Hemoccult Research Articles

Current evidence and development of colorectal cancer screening in Germany

Colon cancer is currently the third leading cause of cancer death in men and women in Germany, with atotal of about 25,000 deaths per year. Established methods for early detection of colorectal cancer include lower gastrointestinal endoscopy and fecal occult blood testing. For both procedures, there is evidence of areduction in colorectal cancer-specific mortality and for endoscopy a reduction of colorectal cancer incidence has been shown.In Germany, the guaiac test for fecal occult blood has been offered since 1977. Additionally, screening colonoscopy has been offered since 2002 and in 2016, the guaiac test was replaced by the immunological fecal occult blood test, which has an improved diagnostic performance. Overall, participation rates have been low over the past decades and differed between men, women, and age groups.Personal invitations are expected to be sent out starting in 2019 as part of the introduction of an organized colorectal cancer screening program in Germany. The program also provides for measures to systematically monitor and improve the quality of colorectal cancer screening. It remains to be seen which effects these changes will have and whether the trend towards declining colon cancer incidence and mortality that has been observed in Germany will continue in the coming years.

More Than Polyps: A Rare Case of Gastric Plasmacytoma

INTRODUCTION. Plasma cell neoplasms can be divided into four pathology types: multiple myeloma, plasma cell leukemias, solitary plasmacytoma of the bone and extramedullary plasmacytoma. Extramedullary plasmacytoma (EMP) is very uncommon, approximately 2-5% of all plasma cell neoplasms. Gastrointestinal (GI) involvement occurs in only 5% of patients with EMP. Occurrence of different types of plasma cell neoplasms present at once has not been well described. We report the case of a middle aged Caucasian man with solitary sacral plasmacytoma, presenting with concomitant finding of polypoid gastric plasmacytoma. CASE PRESENTATION. A 56-year-old male, with history of peptic ulcer disease and solitary right sacral plasmacytoma, presented with generalized weakness and low Hb (5.4g/dL). Physical exam showed pallor and mild tachycardia. There were no signs of active GI bleed but stool guaiac was positive. Laboratory investigations showed elevated alkaline phosphatase (266 U/L) with normal liver and renal function. Esophagogastroduodenoscopy findings included multiple 1-1.5cm polypoid lesions in lesser curvature of stomach and hiatal hernia, without evidence of bleeding. Histological examination showed diffuse plasma cell infiltrate of lamina propria with large atypical giant cells and immature forms, suggestive of plasma cell neoplasm involving gastric mucosa. Recurrent drops in Hb were attributed to hemophagocytic syndrome. The patient was eventually stabilized and discharged with surveillance by Hematology and Gastroenterology practices. DISCUSSION. About 80% of EMP occurs in the upper respiratory tract, with only 5% of cases being of GI origin, most commonly affecting the small bowel, stomach, colon and esophagus respectively. EMP is predominantly described in Japanese females of 56 years median age. Although multiple site EMP has been sufficiently reported, the combination of different types of plasma cell neoplasms present at once has not been well described. In our case, diagnosis of two different types of plasma cell neoplasms was made on a middle aged Caucasian man, providing unique characteristics from diagnostic and epidemiologic standpoints when compared to the current available data. CONCLUSION. Further identification and reporting of cases of such unique nature are necessary to better understand the incidence of combined plasma cell neoplasms, particularly with GI involvement.2682_A Figure 1. EGD showing 1.5 cm and a 1cm polypoid lesions noted in the lesser curvature of the body suggestive of gastric polyps. A biopsy specimen was obtained from each polyp and sent to the histopathology lab for analysis.2682_B Figure 2. Up: Cytoplasm staining for CD 138/ CD 38 which is plasma cell lineage. Down: Clonal stain for lambda monoclonal positive. Suggestive of monoclonal plasma cell neoplasm Kappa is negative polyclonal2682_C Figure 3. Up: Gastric surface area- not normal crypts reactive. Lamina priopria expanded-small blue cells. Down: Crypts with plasma cells and nucleus pushed to the side and paranuclear halo- typical of plasma cell features

