis on radiological investigations who have intractable symptoms despite medical treatment. 72. HISTOPATHOLOGICAL STUDY OF UPPER GASTROINTESTINAL ENDOSCOPIC BIOPSY IN PATIENTS WITH DYSPHAGIA AND DYSPEPSIA IN SOUTH WESTERN COAST OF INDIA Sushmitha Malpe Gopal, G.N. Srinivas, Rashmi Vaidya 1Melaka Manipal Medical College, Manipal University, Manipal, 2SRL Diagnostics, Mysore, and 3AJ Institute of Medical Sciences, Mangalore, India Background: Patients with non-neoplastic and neoplastic lesions of upper gastrointestinal tract (GIT) exhibit important alarming symptoms like dysphagia and dyspepsia. Upper gastrointestinal endoscopic biopsy is an effective and appropriate investigation to assess these patients. Aims: The aim of this study is to identify various lesions of the upper GIT in patients presenting with dysphagia and dyspepsia along with endoscopic and clinical correlation. For early identification of malignant lesions, screening of premalignant lesions and to differentiate non neoplastic lesions from neoplastic lesions and thus help in its appropriate management. Method: 200 consecutive endoscopic biopsy samples received in histopathology laboratory in and around Mangalore, India for a period of two years was subjected for histopathological examination. All the samples received in the histopathology laboratory sent in 10% formalin was processed, haematoxylin and eosin staining was done. Special stains were done wherever necessary. Results: 80% of the patients presented with dyspepsia. The most common lesion encountered in the oesophagus was malignant lesions followed by premalignant lesions, benign neoplasms and non-neoplastic lesions. The most commonly encountered gastric lesion were non neoplastic lesions followed by malignancy, premalignant lesions and benign neoplasm. Among the duodenal biopsies, non-neoplastic lesions were most common followed by malignancy. Conclusion: The fibreoptic diagnostic upper GI endoscopic biopsy is relatively less invasive, simple, safe, well tolerated procedure, cost effective and provides good diagnostic yield in confirming various upper GIT lesions. There is concordance of endoscopic biopsy findings with post biopsy resected specimens. In routine clinical practice, histopathology is the ‘gold standard’ for the definitive diagnosis of various lesions. 73. INTRAVASCULAR HISTIOCYTOSIS (IVH): A CASE REPORT K. Manoharan, B. Dutta Department of Anatomical Pathology, Laverty Pathology, NSW,

Histopathological study of upper gastrointestinal endoscopic biopsy in patients with dysphagia and dyspepsia in south western coast of India

Histopathological study of upper gastrointestinal endoscopic biopsy in patients with dysphagia and dyspepsia in south western coast of India

Gastrointestinal Endoscopic Ultrasound-Guided Fine-Needle Aspiration Biopsy Specimens: Adequate Diagnostic Yield and Accuracy Can Be Achieved without On-Site Evaluation

Background: Endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNA) is the preferred method for biopsying the gastrointestinal tract, and rapid on-site cytological evaluation is considered standard practice. Our institution does not perform on-site evaluation; this study analyzes our overall diagnostic yield, accuracy, and incidence of nondiagnostic cases to determine the validity of this strategy. Design: Data encompassing clinical information, procedural records, and cytological assessment were analyzed for gastrointestinal EUS-FNA procedures (n = 85) performed at Vancouver General Hospital from January 2012 to January 2013. We compared our results with those of studies that had on-site evaluation and studies that did not have on-site evaluation. Results: Eighty-five biopsies were performed in 78 patients, from sites that included the pancreas, the stomach, the duodenum, lymph nodes, and retroperitoneal masses. Malignancies were diagnosed in 45 (53%) biopsies, while 24 (29%) encompassed benign entities. Suspicious and atypical results were recorded in 8 (9%) and 6 (7%) cases, respectively. Only 2 (2%) cases received a cytological diagnosis of ‘nondiagnostic'. Our overall accuracy was 72%, our diagnostic yield was 98%, and our nondiagnostic rate was 2%. Our results did not significantly differ from those of studies that did have on-site evaluation. Conclusion: Our study highlights that adequate diagnostic accuracy can be achieved without on-site evaluation.

