Gastrointestinal Endoscopic Examination Research Articles

Primary duodenal Burkitt lymphoma presenting as sessile, button-like bleeding polyps

Summary Primary gastrointestinal (GI) lymphoma accounts for 30–50% of all extranodal non-Hodgkin’s lymphomas, making the GI tract the most common site of extranodal non-Hodgkin’s lymphomas. Most GI lymphomas belong to the B cell lineage. Burkitt lymphoma (BL) is a highly aggressive mature B cell neoplasm that occurs in three forms: endemic, sporadic, and immunodeficiency-associated. Sporadic BL accounts for 1–2% of all adult lymphomas and usually presents as an abdominal manifestation of extranodal disease involving the distal ileum or cecum. Primary BL of the duodenum is rare. However, this report emphasizes the importance of awareness of the malignancy potential of duodenal polyps. We report the case of a 70-year-old woman admitted to our ward with upper GI bleeding due to duodenal polyps. An upper GI endoscopic examination showed button-like polyps with central depression, and an immunohistochemical study of the polyps revealed a high-grade B cell malignancy (BL). Consequently, the patient was treated with aggressive chemotherapy. The tumors regressed after chemotherapy. Although primary duodenal Burkitt lymphoma is very rare, the possibility of malignancy should be considered if a patient presents with duodenal button-like polyps with a central depressed surface.

An uncommon diagnosis of celiac disease in a thalassemic girl

s / Digestive and Liver Disease 46 (2014) e85–e127 e117 AN UNCOMMON DIAGNOSIS OF CELIAC DISEASE IN A THALASSEMIC GIRL Monica Montuori1,∗, Maria Paola Smacchia2, Donatella Iorfida1, Stefania Leoni1, Chiara Maria Trovato1, Silvia Gatti 1, Ilaria Celletti 1, Francesco Valitutti 1, Michela Capogna2, Caterina Anania1, Salvatore Cucchiara1 1 UOC Gastroenterologia ed Epatologia Pediatrica, Sapienza Universita di Roma, Roma, Italy 2 Presidio Regionale Malattie Ereditarie, Sapienza-Universita di Roma, Roma, Italy Celiac disease (CD) has a heterogeneous clinical expression. This report describes an uncommon CD diagnosis in a 21 year old girl, affected by thalassemia major and followed at our Hematology Unit. Her ferritin levels used to range between 700 and 1000 g/L when she was on deferoxamine (40mg/kg/day s.c.), therefore replaced with deferosilax (30–40mg/kg/day per os) with stabilization of values around 400 g/L. After EBV infection, recurrent abdominal pains and diarrhea appeared. Few months later, ferritin levels decreased stepwise to 120 g/L albeit the same daily iron intake (blood transfusions) and the same drug dose, leading hematologists to reduce deferosilax up to 13mg/kg/day. Her values increased up to 300 g/L. Thereafter, she was sent at our Gastroenterology and Hepatology Unit because of persisting gastrointestinal symptoms. Screening for CD showed anti-transglutaminase IgA>100UA/mL (<16) and positive antiendomysial antibodies. A reduction in number and height of foldswas found in bulb and duodenum at upper gastrointestinal endoscopy and histological examination confirmed CD diagnosis (MarshOberhuber 3a-3b). Once on gluten-free diet (GFD) ferritin levels rose to 568 g/L, thus requiring to increase deferosilax dose. This report suggests to consider undiagnosedCD in thalassemic patients when ferritin levels unexpectedly decrease demanding a lower iron chelator dose, perhaps due to un underlying malabsorption. Although the GFD leads to increased ferritin levels, it remains essential in order to prevent the risk of CD complication in organs such as liver, pancreas, thyroid, bone and heart, already potentially damaged by hematological condition. http://dx.doi.org/10.1016/j.dld.2014.07.138 A CASE OF ASYMPTOMATIC GASTRITIS NODULAR HP-RELATED AND COELIAC DISEASE Elvira Difrancisca ∗, Maria Letizia Lospalluti, Giuseppe Iacono Azienda Ospedaliera di Rilievo Nazionale ad Alta SpecializzazioneCivico, G. Di Cristina Benfratelli,

Histopathological Pattern of Endoscopic Gastric Biopsy in a District Hospital in Nigeria: A Review of 118 Consecutive Cases