Colonic Stricture Secondary to Recurrent Ischemic Colitis: A Case Report

Colonic ischemia is the most common gastrointestinal disease, which frequently affects elderly population with multiple comorbidities. Here we present a case of colonic stricture secondary to recurrent ischemic colitis. Case Description: 86-year-old female was admitted for 2 days history of hematochezia and intermittent abdominal pain. Her PMH included diabetes mellitus, hypertension, heart failure and CAD requiring PCI. She also had a prosthetic mitral valve and AF on anticoagulation therapy but was non-adherent with the regimen. She had a recent admission with similar complains where CT angiogram of the abdomen was suspicious for ischemia of hepatic flexure. On physical examination, she was afebrile, and had epigastric abdominal tenderness and rectal examination with brown stool but guaiac test was positive. Laboratory tests revealed a new onset anemia with a hemoglobin of 6.7 g/L, and a subtherapeutic INR of 1.1. Her CBC and CMP was normal. CT angiogram of abdomen showed patent celiac axis and mesenteric arteries, but a focus of thickened and friable intestinal wall in transverse colon with minimal fatty stranding, indicating ischemia or inflammation. Colonoscopy showed moderate to severe colonic stenosis at hepatic flexure. To further delineate characteristics of the stricture, a barium enema was performed, which showed 4.4-cm-long segment of narrowing at proximal transverse colon. Patient received blood transfusion and the hematochezia stopped spontaneously. The colonic stricture was considered due to prior ischemic colitis. Anticoagulation was restarted with no further bleeding. Right sided hemicolectomy was also recommended to address the stricture; however patient refused the surgery because of the absence of other clinical symptoms. She was discharged on medical management. Discussion: Ischemic colitis is one of the most common gastrointestinal disturbances; the incidence is estimated to be 16 cases per 100,000 person-years. However, most cases remain undetected until further complications emerge because of its insidious clinical presentations. About 20 percent of patients develop chronic ischemic colitis if untreated. Therefore all medical trainees need to identify risk factors and assess patients properly. Most patients improve within one or two days and have a complete resolution within one to two weeks. Severe or recurrent ischemia can lead to chronic ischemic colitis or intestinal stricture requiring surgical intervention.

Qualitative Investigation of FIT Colorectal Cancer Screening Uptake in an Uninsured Urban Minority Population

Introduction: Colorectal cancer (CRC) is the 2nd leading cause of cancer death in the USA. Screening and prevention of CRC with stool testing and colonoscopy is cost effective and greatly reduces the risk for CRC and death. Fecal immunochemical testing (FIT) has been shown to be more accurate than guaiac testing for CRC and advanced adenoma detection. Our post-intervention analysis aims to identify barriers to FIT in patients who were provided with free FIT as part of a comprehensive cancer screening program. Methods: Validated standardized surveys were mailed to 100 patients who ‘returned' FIT kits and 100 patients who ‘refused to return' FIT kits (Image 1). Patients received a $5 gift card if they completed the questionnaire. Postage-paid return envelopes were included. Patients had two months to return the completed questionnaires. Results: A total of 17 ‘returned' questionnaires and 8 of ‘refused' questionnaires were completed. Of the 17 ‘returned' questionnaires, 13 were female and 4 were male. 8 of the ‘returned' respondents were African American, while 3 were Caucasian, 4 were Hispanic and 2 were Asian. Further demographics are shown in Image 2.2763_A Figure 1. Mailed Surveys2763_B Figure 2. Study DemographicsConclusion: We report low response rates for both questionnaires. This suggests that identifying barriers to FIT/colonoscopy screening remains challenging in an uninsured urban minority population. African American females with income <$10,000 were the predominant respondents from the ‘returned' cohort, which may indicate better screening uptake among this subpopulation. Six (35%) of ‘returned' respondents reported previous FIT, while none of the ‘refused' cohort had previous FIT. This may represent an unfamiliarity factor among ‘refused' respondents. Among the ‘returned' respondents, some of the identified reasons that influenced use of the FIT kit included lack of insurance, family history of colon polyps, interest in preventative screening and physician recommendation during an encounter for screening mammogram. ‘Difficult instructions' was listed as a reason for not using the FIT kit by 12.5% of the ‘refused' respondents while others from this cohort reported not receiving the kit or not having time to perform the testing. Although eliciting information regarding barriers to FIT kit use remains challenging, more study into this area is warranted to increase CRC screening rates.

Complicaciones graves en las colonoscopias de cribado del cáncer colorrectal en la Comunidad Valenciana

