History Of Non-steroidal Anti-inflammatory Use Research Articles

A177 AN UNUSUAL CULPRIT OF AN UPPER GASTROINTESTINAL BLEED IN A PAEDIATRIC PATIENT

Abstract Background Leiomyomas are benign tumors originating from mesenchymal cells in the muscularis propria that present equally among the sexes usually as localized lesions after the fifth decade. Though rare, esophageal leiomyomas (EL) make up the majority of benign esophageal tumors and are typically located distally. Of all known cases, 2.6% are paediatric. In this population they are 1.71 times more common in females and are often diffuse. Most are slow growing and asymptomatic but when >5cm patients describe dysphagia, vomiting, pain, cough and anorexia. Gastric leiomyomas causing upper gastrointestinal bleeding (UGIB) in adults are reported. Aims To discuss a rare cause of UGIB in a child. Methods Case report. Results We present a 16-year-old Asian boy with no significant past medical history who was transferred to our institution for an UGIB following 3 days of dark black stools, 1 day of coffee ground emesis and pre-syncope. There was no history of non-steroidal anti-inflammatory use. At presentation he was in shock and received fluid resuscitation and a pantoprazole infusion. His hemoglobin dropped to 81 from 150g/L and corrected with 2 units of packed red blood cells. He was pale, non-dysmorphic with no cutaneous lesions, abdomen was non-distended and non-tender with no masses or hepatosplenomegaly. An abdominal ultrasound showed mild bowel wall thickening in the cecum and terminal ileum. Emergent upper endoscopy identified an ulcerated sessile mass at the gastro-esophageal junction. Biopsies revealed polypoid inflamed gastric mucosa with a focal intestinal metaplasia, negative for malignancy. Magnetic resonance scan characterized a 3.8x4.3x2.5cm lesion in the stomach cardia not extending beyond the serosa with suggested causes including EL and gastrointestinal stromal tumor (GIST). Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) demonstrated a 2.8x1.8cm well circumscribed homogenous hypoechoic mass in the muscularis propria of the distal esophagus. Histopathology showed bland tumor cells with eosinophilic cytoplasm and nuclei that did not demonstrate atypia. Immunohistochemistry (IHC) stains were positive for smooth muscle actin and desmin. CD117, S-100 and DOG1 were negative. Findings were therefore in keeping with a leiomyoma and not a GIST. He was referred to the Cancer Genetics clinic for consideration of hereditary leiomyomatosis renal cell cancer and General Surgery for resection. Conclusions This case highlights a rare cause of UGIB in a child. EL are scarcely found in children and at present there are no reports of EL causing UGIB. They can be associated with Alport Syndrome or Familial Leiomyomatosis. IHC is an essential diagnostic tool, enabling differentiation of EL from GIST which is important as the latter has malignant potential. EL can be monitored with endoscopy if small but are surgically resected if symptomatic, ulcerated, or growing. Funding Agencies None

Every Cent Counts: A Case of Foreign Body Ingestion

Foreign body ingestion represents a relatively common reason for gastroenterologist consultation. While over 80% of swallowed foreign bodies will ultimately pass uneventfully through the gastrointestinal tract, 10-20% of cases will require endoscopic retrieval. We present an unusual case of foreign body ingestion involving a patient presenting with abdominal pain and melena. A 68 year-old man with a history of coronary artery disease presented to the hospital with a 3 day history of unremitting, burning epigastric pain associated with 1 episode of melenic stool. He denied hematochezia and weakness but did endorse a history of non-steroidal anti-inflammatory use. Upon admission he was found to be hemodynamically stable. Laboratory values including complete blood count, basic metabolic panel, and protime were unremarkable. Plain abdominal film on admission revealed an elongated radiopaque object concerning for foreign body in the antrum. The patient denied ingestion of any known non-food items. Upper endoscopy was performed. An elongated Forrest 2c 7mm x 2cm pyloric ulcer was discovered (figure 1). On retroflexion in the stomach, a quarter was visible in the greater curvature (figure 2). Closer inspection revealed a dime underneath the first coin (figure 3). Both coins were successfully retrieved with the Roth retrieval net. Biopsies for Helicobacter Pylori were negative. The patient was started on 40mg esomeprazole daily and was soon discharged with a plan for repeat upper endoscopy in 3 months. While the majority of ingestions can be managed with conservative measures, cases with airway compromise or peritoneal signs often call for urgent endoscopic or surgical evaluation. Concerning ingestions include sharp objects, disk batteries, magnets, or items with diameter greater than 25mm as they are less likely to pass through the pylorus. Ingestion of foreign non-food objects is more commonly encountered in the pediatric population with coins representing the majority of cases. When seen in adults, there is usually concomitant alcoholism or cognitive and psychiatric disorders. In our patient's case, there was a history of excessive alcohol abuse. It is likely that the coins were ingested while intoxicated. The patient's use of non-steroidal anti-inflammatory drugs likely lead to ulcer development; however, it is possible that the coins may also have contributed as ulcers have been reported with similar blunt objects.Figure 1Figure 2Figure 3