Background: The use of endoscopes for visualization of gastric mucosa has improved over times and in taking biopsy for histology. The study sets out to determine the histopathological pattern of gastritis in dyspeptic patients and correlate the histological detection of H. pylori with that of urease breath test (UBT). Method: Prospective study of 118 consecutive patients with chronic dyspepsia who underwent upper gastrointestinal endoscopic examination and UBT using heliprobe. Biopsy of gastric antrum were taken at endoscopy and sent for histopathological analysis. Routine HE UBT, 46(69.6%) were positive for H. pylori and 20(30.4%) negative. There was a strong correlation between the true positive and true negative patients for the first 66 consecutive cases for both histology and UBT based diagnosis for detecting H. pylori. (Correlation coefficient=0.862, p=0.01). Conclusion: The study showed that histology and UBT are both useful for H. pylori detection. Large multi centre studies should be done to adopt the non-invasive UBT in resource poor economies for the eradication of H. pylori.

Hyperbaric oxygen therapy for bleeding due to gastritis induced by chemoradiotherapy for regional recurrence of esophageal cancer post-radical esophagectomy

Chemoradiotherapy is effective for locoregional recurrence of esophageal cancer after esophagectomy, although it is important to watch out for adverse events, especially following the late phase. We encountered a patient with bleeding from the gastric conduit caused by chemoradiation-induced gastritis after chemoradiotherapy for mediastinal lymph node recurrence post-radical esophagectomy for esophageal cancer. A 58-year-old male was undergoing chemoradiotherapy for mediastinal lymph node recurrence. About 3 months after the start of the therapy, the patient presented with anemia and bleeding from the gastric conduit caused by chemoradiation-induced gastritis as assessed by fiber optic upper gastrointestinal endoscopy and blood examination. Multiple sessions of argon plasma coagulation for ablation of the gastric mucosal telangiectasia proved ineffective. However, hyperbaric oxygen therapy was effective and the symptom has not recurred until date after this therapy.

Diffuse nodular lymphoid hyperplasia of the small bowel associated with common variable immunodeficiency and giardiasis: a rare case report

Diffuse nodular lymphoid hyperplasia (DNLH) of the intestine is an extremely rare lymphoproliferative disorder of uncertain etiology. Typically, numerous polypoid nodules composed of hyperplastic benign lymphoid tissue are present in the small and/or large intestinal mucosa. DNLH has been observed in association with common variable immunodeficiency (CVID). A 38-years-old man was admitted to our clinic due to dyspeptic complaints. An upper gastrointestinal system endoscopic examination revealed DNLH in the duodenum. A biopsy specimen showed the presence of nodular lymphoid hyperplasia and a Giardia lamblia infection in the duodenum. CVID was suspected, and the diagnosis was established by demonstrating a significant reduction in the serum gamma-globulin levels. DNLH is a rare benign condition with regards to diagnosis and treatment of unknown etiology. In patients with DNLH, screening for the immune deficiencies is being important in addition to histopathological examinations.

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.

Esophageal actinomycosis in a patient with end‐stage renal disease

Actinomycosis of esophagus is uncommon. Herpes simplex virus, cytomegalovirus, candidiasis, tuberculosis, and other fungal infections are the commonly reported infections in both immunocompromised and immunocompetent patients. We report a case of esophageal actinomycosis in an end-stage renal disease patient. A 28-year-old lady, known case of systemic lupus erythematosus, hepatitis B virus infection with end-stage renal disease on regular maintenance hemodialysis since 5 years presented with history of epigastric pain and odynophagia for 1 week. Her upper gastrointestinal endoscopic examination revealed extensive necrotic areas with membrane in the esophagus. Histopathology revealed actinomycotic colonies and bacterial clumps. She was treated with intravenous penicillin followed by oral ampicillin for 6 months. She showed marked clinical improvement, and repeat endoscopy showed healing of ulceration and no evidence of actinomycosis.

Gastric outlet obstruction due to a giant antral polyp which have malignant transformation

Introduction: Gastric polyps are seen 2–3% in all gastrointestinal endoscopic examinations. Hyperplastic polyps, the most common type of gastric polyps, are present 85–90% of cases. Giant villous tumors of the stomach are somewhat rare and the high incidence of malignant transformation of them requires prompt diagnosis. Giant gastric polyps can also cause gastrointestinal bleeding that leads to iron deficiency anemia or partial gastric outlet obstruction. All giant polyps must be resected endoscopically or surgically and still there are no marked

Epiglottic cyst incidentally discovered during screening endoscopy: a case report and review of literature.