The relationship between cytotoxin-associated gene A positive Helicobacter pylori infection and autoimmune thyroid disease

Objective: The aim of this study was to determine whether there is an association between cagA [cytotoxin-associated gene A] positivity and thyroid autoimmunity and thyroid volume. Methods: This prospective study included 78 Helicobacter pylori-positive (H. pylori) dyspeptic patients in the study group, and 50 age-, gender-, and body mass index-matched H. pylori-negative dyspeptic patients in the control group. All the controls were evaluated via upper gastrointestinal endoscopic biopsy or breath test, and were found as H. pylori negative. Gastric biopsy specimens were obtained via endoscopy and histological examination was performed for documentation of H. pylori. Results: In all, 55.1% (n = 43) of the H. pylori-positive patients were cagA positive. There was no significant difference in metabolic syndrome parameters or thyroid function test results between the study and control groups. The frequency of anti-TPO and Hashimoto’s thyroiditis positivity was significantly higher in the study group than in the control group. Thyroid volume was higher and severe parenchymal heterogeneity was more common in the H. pylori-positive patients. Conclusions: H. pylori infection might be a risk factor for autoimmune thyroid disease and high thyroid volume in patients diagnosed with histological evaluation. However, cagA positivity has no additional effect on these parameters.

Gastrointestinal complications in renal transplant recipients detected by endoscopic biopsies in a developing country.

Renal transplantation is the treatment of choice for patients with end-stage renal disease. The renal transplant recipients are susceptible to a variety of gastrointestinal (GI) complications such as infections, ulcer disease, and malignancies. We aimed to determine the frequency of pathological lesions in GI endoscopic biopsies in recipients of live related renal transplantation in our setting. This retrospective survey was carried out at Histopathology Department of Sindh Institute of Urology and Transplantation, Karachi, from December 2010 to January 2011. All consecutive renal transplant patients of all ages and both genders on regular follow up, presenting with GI complaints and in whom GI endoscopic biopsies were performed, were included. The demographic, clinical, and laboratory data were retrieved from case files and the pathological diagnoses from the original biopsy reports. A total of 200 consecutive renal transplant patients were enrolled. The biopsies comprised of 19 (9.5%) esophageal biopsies, 119 (59.5%) gastric biopsies, 148 (74%) duodenal biopsies, and 66 (33%) colorectal biopsies. The main pathological lesions included cytomegalovirus infection in 22 (11%) of all patients, Helicobacter pylori in 11 (9.2%) of gastric biopsies, cryptosporidium in 4 (1.6%), giardiasis in 30 (15%), immunoproliferative small intestinal disease in 5 (3.4%), tropical sprue in 33 (15%), tuberculosis in 3 (2%) of the small intestinal biopsies, and gastric adenocarcinoma in 1 (1.7%) gastric biopsy. A wide spectrum of pathological lesions including opportunistic infections was seen in GI endoscopic biopsies in renal transplant patients. Endoscopic biopsies play an important role in the diagnosis and management of GI disease in renal transplant patients.

Imprint cytology: A diagnostic aid in interpretation of upper gastrointestinal endoscopic biopsies

Abstract Context: Although major advances have occurred in the cytological diagnosis of various organ pathologies, gastrointestinal (GI) cytology has not gained popularity and is only occasionally practiced in the form of brushings and washings. Biopsy touch imprint cytology (IC) is a rapid, simple and inexpensive method of diagnosis of upper GI lesions. Thus, a study to show a correlation of IC and standard histopathology will allow the procedure to be performed routinely as adjunct to histopathology. Aims: To correlate results of imprints made from upper GI biopsies with histopathology in case of suspected upper GI lesions and to compare detection of Helicobacter pylori by IC and histopathology in suspected H. pylori infection. Subjects and Methods: One hundred and ten cases of upper GI endoscopic biopsies were included in the study. Touch imprints were made from the biopsies, stained and studied. The same tissue was put in 10% formalin for histopathological processing. Results of IC were compared with histopathology. Statistical Analysis Used: Chi-square/Fisher exact test were used to find out significance of study parameters. Results: Sensitivity and specificity of IC for neoplastic lesions were 94.3%, 100% for esophageal lesions; 88.2%, 97.14% for gastric lesions and 100%, 100% for duodenal lesions respectively, which correlated with other studies. Imprint smears for H. pylori had sensitivity of 80%, which was higher than that of brush cytology. Conclusions: IC is a valuable diagnostic tool and can be routinely applied as an adjunct to histopathological examination in the diagnosis of GI lesions.

Gastrointestinal pathological changes in stem cell transplant patients

The last 5 years have seen an expansion of knowledge about the gastrointestinal diseases that may present in haematopoietic stem cell transplant (HSCT) patients and also about new gastrointestinal diseases in this patient population. This article summarizes the recent opinions and findings regarding gastrointestinal graft-versus-host disease, and viral and other opportunistic gastrointestinal infections that can develop in HSCT patients. This article also discusses the more newly described entities of mycophenolate-mofetil-related gastrointestinal injury and cord colitis syndrome. This review emphasizes the need for comprehensive clinical information when assessing gastrointestinal endoscopic biopsies from HSCT patients. It is crucial that both clinicians and histopathologists are aware of several specific but rare gastrointestinal diseases that may develop in these patients, because several of these diseases have specific treatments.