ObjectiveTo identify and characterise the severe complications of diagnostic confirmation colonoscopies carried out as part of the Colorectal Cancer Screening Program of the Valencian Community (CCSP-VC). MethodA retrospective observational study from 2005 to 2012. To identify complications, the CCSP-VC information system was used, as well as Spanish Minimum Basic Data Set hospital discharge summaries and medical records. Cumulative incidence rates were estimated for all complications, immediate complications (occurring the same day as the colonoscopy) and delayed complications (occurring 1-30 days after the colonoscopy) for the 1,000 colonoscopies performed. A bivariate analysis using the Chi-square test was performed for the onset of complications, according to gender, age and type of test (guaiac/immunological), as well as for the complication onset time (immediate/delayed) based on the type of colonoscopy (diagnostic/therapeutic) and type of complication (haemorrhage/perforation). ResultsOf the total 8,831 screening colonoscopies performed, 23 severe complications were observed, 13 of which were perforations (56.5%) and 10 haemorrhages (43.5%). No serious vagal syndrome, peritonitis or deaths were recorded. The cumulative incidence rate was 2.60‰; 2.85‰ for the guaiac test and 2.56‰ for the immunological test. The incidence rate was higher in men (2.93‰) than in women (2.16‰), as well as in older groups (3.02‰ versus 1.98‰). Of the total complications, 61% (n=14) were immediate. ConclusionsThe severe complication rates of screening colonoscopies are a quality indicator for population-based colorectal cancer screening programs that require extensive research in order to maintain the appropriate risk/benefit ratio of such programs.

Positive guaiac and bloody stool are poor predictors of intussusception

BackgroundCurrant jelly stool is a late manifestation of intussusception and is rarely seen in clinical practice. Other forms of GI bleeding have not been thoroughly studied and little is known about their respective diagnostic values. ObjectiveTo assess the predictive value of GI bleeding (positive guaiac test, bloody stool and rectal bleeding in evaluation of intussusception. MethodsWe performed a retrospective cross-sectional study cohort of all children, ages 1month-6years of age, who had an abdominal ultrasound obtained evaluating for intussusception over 5year period. We identified intussusception if diagnosed by ultrasound, air-contrast enema or surgery. Univariate and a multivariate logistic regression analysis were performed. ResultsDuring the study period 1258 cases met the study criteria; median age was 1.7years (IQR 0.8, 2.9) and 37% were females. Overall 176 children had intussusception; 153 (87%) were ileo-colic and 23 were ileo-ileal. Univariate risk ratio and adjusted Odds ratio were 1.3 (95% CI, 0.8, 2.0) and 1.3 (0.7, 2.4) for positive guaiac test, 1.1 (0.6, 2.1) and 0.9 (0.3, 3.0) for bloody stool, and 1.7 (1.02, 2.8) and 1.3 (0.5, 3.1) for rectal bleeding . ConclusionBlood in stool, whether visible or tested by guaiac test has poor diagnostic performance in the evaluation of intussusception and is not independently predictive of intussusception. If the sole purpose of a rectal exam in these patients is for guaiac testing it should be reconsidered.

Portal Hypertensive Polypoid Enteropathy Without Overt Endoscopic Features of Portal Hypertension: A Case Report

Introduction: Portal hypertensive polypoid enteropathy is an under recognized complication of portal hypertension. It is a rare manifestation of portal hypertensive enteropathy (PHE), polypoid lesions are seen in about 0.3% cases in the small intestine. Endoscopic findings of portal hypertension may or may not be present. Case description: A 60 year-old female with a history of liver cirrhosis from NAFLD and chronic GI bleeding was referred for evaluation of transfusion-dependent anemia requiring IV iron and packed red blood cells. Encephalopathy was her only known complication from cirrhosis. Previous work-up revealed a polypoid lesion in the duodenum which was removed (histology: chronic active duodenitis with ulceration, polypoid inflamed granulation tissue). EGD did not show varices, GAVE, or portal hypertensive gastropathy. She also had a history of large internal hemorrhoids and diverticulosis which were previously treated. Despite management of suspected lesions, anemia persisted with hem occult positive stools. VCE was performed using PillCam system which showed a 6-8mm villous polyp with surface erosion without bleeding in the proximal duodenum. Clusters of erythema and red villi were noted in small intestine which did not appear to be discrete angiodysplasias. At mid-small intestine (57% transit) 1cm sessile polypoid lesion with active bleeding was noted that appeared to be an inflammatory polyp or granulation tissue. Upper DBE showed small bowel findings consistent with portal enteropathy without discrete AVM (Figure 1). Small inflammatory polyps were removed from duodenum. Histopathology showed benign inflammatory polyp c/w portal enteropathy. Lower DBE revealed a 1 cm sessile polyp in mid- ileum (40 cm upstream of colon) which matched the lesion seen on VCE. Polyp was removed with hot snare. Histopathology of the polypoid specimen showed numerous ectatic vessels and ulcerations (Figure 2, 3). The findings were suggestive of polypoid portal hypertensive enteropathy.Figure: Upper DBE showed small bowel findings consistent with portal enteropathy without discrete AVM.Figure: Histopathology of the polypoid specimen showed numerous ectatic vessels and ulcerations.Figure: Histopathology of the polypoid specimen showed numerous ectatic vessels and ulcerations.Discussion: Introduction of VCE and deep enteroscopy has enabled us to perform diagnostic and therapeutic evaluation of small bowel in PHE. Portal hypertensive polypoid enteropathy should be kept high in the differential in patient s with liver cirrhosis presenting with occult GI blood loss. Management of PHE is yet to be standardized, individualized approach should be sought.