From the endoscopists' point of view, although the main focus of upper gastrointestinal endoscopic examination is the esophagus, stomach, and duodenum (usually bulb and 2nd portion including ampulla of Vater), the portions of the upper airway may also be observed during insertion and withdrawal of the endoscope, such as pharynx and larynx. Thus, a variety of pathologic lesions of the upper airway can be encountered during upper endoscopy. Among these lesions, an epiglottic cyst is relatively uncommon. The cyst has no malignant potential and mostly remains asymptomatic in adults. However, if large enough, epiglottic cysts can compromise the airway and can be potentially life-threatening when an emergency endotracheal intubation is needed. Thus, patients may benefit from early detection and treatment of these relatively asymptomatic lesions. In this report, we present a case of epiglottic cyst in an asymptomatic adult incidentally found by family physician during screening endoscopy, which was successfully removed without complication, using a laryngoscopic carbon dioxide laser.

Sedation and analgesia for gastrointestinal endoscopy in children

Different sedation or anesthesia protocols are available to enable gastrointestinal endoscopic examinations in children. None is optimal. Sedation is organized according to the medical system, resources and the availability of personnel and medication (sedatives, anesthetics, analgesics). If anesthesiologist’s sedation teams for children are not available, strong evidence supports sedation safety and efficiency when it is performed by specially educated non-anesthesiologists and registered nurses. This review is a brief synthesis of main guidelines and position papers of procedural sedation in children and, when unavailable, in adults, who are eligible for pediatric gastrointestinal endoscopy sedation by non-anesthesiologist. Published data are supplemented by clinical experience and the findings of author’s research on ketamine sedation. Other established sedative combinations are benzodiazepine and opioid or propofol as a sole agent or in combination with analgesics. Special stress is given on a proper choice of the sedation protocol for specific examination or procedure in accordance with institution’s policy. Whole endoscopic team has to be engaged in the implementation of new evidence and continuous education to achieve the highest possible safety and quality standards.

Esophagitis resulting from treatment with crizotinib for anaplastic lymphoma kinase rearrangement-positive lung adenocarcinoma: A case report

Non-small-cell lung cancer (NSCLC) is the most commonly diagnosed type of cancer and is a leading cause of cancer-related mortality worldwide. Treatment is currently focused on individualization according to the molecular profile of the disease. Here we present the case of a 41-year-old patient who presented with multiple pulmonary nodules, a left pleural effusion and an ovarian tumor. Adenocarcinoma of the lung was diagnosed from pathological examination of the pleural effusion and the surgically resected ovarian tumor, and chemotherapy was initiated. Relapse was experienced following third-line chemotherapy with pemetrexed and anaplastic lymphoma kinase (ALK)-positive adenocarcinoma was diagnosed using a specimen from the resected ovarian tumor. Subsequently, crizotinib therapy was initiated. Eight days later the patient developed severe nausea and vomiting and esophagitis was diagnosed by gastrointestinal endoscopic examination. Following the interruption of crizotinib treatment by treatment with a proton pump inhibitor (PPI), crizotinib treatment was re-initiated and was effective for a minimum of 6 months. Clinicians should be aware that treatment with crizotinib may result in severe esophagitis.

Gastropleural Fistula: A Rare Complication of Ewing Sarcoma

Gastropleural fistula (GPF) is a rare condition that can occur as a consequence of prior pulmonary surgery, trauma, or malignancy. Conservative management usually fails, and gastrectomy and even thoracotomy is often required, especially in debilitated patients. We present a patient with GPF who had a history of Ewing's sarcoma. Diagnosis of GPF was confirmed by upper gastrointestinal system endoscopy and radiographic contrast examination, and the patient underwent a laparoscopic wedge resection of the fistula. To our knowledge, this is the first report of a GPF, in the formation of which recurrence of Ewing's sarcoma had played a role and in the treatment of which wedge resection of the fistula was performed. Laparoscopic treatment of GPF may be associated with less morbidity and should be considered as the initial procedure of choice.