Isolated Upper Tract Crohnʼs Disease Presenting as Gastric Outlet Obstruction Successfully Treated with Adalimumab

Introduction: Isolated upper tract Crohn's disease is a rare presentation of this disease. Gastric outlet obstruction (GOO) is an even more rare presentation of Crohn's disease. Pyloric stenosis from Crohn's disease has been reported, but our case is the first time isolated Crohn's duodenal strictures have presented with GOO, and have been successfully treated with adalimumab. Case: 27 y/o active duty soldier with a past medical history of psoriasis was evacuated out of Iraq to Walter Reed National Military Medical Center with a greater than 1 year history of post prandial nausea, vomiting, intolerance of food and 60 lb weight loss. On initial evaluation, Computed Tomography reported a massively dilated stomach and stricture in the third portion of the duodenum, which was confirmed on esophagogastroduodenoscopy (EGD). A diagnosis of a peptic-related duodenal stricture was made with no history of non-steroidal anti-inflammatory use. A trial of high dose proton-pump inhibitor (PPI) therapy and antiemetics did not control symptoms, which lead to a small bowel enteroscopy identifying extensive circumferential nodularity with mucosal ulcerations of the third portion of the duodenum, two separate inflammatory strictures and ulcerations extending into the proximal jejunum. The strictures were successfully traversed and no dilation was performed. Magnetic Resonance Enterography and colonoscopy revealed no additional locations of stricturing or inflammation. Biopsies obtained described chronic duodenitis with foveolar metaplasia. The diagnosis of upper tract Crohn's was made based on clinical, radiologic and histologic findings. The patient was started on adalimumab and continued on high-dose PPI therapy. After 3 months of treatment the patient reported complete resolution of symptoms with associated 55 lb weight gain and significant improvement in inflammation, nodularity and duodenal stenosis on surveillance endoscopy forgoing need for dilation or surgical management. Discussion: Symptomatic upper tract Crohn's disease is a rare presentation, occurring in 0.5-4% of Crohn's patients, and typically presenting with abdominal pain, dyspepsia, diarrhea, nausea and other systemic symptoms. Gastric outlet obstruction is an extremely unusual presentation of Crohn's disease and is usually associated with pyloric stenosis. Medical management of this presentation is often unsuccessful requiring alternative therapies such as balloon dilation or surgery for symptomatic relief. To our knowledge, this case represents a unique description of successful management with adalimumab of duodenal Crohn's disease presenting with a gastric outlet obstruction.

An investigation into the neuroprotective properties of ibuprofen.

There is increasing evidence suggesting a protective role for anti-inflammatory medications in neurological disorders such as Alzheimer's disease (AD). While there has not been any direct evidence for this, a number of clinical studies indicate that those patients who have had a history of nonsteroidal anti-inflammatory use, have a lower incidence of AD. Since there is currently no evidence on the mechanism by which these agents offer possible neuroprotection, we investigated the potential neuroprotective properties of the nonsteroidal anti-inflammatory drug, ibuprofen, by examining whether this agent could reduce lipid peroxidation and superoxide radical generation. Quinolinic acid and cyanide, known neurotoxins, were used to induce lipid peroxidation and superoxide anion formation respectively, in rat brain homogenate. The results show that ibuprofen significantly (p<0.05) reduced quinolinic acid-induced lipid peroxidation and cyanide-induced superoxide production. The results of the present report therefore suggest a possible mechanism for the neuroprotective effect of ibuprofen.