Factors influencing participation in colorectal cancer screening programs in Spain

To analyze the sociodemographic and organizational factors influencing participation in population-based colorectal cancer screening programs (CRCSP) in Spain, a retrospective study was conducted in a cohort of people invited to participate in the first 3 screening rounds of 6 CRCSP from 2000 to 2012. Mixed logistic regression models were used to analyze the relationship between sociodemographic and organizational factors, such as the type of fecal occult blood test (FOBT) used and the FOBT delivery type. The analysis was performed separately in groups (Initial screening-first invitation, Subsequent invitation for previous never-responders, Subsequent invitation-regular, Subsequent invitation-irregular intervals). The results showed that, in the Initial screening-first invitation group, participation was higher in women than in men in all age groups (OR 1.05 in persons aged 50–59years and OR 1.12 in those aged 60–69years). Participation was also higher when no action was required to receive the FOBT kit, independently of the type of screening (Initial screening-first invitation [OR 2.24], Subsequent invitation for previous never-responders [OR 2.14], Subsequent invitation-regular [OR 2.03], Subsequent invitation-irregular intervals [OR 9.38]) and when quantitative rather than qualitative immunological FOBT (FIT) was offered (Initial screening-first invitation [OR 0.70], Subsequent invitation for previous never-responders [OR 0.12], Subsequent invitation-regular [OR 0.20]) or guaiac testing (Initial screening-first invitation [OR 0.81], Subsequent invitation for previous never-responders [OR 0.88], Subsequent invitation-regular [OR 0.73]). In conclusion, the results of this study show that screening participation could be enhanced by inclusion of the FOBT kit with the screening invitation and the use of the quantitative FIT.

What percentage of advanced colonic neoplasms can be found by colonoscopy, flexible sigmoidoscopy, and stool guaiac?

EVIDENCE-BASED ANSWER Colonoscopy detects about 98% of large (≥10 mm) adenomas (SOR: A, meta-analysis of cohort studies). When colonoscopy is used as the reference standard, simulated flexible sigmoidoscopy has a sensitivity for detecting any advanced colonic neoplasm throughout the colon of 70% to 86% (SOR: A, systematic review of cohort studies) and a single stool guaiac test is 50% to 65% sensitive for detecting colorectal cancer (SOR: B, small prospective cohort study with a case-control arm).

Covering the Cover

Covering the Cover

A brief pictorial and historical introduction to guaiacum - from a putative cure for syphilis to an actual screening method for colorectal cancer.

Having re-emerged on a global scale during the last few decades, with an estimated incidence in adults of 10.6 million cases in 2008 2, syphilis (Lues venerea), a bacterial infection caused by Treponema pallidum, was first mentioned in European medical writings in the 1490s, as a consequence of the return of Columbus's crew to Europe in 1492 and the later epidemic during the French invasion of Naples in 1495. While the presence of the disease in the Old World prior to Columbus's voyages has long been at the heart of a heated palaeopathological debate 3, reconstructing the historical presentations and evolutionary history of the disease and its treatment can be achieved both via analysis of ancient human remains as well as consultation of literary and artistic sources 4, 5. With respect to the latter, we would like to highlight an engraving by Philip Galle (1537–1612), reproducing the artist Jan van der Straet's (1523–1605) painting, dating back to the late 16th century, of a scene depicting a wealthy man receiving treatment for syphilis by means of Guaiacum officinale (Figure 1). From a pharmacological perspective, this denotes the immense reputation that this plant acquired as a putative cure for syphilis in the course of the 16th century. It was the first drug administered to treat syphilis in Europe, after being first imported in 1508 from the Dominican Republic. Its use became widespread due to its alleged miraculous effects, much discussed by physicians and prominent victims, such as the humanist Ulrich von Hutten (1488–1523) 6. The then widespread belief that remedies could be found where their target diseases originated is likely to have facilitated its entrance into the European pharmacopoeia. Guaiacum treatment requirements were diarrhoea induced by enemas and profuse sweating by resting for 40 days in a dark and hot room, following a strict fasting therapy. Guaiacum was administered externally in ointments and internally in potions. As with other remedies that were not effective in the way they were proclaimed to be, guaiacum eventually fell into disuse. Historical records state that 21 tons of guaiacum reached Seville between 1568 and 1608, while by the 18th century guaiacum imports disappeared from Spanish trade records 7. It was not until 1864, with Izaac Van Deen's (1805–1869) discovery of guaiacum's property of detecting blood in the urine and faeces, by making use of the pseudoperoxidase action of the heme in haemoglobin, which oxidizes guaiac acid to guaiac blue, that its medicinal use was rehabilitated. Today, the guaiac-based faecal occult blood test (gFOBT) or guaiac test (a modified method according to Greegor) is used for the biochemical detection of macroscopically invisible blood in the stool 8. The newest generation of guaiac tests provides excellent sensitivity and specificity. FOBT screening is currently recommended by most screening guidelines as it has proved to reduce colorectal cancer mortality 9. This shows that even ancient misconceived medications can make their way back into clinical practice eventually contributing to the advancement of medicine. There are no competing interests to declare. The authors wish to thank the Mäxi Foundation for supporting this research.