Safety of gastrointestinal endoscopic biopsy in patients taking antithrombotics.

Current Japanese gastrointestinal (GI) endoscopic guidelines permit endoscopic biopsy without cessation of antiplatelet agents and warfarin in patients with a therapeutic range of prothrombin time-international normalized ratio (PT-INR) levels, although the evidence levels are low. We evaluated the safety of endoscopic biopsy in patients currently taking antithrombotics. Consecutive patients receiving antithrombotics who underwent GI endoscopy from August 2012 to August 2013 were enrolled. Adverse events and endoscopic hemostasis after biopsy were evaluated. PT-INR level was measured in patients taking warfarin the day before endoscopy. Among 7939 patients undergoing endoscopy, 1034 patients (13.0%, 706 men and 328 women, average age 72.8 years) were receiving antithrombotics. Antithrombotics included aspirin (44.8%), warfarin (34.7%), thienopyridine (16.1%), cilostazol (10.3%), dabigatran (4.8%) etc. PT-INR levels in patients taking warfarin were >3.0 in 13 patients (4.3%), between 2.5 and 3.0 in 18 patients (6.0%), <2.5 in 269 patients (89.7%). Two hundred and six patients received endoscopic biopsy while taking aspirin (51.2%), warfarin (22.8%), and thienopyridine (13.6%). Endoscopic hemostasis was required in three patients after endoscopic biopsy (spraying thrombin in two patients, spraying thrombin and clipping in one patient). There were no major complications. The incidence of endoscopic hemostasis after biopsy in patients without antithrombotic cessation was not significantly different than in the controls not taking antithrombotics (1.5% vs 0.98%, P = 0.51). Endoscopic biopsy did not increase the bleeding risk despite not stopping antithrombotics prior to biopsy even among patients taking warfarin whose PT-INR was within the therapeutic range.

English

Stomach is the commonest extranodal site of lymphomas. A case of Non-Hodgkin's Lymphoma of stomach is reported here for its unusual way of presentation. Fifty year old male presented with features of perforation peritonitis, which on exploration turned out to be a Non- Hodgkin's lymphoma of stomach with perforation. Usually gastric lymphomas are diagnosed on upper gastrointestinal endoscopic examination and biopsy in patients with epigastric pain, early satiety and weight loss. Detailed review of literature denotes that spontaneous perforation in a case of lymphoma of the gastrointestinal tract is uncommon, although many cases of perforation after chemo or radiotherapy are reported.

Role of Imprint Cytology in the Diagnosis of Upper Gastrointestinal Tract Lesions

Background: Histological study of the upper gastrointestinal (GI) endoscopic biopsies provides an accurate diagnosis of the lesions occurring in these regions. But the limitation of histology is longer time required. Study of imprint smears of endoscopic biopsies enables an immediate report. Aim: To compare the accuracy of endoscopic biopsy imprint cytology with histology in the diagnosis of upper gastrointestinal tract lesions. Materials and Method: A total of 77 cases were studied over a period of two years. The endoscopic biopsy tissue was first taken on a clean glass slide and rolled gently with the help of a needle to make an imprint of the tissue on the slide. These imprint smears were immediately fixed with 95% alcohol and stained with H and E and PAP stain. After the imprint smears are made the same biopsy tissue was then put in 10% formalin for routine histopathological processing. Two separate staff studied the imprint smears and histopathology slides independently and later the findings were correlated. Results: Biopsy histology results were found to be correct in 100% cases. Imprint cytology had an overall accuracy of 97.6%, 100% and 100% for the diagnosis of malignancies of the oesophagus, stomach and duodenum respectively. One false result was obtained in oesophageal lesions. The combined diagnostic accuracy of imprint cytology and histology for all upper GI lesions was 100%. Conclusion: Imprint cytology can serve as a useful and simple tool for an immediate and accurate diagnosis of upper GI malignancies.