Evidence-Based Approach to Dyspepsia: From Helicobacter pylori to Functional Disease

Patients with dyspepsia may present with associated complaints of abdominal pain, bloating, fullness, acid reflux, and epigastric tenderness on examination. The evaluation of patients with dyspepsia includes taking a comprehensive history and performing a physical examination. Although taking a patient history has its limitations in making an accurate diagnosis, it is useful in guiding the selection of subsequent diagnostic tests. Differential diagnoses of dyspepsia are best addressed using an anatomical approach. Patients with chronic dyspepsia lasting > 1 month should be evaluated for the presence of alarm features. Alarm features mandate an upper gastrointestinal endoscopy examination, as these may be suggestive of a malignancy. In patients without alarm features, a Helicobacter pylori test-and-treat strategy is cost-effective if the prevalence of H pylori infection is high. Tests for H. pylori infection can be divided into non-invasive and minimally invasive tests. Many different antibiotic combination therapies (eg, triple therapy, quadruple therapy, levofloxacin-based therapy, sequential therapy, concomitant therapy, and probiotics with eradication therapy) are now available for the eradication of H pylori infection. In patients who are symptomatic without an organic pathology, functional dyspepsia and other causes of abdominal pain need to be considered. Functional dyspepsia is best managed using a multifaceted approach by establishing a good physician-patient relationship, dietary and lifestyle interventions, medical therapy, psychotherapy, and the use of psychotropic medications. This review rationalizes the current-day recommendations for the evaluation and management of patients with dyspepsia in a clinical setting.

Gastric juice MicroRNAs as potential biomarkers for the screening of gastric cancer

MicroRNAs (miRNAs) play a crucial role in carcinogenesis; however, it largely remains unclear whether miRNAs in gastric juice, which is specific for gastric tissues, can be used as biomarkers for gastric cancer. The objective of the current study was to investigate the feasibility of using gastric juice miRNAs as potential biomarkers to assist in screening for gastric cancer. Gastric juice samples were collected from 141 patients who underwent upper gastrointestinal endoscopy examination between September 2010 and December 2011. Gastric cancer and adjacent normal biopsy specimens also were collected. The existence and stability of miRNAs in gastric juices were determined by real-time reverse transcriptase-quantitative polymerase chain reaction (RT-qPCR) and sequencing. miRNA levels in tissues and gastric juices were detected by RT-qPCR. A receiver operating characteristic (ROC) curve was constructed for differentiating gastric cancer from benign gastric diseases. Levels of miRNA-21 (miR-21) and miR-106a in gastric cancer tissues were significantly higher compared with the levels in adjacent tissues (P = .006 and P = .001, respectively). Patients who had gastric cancer had significantly different levels of gastric juice miR-21 and miR-106a compared with patients who had benign gastric diseases (both P < .001). There were significant correlations between miR-21/miR-106a levels and Borrmann types. miR-21 levels in intestinal type gastric cancer specimens were higher than that in diffuse (P = .003) or mixed (P < .001) gastric cancer types. The area under the ROC curve was up to 0.969 for miR-21 and 0.871 for miR-106a. The current results indicated that certain miRNAs in gastric juice are potential biomarkers that can assist in screening for gastric cancer.

Elevated CA 19-9 Levels Observed in Association with a Pulmonary Neuroendocrine Tumour and Amyloid

Investigations completed in a 77-year-old ex-smoker presenting with weight loss showed raised CA 19-9 levels. The findings of chest radiograph, abdominal computed tomography (CT) and gastrointestinal endoscopic examinations were all normal. On follow-up, the patient developed left upper lobe collapse on chest radiograph with increasing CA 19-9 levels. Chest CT findings suggested the presence of a left upper lobe tumour. The results of a biopsy of the left upper lobe nodule seen on bronchoscopy suggested a diagnosis of amyloidosis; however, this was not the only diagnosis. The left upper lobe mass comprised a neuroendocrine tumour with amyloid deposition just beneath the bronchial epithelium and focally between the nests of the tumour cells. We report and discuss this uncommon association and presentation.

Coexistence of multiple gastrointestinal stromal tumors and signet ring cell carcinoma of stomach in a patient with neurofibromatosis type-1: case report

Gastrointestinal stromal tumors are mesenchymal neoplasias which are derived from Cajal's interstitial cells. The most common site of involvement is the stomach. It may be multiple in patients with Neurofibromatosis Type-1, while the small intestine is the most common location. In this case report, we aimed to present a Neurofibromatosis Type-1 patient, showing coexistence of multiple gastrointestinal stromal tumors in the stomach and small intestine with a signet ring cell carcinoma in the stomach. A 74-year-old female patient with poor appetite, vomiting and stomach ache was admitted to the hospital. After detection of a tumoral lesion with an ulcerated surface in stomach during the upper gastrointestinal tract endoscopic examination, the patient underwent surgery. During the operation, multiple nodular lesions were observed in the serosal surfaces of the small intestine and stomach. Gastrectomy and partial small intestine resection specimens were evaluated and the patient was diagnosed as signet ring cell carcinoma in the stomach, and multiple gastrointestinal stromal tumors in the serosal surfaces of both the stomach and small intestine. Resection specimens of patients with GIST need to be evaluated carefully on macroscopic examination, considering the possible presence of a coexistent tumoral lesion.