Submitted, Not Presented: Clinical Vignettes/Case Reports - Colorectal Cancer Prevention.

Our patient is a 47-year-old male with no significant medical history who presented with progressively worsening dyspnea, decreased exercise tolerance, and bilateral lower extremity edema for the last 5 weeks. He reported diarrhea but denied any dark stools, and had a 60-pound intentional weight loss over the previous four months. He recently returned from a 4-week cruise from Florida to Denmark and his symptoms began while aboard the ship. On exam, he was afebrile with stable vital signs. He was morbidly obese with a BMI of 61 and appeared pale. A grade III/VI systolic murmur was noted at the second intercostal space and he had bibasilar crackles and 2+ bilateral lower extremity pitting edema. Initial stool guaiac testing was negative. He was found to have a profound anemia with a hemoglobin of 3.6 g/dL and a hematocrit of 13.5%. His ferritin and iron levels were also significantly decreased. His symptoms improved blood transfusions and intravenous Lasix, however, his hemoglobin continued to decrease slowly over the next several days requiring additional blood transfusions. His echocardiogram revealed no abnormalities and a repeat stool guaiac test was positive. A colonoscopy was performed revealing a large mass in the ascending colon, and histological analysis was consistent with invasive colonic adenocarcinoma. Further imaging showed metastases to the peritoneum and he was classified as having Stage IVB colon adenocarcinoma. Discussion: In the United States colorectal cancer is the third most commonly diagnosed cancer and is the second leading cause of cancer-related deaths. A common presentation of colonic adenocarcinoma is iron deficiency anemia, especially when located in the ascending colon. However, it is uncommon to remain asymptomatic from severe anemia until developing signs of heart failure. His heart failure symptoms resolved after adequate resuscitation with blood products, however he continued to require transfusions due to continual slow blood loss from the tumor. Unfortunately, he did not have any family history of gastrointestinal disorders or cancers and his first screening colonoscopy was not due for another three years. Obesity itself increases the frequency of colon cancer, and this appears to be our patient's sole identifiable risk factor. Our case illustrates the importance of recognizing early symptoms of iron deficiency anemia and correlating this with its most common cause, which is occult gastrointestinal blood loss.

Endoscopic Appearance of Oropharyngeal and Upper GI Kaposiʼs Sarcoma in an Immunocompromised Patient: A Case Report

Introduction: Kaposi's Sarcoma (KS) usually manifests as a cutaneous disease but GI mucosal manifestation are often rare. It is associated with human herpes virus-8 infection (HHV-8) and often seen in immune-compromised patients. In the USA, the widespread use of highly active anti-viral therapy (HAART) as drastically reduced the incidence of KS in HIV-infected patients. Here we present a case of oropharyngeal manifestations of Kaposi Sarcoma in a patient with HIV Case Report: A 65 year old male with history of human immunodeficiency virus (HIV) was admitted to the intensive care unit (ICU) after having a cardiopulmonary arriest secondary to hyperkalemia 7.5 meq/L. Following the placement of orogastric and endotracheal tube (ETT), significant amount of blood was noticed in the ETT. Hemoglobin was found to have trended downwards from 9.6 mg/dL to 6.7 mg/dL over the following five days. Stool guaiac was found to be positive for occult blood. Esophagogastroduodenoscopy (EGD) was initially performed and revealed multiple large hyper-vascularized violaceous submucosal nodular lesions with stigmata of recent bleeding seen on the soft palate, pharynx and within the crico-pharyngeal area close to the vocal cords. No active bleeding was noted. Examination of the distal esophagus revealed a severe ulceration with a small hiatal hernia. Biopsy of soft palate lesions showed proliferation of neoplastic spindle shaped cells arranged in bundles with slit-like capillary spaced containing erythrocytes which is consistent with Kaposi sarcoma. Biopsy was also positive for HHV-8. Colonoscopy was unremarkable for similar lesions, polyps or diverticulosis. There were no cutaneous manifestations of the disease. Conclusion: GI involvement of Kaposi sarcoma must be considered in immune-compromised patients and can be confirmed by endoscopic methods.