Gastrointestinal Bleed Secondary to Renal Cell Carcinoma

Introduction: Occult gastrointestinal (GI) bleeding can be a vexing problem to the physician. Malignant causes for upper GI bleed account for 1-4% of causes with duodenum being least frequent site involved. We present a case to present the clinical entity of metastatic malignancy of duodenum as a rare cause of GI bleeding. Case: An 80-year-old male was admitted to our institution for black tarry stools for the last three months of duration. Past medical history was significant for renal cell cancer status post right sided nephrectomy one year ago. Examination revealed pallor and orthostatic hypotension. Laboratory values revealed anemia with Hb of 5.6 gm/dL for which he received blood transfusion. CT scan abdomen revealed heterogenous soft tisuue mass in the right nephrectomy bed invading the duodenum. Upper GI endoscopic biopsy confirmed the presence of metastatic renal cell cancer (Figure 1). Howerever, due to extensive metastatic disease, patient was placed on palliative chemotherapy as surgical options were ruled out. The patient received multiple blood transfusions due to persistent GI bleeding and died ten months later. Discussion: Gastrointestinal bleeding is always challenging and diagnosing duodenal metastasis as a cause of GI bleeding is intricate due to its rarity and hence low index of suspicion. Duodenal metastasis present as acute or chronic GI haemorrhage, duodenal obstruction or obstructive jaundice. Involvement is usually the result of direct infiltration, lymphatic, hematogenous or transcoelomic spread. Duodenal lesions may be apparent on barium studies or CT scan abdomen demonstrating thickening of wall or folds in the involved segment. Endoscopy reveals non-ulcerative mass, submucosal tumor masses or multiple nodules with ulceration. Management depends on general condition including gastroduodenal artery embolization or surgical intervention. Our case report reiterates the importance of maintaining a high index of suspicion for considering malignancy as a cause of gastrointestinal bleed which needs prompt diagnosis to initiate therapy in a timely fashion.Figure 1: Endoscopic picture of fungating mass in the duodenum.

Duodenal Endoscopic Findings and Histopathologic Confirmation of Intestinal Lymphangiectasia in Dogs

The diagnosis of intestinal lymphangiectasia (IL) has been associated with characteristic duodenal mucosal changes. However, the sensitivity and specificity of the endoscopic duodenal mucosal appearance for the diagnosis of IL are not reported. To evaluate the utility of endoscopic images of the duodenum for diagnosis of IL. Endoscopic appearance of the duodenal mucosal might predict histopathologic diagnosis of IL with a high degree of sensitivity and specificity. 51 dogs that underwent upper gastrointestinal (GI) endoscopy and endoscopic biopsies. Retrospective review of images acquired during endoscopy. Dogs were included if adequate biopsies were obtained during upper GI endoscopy and digital images were saved during the procedure. Images were assessed for the presence and severity of IL. Using histopathology as the gold standard, the sensitivity and specificity of endoscopy for diagnosing IL were calculated. Intestinal lymphangiectasia (IL) was diagnosed in 25/51 dogs. Gross endoscopic appearance of the duodenal mucosa had a sensitivity and specificity (95% confidence interval) of 68% (46%, 84%) and 42% (24%, 63%), respectively for diagnosis of IL. Endoscopic images in cases with lymphopenia, hypocholesterolemia, and hypoalbuminemia had a sensitivity of 80%. Endoscopic duodenal mucosa appearance alone lacks specificity and has only a moderate sensitivity for diagnosis of IL. Evaluation of biomarkers associated with PLE improved the sensitivity; however, poor specificity for diagnosis of IL supports the need for histopathologic confirmation.

A Case of Steroid-induced Hyperinfective Strongyloidiasis with Bacterial Meningitis

Strongyloides stercoralis is a soil transmitted intestinal nematode that is endemic in the tropical and subtropical regions. In most individuals who are infected, chronic, usually asymptomatic, gastrointestinal infection persists. But, in immunocompromized hosts or in patients receiving immunosuppressive therapy, autoinfection of S. stercoralis may result in the dissemination of larvae, leading to fatal hyperinfection and increased rate of complications. We report a case of hyperinfective strongyloidiasis with bacterial meningitis in a patient receiving steroid therapy. Strongyloidiasis was diagnosed by the presence of filariform larvae of S. stercoralis in the bronchoalveolar lavage cytology and upper gastrointestinal endoscopic biopsy specimen. Her clinical symptoms had progressively aggravated and developed bacterial meningitis during treatment. She died despite aggressive antibiotic and antihelminthic therapy.

Sarcina Organisms in the Gastrointestinal Tract

Sarcina organisms were first observed in and recorded from the stomach contents of a patient suffering from vomiting by John Goodsir in 1842. Since that time, their fine structure, phylogenetic classification, and biochemical characteristics have been described. Although numerous cases of fatal disease have been attributed to this organism in the veterinary literature, only a few human cases have been documented. As a result, whether this organism causes disease in humans has not been definitively established. We report the clinicopathologic findings in a series of 5 patients with Sarcina-like organisms identified in upper gastrointestinal endoscopic biopsies with molecular confirmation. Our findings have shown that the organism is most commonly found in patients with a history of gastric outlet obstruction or delayed gastric emptying. Although many of the patients do not demonstrate direct mucosal injury from the organism, the presence of a concurrent gastric ulcer puts the patient at increased risk for complications such as emphysematous gastritis or perforation. The finding of Sarcina organisms should prompt further investigation for functional causes of gastric outlet obstruction and delayed gastric emptying, such as occult malignancy.