An Iatrogenic Sigmoid Perforation Caused by an Aortobifemoral Graft Mimicking an Advanced Colon Cancer

A 74-year-old man was transferred to our hospital due to melena and syncope. He had a history of an abdominal aortic aneurysm treated with aortobifemoral grafting 15 years previously. One month before admission, he reported several episodes of melena for which he underwent repeated gastrointestinal endoscopic examinations. None of these examinations revealed the site of gastrointestinal bleeding. Aortoenteric fistulae can therefore be missed if they are not considered in the differential diagnosis of gastrointestinal bleeding due to their rarity. As a result, secondary aortoenteric fistulae should therefore be considered in any patient presenting with gastrointestinal bleeding and a history of aortic surgery.

Observable Laryngopharyngeal Lesions during the Upper Gastrointestinal Endoscopy

Regardless of outstanding developments in the endoscopic field, laryngopharyngeal lesions are generally considered as a field of otolaryngology, and thus it is thought that not a lot of gastrointestinal endoscopists commonly take interest in these lesions during the upper gastrointestinal endoscopic examinations. Therefore, here in this thesis, I reviewed the availability of upper gastrointestinal endoscopy in laryngopharyngeal area, normal structures of laryngopharynx, and the lesions that can be observed with the standard upper gastrointestinal endoscopic procedure.

Appendiceal intussusception caused by endometriosis

In September, 2011, a 44-year-old woman presented to our surgical outpatient department with lower abdominal pain of a few weeks’ duration, nausea, and vomiting. There was no change in her bowel habits and no rectal bleeding. Her medical history included hiatus hernia, iron and folate defi ciency anaemia, and chronic fatigue syndrome. On physical examination she had lower abdominal tenderness, without signs of peritoneal irritation. Routine blood investigations showed low haemoglobin and high C-reactive protein concentrations. A gastrointestinal endoscopic examination was done because of her chronic symptoms and iron defi ciency anaemia, Gastroscopy did not show any upper gastrointestinal changes other than the hiatus hernia. However, colonoscopy showed a 3 cm luminal invagination of the caecum at the site of the appendiceal orifi ce, suggestive of an appendiceal intussusception (fi gure A). Appendiceal intussusception was confi rmed by a CT scan, which showed an intraluminal lesion corres ponding to an inverted appendix. Our patient was off ered open surgical resection. During surgery, caecal thickening with a complete appendiceal intussception was seen. The caecum and terminal ileum were well perfused. A partial caecectomy that included the intussuscepted appendix was done. Histological examination of the specimen confi rmed complete intussusception of the appendix, consistent with a Type-V McSwain classi fi cation, and previously unsuspected foci of endomet riosis scattered in the submucosa and muscularis propria, with involvement of the serosal surface (fi gure B). Our patient recovered and at 2-month follow-up in January, 2012, was pain free and on hor monal suppression of endometriosis. The reported incidence of endometriosis of the appendix is less than 1%. Endometriosis causing intussusception of the appendix is rare with only 37 published cases. Most reports have highlighted the diagnostic and management challenges. Young adults presenting with lower abdominal pain are commonly diagnosed with infl ammatory

Magnetic resonance imaging features of multiple duodenal lipomas: a rare cause of intestinal obstruction

A 65-year-old man was evaluated because of vomiting and epigastric pain. The patient underwent upper gastrointestinal endoscopy and endoscopic ultrasound examination and was found to have multiple polypoid lesions in the D1 and D2 portions of the duodenum, causing almost complete obstruction of the duodenal lumen. The lesions were hyperintense on T1-weighted and intermediately intense on T2-weighted images, with a drop in signal on T1- and T2-weighted fat-suppressed images, consistent with a diagnosis of duodenal lipomas. Pathohistological examination confirmed the diagnosis of duodenal lipomas.