An Unusual Presentation of a Left Gastric Artery Pseudoaneurysm

A 41 year-old male with no significant past medical history was admitted for nausea, hematemesis, and abdominal pain. On presentation, hemoglobin was 12.5 mg/dL (baseline 15 mg/dL), ALP 64 U/L, AST 21 U/L, ALT 16 U/L, lipase 32 U/L, and total bilirubin 0.6 mg/dL. Stool guaiac was mildly positive. The patient denied any recent aspirin or ibuprofen use. He used tobacco intermittently but denied current alcohol use. Computed tomography (CT) with intravenous and oral contrast showed a 5 cm lobular mass that projected superiorly from the body/tail of the pancreas and displaced the lesser curvature of the stomach. Gastroenterology was consulted for further evaluation. Esophagogastroduodenoscopy (EGD) showed gastric fundal varices with oozing and extrinsic compression of the duodenal bulb. The liver appeared normal on imaging and the platelet count, INR, and liver function tests were within normal limits making intrinsic liver disease unlikely. As compression of splenic vessels can lead to gastric varices, additional imaging was ordered to further evaluate the mass. Magnetic resonance cholangiopancreatography (MRCP) showed a large 5 cm highly vascular mass with indeterminate origin and suggested doppler sonography for further evaluation. Ultrasound showed an anechoic structure with strong arterial flow along its periphery. An abdominal arteriogram confirmed a large gastric pseuduoaneurysm measuring 5.3 x 2.2 cm arising from a branch of the left gastric artery. Successful coil embolization of the pseudoaneurysm was performed and the patient had complete resolution of his symptoms. Follow-up CT one month later showed significant improvement in the size of the pseudoaneurysm. Pancreatitis with or without pseudocyst or abscess formation is the major etiologic factor for pseudoaneurysm formation. Pseudoaneurysms are a known but relatively uncommon complication of acute pancreatitis that has been shown to occur in up to 10% of cases. The splenic artery is most commonly affected followed by the gastroduodenal, pancreaticoduodenal, gastric, and hepatic arteries. Our patient had a lipase within normal limits, no epigastric pain, and no imaging findings to support acute or chronic pancreatitis and no history of trauma making this case exceedingly rare. It is reported that 40-60% of ruptured pseudoaneurysms result in a fatal outcome. Thus, when an extrinsic mass is found to compress the stomach the differential diagnosis of a pseudoaneurysm should be considered.Figure 1Figure 2Figure 3

Gastroduodenal Polyps: An Atypical Presentation of Metastatic Renal Cell Carcinoma

Introduction: Metastatic disease of the small bowel is very rare. Tumors, most commonly known to metastasize to small bowel include melanoma, lung cancer, cervical carcinoma and renal cell carcinoma (RCC). Although, RCC has a strong potential for hematogenous spread, gastroduodenal metastasis from RCC is extremely rare and only a few cases have been reported in literature. Herein, we describe an unusual case of metastatic RCC presenting as duodenal and gastric polyps. Case: A 80 year old female with history of stage 1 clear cell RCC (T1b), s/p nephrectomy 5 years ago, currently on pazopanib, presented with dizziness and fall. She was found to be severely anemic with a positive stool guaiac at presentation. Esophagogastroduodenoscopy was performed, which revealed multiple ulcerated erythematous polyps (4-10 mm size) in gastric antrum, fundus and duodenum. Biopsies were obtained and histopathology and Immunohistochemical results confirmed renal epithelial origin of the cells. Further imaging revealed pulmonary and lymph node metastases. Patient subsequently developed left eye proptosis with progressive blurring of vision and was found to have a large intraconal mass. Debulking surgery was performed and pathology results were consistent with metastatic RCC. Patient was started on palliative radiotherapy and chemotherapy with sunitinib.Figure 1Figure 2Figure 3Discussion: RCC accounts for 3% of all adult malignancies with clear cell RCC is the most common histological subtype. RCC is known for its ubiquitous pattern of metastasis and most common sites of metastasis are the lungs, bones, liver and brain. Gastroduodenal metastasis from RCC is very rare and can be involved by direct invasion of the tumor or through lymphatic or hematogenous spread. The main presenting features are upper gastrointestinal bleeding (69%), obstructive symptoms and anemia. Endoscopically, the lesions can be seen as a polypoid mass or submucosal tumor with ulceration, usually involving the periampullary region or duodenal bulb. Several treatments have been reported in literature, including Whipple procedure, segmental resection, embolization and palliative treatment depending upon the extent of disease and metastasis. Unfavorable prognostic factors include, development of early metastasis after nephrectomy and widespread metastasis.

Spontaneous Rupture of Hepatic Metastasis from Pancreatic Adenocarcinoma.

A 58-year-old man with advanced-stage pancreatic adenocarcinoma presented with fatigue and dyspnea. Examination revealed tachycardia (102 b/min) with mild tenderness in right upper quadrant. His hemoglobin (Hb) was 7.9 g/dL (10 days prior to presentation 12.2 g/dL), International normalized ratio (INR), platelet count was normal, and the stool guaiac test was negative. On admission, abdominal computed tomography (CT) scan showed hepatic metastatic lesion with a rupture and hemoperitoneum communicating to the subdiaphragmatic space. This rapid progression of anemia along with presenting symptoms and CT imaging were attributed to diagnosis of spontaneous rupture of liver metastasis from pancreatic adenocarcinoma. Patient received blood transfusion and hemoglobin was monitored in successive intervals. His general condition and anemia improved with conservative management and he was discharged in 3 days. Repeated CT after 4 months showed resolving hemoperitoneum and stable hemoglobin levels. The patient deceased 9 months after being diagnosed. A literature search revealed limited data regarding the incidence and management of spontaneous rupture of metastatic lesion secondary to pancreatic adenocarcinoma which has been managed conservatively and thus we are reporting our experience.

Embolic Stroke due to a Common Carotid Artery Thrombus in a Young Patient with Severe Iron-Deficiency Anemia without Thrombocytosis.

This case report describes a 41-year-old previously healthy male who presented with stuttering transient ischemic symptoms and radiographic evidence of a left common carotid artery thrombus as well as acute and subacute ischemic infarcts in the left middle cerebral artery territory. An exhaustive stroke work-up did not provide a plausible etiology for his symptoms. His complete blood count and iron studies, however, revealed evidence of severe iron-deficiency anemia without reactive thrombocytosis. His stool guaiac test was positive. He was discharged home on oral antithrombotic agents and aggressive iron replacement therapy with a plan for repeat vascular imaging in 3 months and a colonoscopy. This case report suggests that severe iron-deficiency anemia with or without reactive thrombocytosis should be viewed as a possible hematologic condition associated with thrombotic tendencies and a risk factor for ischemic stroke, especially in young adults. Aggressive iron supplementation and short-term antithrombotic therapy with follow-up vascular imaging are a reasonable treatment for these patients.

The advantages of the immunochemical test in detecting hidden blood in the stool

The aim of the study: to compare new generation immunochemical test (FIT) with traditional guaiac test (FOB) in detection of fecal occult blood. A cohort of 300 patients referred for colonoscopy was examined by two different tests for FOB: quick test (CV) (FIT test for haemoglobin (Hb) and haemoglobin/haptoglobin (Hb/Hp) complex) and (quaiac test for Hb). Three fecal samples were tested and all subjects were examined by diagnostic colonoscopy with biopsy verification. The performance indicators (sensitivity (SE), specificity (SP), positive predictive value (PPV), negative predictive value (NPV) and area under the curve (AUC)) were calculated for both tests using three endpoints (adenoma (A), adenoma/ carcinoma (A/AC) and carcinoma (AC)). Colonoscopy (and biopsies) disclosed normal results in 114 (38.0 %) subjects, A in 91cases (30.3 %) and AC in 95 (31.7 %) patients. For the combined A + AC endpoint, the HS test had SE of 58.3 % and SP of 96.5 % (AUC = 0.774), while the CV test had 97.2 % SE and 85.8 % SP (AUC = 0.916) (p = 0.0001). For the A endpoint, the difference between HS and CV was even more significant, AUC = 0.637 and AUC = 0.898, respectively (p = 0.0001). For the AC endpoint, the HS test had SE of 85.3 % and SP of 96.5 % (AUC = 0.909), while the CV test had 100.0 % SE and 85.1 % SP (AUC = 0.925) (p = 0.0001). The ColonView test can be represented as a rapid test in the screening programme for colorectal cancer.

Rapid Resolution of Milk Protein Intolerance in Infancy

To investigate whether some infants with milk protein intolerance become tolerant sooner than 12 months of age.Infants <4 months of age (N = 16) receiving breast milk (n = 1) or a cow’s-milk (n = 2) or casein hydrolysate (n = 13) formula who presented to a pediatric gastroenterology practice during an 18-month period and had a positive stool guaiac test. Exclusion criteria included iron supplementation and or conditions such as anal fissure, infection, enterocolitis, and history of intestinal surgery.Parents submitted stool specimens on guaiac cards once weekly. After demonstrating guaiac-negative stools for at least 2 consecutive months on a casein hydrolysate or amino acid formula, infants in this prospective, longitudinal cohort study were rechallenged with their prestudy formula.By age 7 months, milk protein intolerance was resolved in 12 of 16 of infants, the remainder having resolved by 10 months. The average age of resolution was 6.7 ± 1.0 months (mean ± SD).It may be reasonable to treat infants with milk protein intolerance for 2 to 3 months with a hypoallergenic formula and rechallenge them at 6 months of age. Rechallenging before 12 months could result in significant cost savings.This was a rather small study, but it challenges the practice of delaying reintroduction of a milk- or soy-based formula (or beverage) in infants with benign proctocolitis until 12 months of age.

Screening for colon cancer: A test for occult blood.

The relevance of the problem of colorectal cancer (CRC) is evident because of extremely high morbidity and mortality rates, associated with this disease. CRC is mostly diagnosed only at very advanced stages. The reduction of mortality can be achieved by the popularization of screening-methods for early identification of CRC and adenomatous polyps of the colon, which are proved to be precancerous condition. Fecal occult blood test is a well-known method of screening for CRC. The advantages of this method when compared, for example, with colonoscopy are its simplicity and cost-effectiveness.Two techniques are usually used for detection of occult blood in the stool: Hemoccult (Guaiac) test and immunochemical test for hemoglobin. There is no consensus among researchers regarding the validity of these tests for the diagnosis of colorectal cancer. For example, J.S. Mandel (1996) notes 60% sensitivity of Guaiac-test for the detection of the early forms of colorectal cancer, while O.I. Kit (2014) suggets that it is not higher than 30%. There are also various opinions about specificity of these two tests. To review the literature on the validity of the fecal occult blood tests for the diagnosis of CRC. We looked for articles (electronic versions) available for free in the full-text versions, published from June 1, 1990 to December 31, 2014 in Russian or English. The following databases were used for search: E-LIBRARY; Cochrane; MEDLINE; EMBASE; Google search. Only original research papers were analyzed. Literature reviews or systematic reviews were not taken for analyses. 1) use of Guaiac and/or immunochemical fecal occult blood test as screening-tests for the detection of colorectal cancer and/or colon polyps (1 cm or more in diameter) in people older than 45 years; 2) comparing of results with the results of colonoscopy (colonoscopy is counted by majority of the authors as a "gold standard" for the diagnosis of CRC and adenomatous polyps). Initial keyword search returned 803 000 results, of which 449 sources were selected. After reading the abstracts, 29 articles that met inclusion criteria were kept. 10 other articles were excluded after that because they did not contain enough data for extraction or did not contain a control group. At the final step 19 articles were used for meta-analysis.Forest plot and Rock curve, which were developed with inclusion of the data from all studies, showed heterogeneity of the data. Additional analyzes were performed in subgroups with different diagnoses and various tests.The sensitivity of the Guaiac test for the diagnosis of colorectal cancer varied from 0.13 to 1.00, and specificity - from 0.69 to 0.99. The sensitivity of the immunochemical test for the diagnosis of CRC ranged from 0.42 to 0.94 with specificity ranging from 0.40 to 1.00.The sensitivity of the Guaiac test for the diagnosis of the colon polyps was between 0.05 and 0.69, and its specificity - from 0.67 to 0.98. The sensitivity of the immunochemical test for the diagnosis of polyps was from 0.24 to 0.75, and its specificity - from 0.40 to 0.97.Bivariate analysis of the validity of Guaiac test and immunochemical method for the diagnosis of colorectal cancer showed better results for the immunochemical test compared to Guaiac test. The tests showed very similar results when used for the diagnosis of polyposis. Bivariate analysis, comparing the validity of tests for the diagnosis of colorectal cancer versus polyposis demonstrated better results for CRC.Multivariate analysis of the validity of the Guaiac and immunochemical tests for the diagnosis of colorectal cancer and polyps also showed better results for detection of colorectal cancer compared with the polyps for both tests. At the same time the highest validity for the diagnosis of CRC was demonstrated for immunochemical analysis. 1. The sensitivity of the Guaiac test for occult blood in stool is lower than its specificity.2. Broad dispersion of the validity characteristics of the fecal occult blood tests was observed.3. The validity of tests for occult blood was higher when they were used for detection of colorectal cancer than of colon polyposis.4. The highest validity rate has been demonstrated for the immunochemical test when it was used for colon cancer screening.