Bariatric and Metabolic Endoscopy: A New Paradigm

The prevalence of obesity, type 2 diabetes mellitus, and metabolic syndromes is increasing globally. Minimally invasive metabobariatric (MB) endoscopic therapies are adjunct treatments that can potentially bridge the gap between surgical interventions and medical therapy. A growing number of MB techniques are becoming available, allowing for more personalized and patient-targeted treatment options for specific disease states. MB techniques are less invasive than surgery and can precisely target different parts of the gastrointestinal tract that may be responsible for the pathophysiology of obesity and metabolic syndromes such as type 2 diabetes mellitus. These alternatives should be selected on an individualized patient basis to balance the expected clinical outcomes and desired anatomical targets with the level of invasiveness and degree of acceptable risk. Each MB intervention presents great flexibility allowing for a tailored intervention and different levels of patient engagement. Patient awareness and motivation are essential to avoid therapy withdrawal and failure. Differences between MB procedures in terms of weight loss and metabolic benefit will be discussed in this review, along with the insights on clinical decision-making processes to evaluate the potential of further evolution and growth of bariatric and metabolic endoscopy.

Primary malignant giant cell tumor of the sternum

Primary malignant giant cell tumor (PMGCT) is a diagnosis based on the presence of a high-grade sarcomatous component along with a typical benign giant cell tumor (GCT). We report the first case of PMGCT of the sternum in a 28-year-old male with painless swelling over the manubrium sterni. The differential diagnoses of PMGCT and giant cell-rich osteosarcoma were considered. Surgical resection was performed, and the reconstruction was done with a neosternum using polymethyl methacrylate and prolene mesh. At 30 months follow-up, the patient is disease-free.

COVID-19 infection in patients with intestinal failure: UK experience

BACKGROUND

The direct effect of the coronavirus disease 2019 (COVID-19) pandemic on patients with intestinal failure (IF) has not been described.

METHODS

We conducted a nationwide study of UK IF centers to evaluate the infection rates, presentations, and outcomes in patients with types 2 and 3 IF.

RESULTS

A total of 45 patients with IF contracted COVID-19 between March and August 2020; this included 26 of 2191 (1.2%) home parenteral nutrition (HPN)-dependent adults and 19 of 298 (6.4%) adults hospitalized with type 2 IF. The proportion of patients receiving nursing care for HPN administration was higher in those with community-acquired COVID-19 (66.7%) than the proportion in the entire HPN cohort (26.1%; P < .01). Two HPN-dependent and 1 hospitalized patient with type 2 IF died as a direct consequence of the virus (6.7% of 45 patients with types 2 or 3 infected).

CONCLUSION

This is the first study to describe the outcomes of COVID-19 in a large cohort of patients requiring long-term PN. Methods to reduce hospital and community nosocomial spread would likely be beneficial.

Recurrent giant simple hepatic cyst: an unusual cause of dyspnoea in an elderly man

An 88-year-old man presented to the emergency department with exertional dyspnoea and orthopnoea. Clinical examination revealed mildly raised jugular venous pressure, increased respiratory rate, palpable non-tender hepatomegaly and reduced right basal breath sounds. Ultrasonography showed a large right simple hepatic cyst, multiple small left hepatic and renal cysts. A non-contrast CT scan revealed a large, right hepatic thin-walled cyst of volume 4.2 L, exhibiting few thin septae and tiny nodular mural calcifications. Pressure effects were elevated right haemidiaphragm, right atrial compression and adjacent atelectasis. He had a similar episode 2 years ago, treated by percutaneous needle aspiration. Giant simple hepatic cysts are rare and present when symptomatic due to pain, mass effect on adjacent organs, infection or rupture. These may unusually cause dyspnoea or orthopnoea by compressing cardiac chambers. Simple aspiration has a high recurrence rate. Percutaneous sclerosant injection, laparoscopic deroofing and cystectomy are better treatment modalities.

Skeletal Muscle Involvement in Wilson Disease: Clinical and Magnetic Resonance Imaging (MRI) Observations in 2 Families

OBJECTIVE

Skeletal muscle involvement in Wilson disease is rare. Calf muscle pain might be attributed as growing pain in children. We report calf muscle involvement in Wilson disease and describe the magnetic resonance imaging (MRI) findings of leg, differential diagnosis with literature review.

PATIENTS AND METHODS

Our observations describe calf muscle MRI abnormality in 5 cases of Wilson disease from 2 families. The clinical presentations were neurologic in 3, hepatic in 1, and asymptomatic in 1 patient. We systematically describe the clinical characteristics and their calf muscle MRI findings.

RESULTS

Three patients had bilateral calf pain and intermittent cramps. The pain was of mild to moderate intensity and managed symptomatically. Serum alkaline phosphatase, creatinine phosphokinase, and needle electromyography were normal. Turbo inversion recovery magnitude sequence MRI of calf muscle revealed hyperintensity in bilateral gastrocnemii muscles. These muscles appear hyperintense in diffusion-weighted imaging.

CONCLUSION

The calf muscle involvement could be attributed to muscle edema due to copper-induced muscle toxicity mediated by inhibition of Na⁺/K⁺-ATPase on cellular membranes of fast-twitch gastrocnemii muscles which contain predominant type II myofiber. In Wilson disease patients with calf pain or cramps, muscle MRI may show nonspecific gastrocnemius hyperintensity. Further evaluation may give insight into its pathophysiology.

Intracranial, Extradural, Hemangiopericytoma in a Neonate

Intracranial infantile hemangiopericytoma (HPC) is a rare, sparsely documented neoplasm with a relatively favorable prognosis than its adult counterpart. We describe a neonatal extradural, intracranial, infantile HPC managed with near-total excision.

Giant cervicomediastinal thymic cyst in an elderly: diagnosis by multimodality imaging and fine-needle aspiration cytology with immunocytochemistry

A 65-year-old woman, a non-smoker, presented to the pulmonary medicine outpatient department with chest pain, mild dyspnoea, right side neck swelling and mild facial puffiness. The cervical swelling was soft, non-tender and fluctuant on palpation. Multimodality imaging revealed a large, thin-walled cervicomediastinal cystic lesion with septations, haemorrhage, septal calcification and without any solid component. Image-guided fine-needle aspiration cytology from the septa with immunocytochemistry helped to establish the thymic origin and benign nature of the cyst preoperatively and differentiate it from cystic thymoma, lymphangioma, thymic carcinoma or lymphoma with confidence. As the haemorrhage resolved, the size of the swelling was significantly reduced, and the patient became asymptomatic due to which she deferred surgery but remained on close follow-up and was doing well. Thymic cysts can occur in a cervicomediastinal location, rare in elderly age, usually asymptomatic and clinically apparent when intracystic haemorrhage leads to an increase in size and chest pain.

Tuberculous splenic abscess in the immunocompetent host: a report and review of literature

Tubercular splenic abscess is rare, particularly in immunocompetent patients. Diagnostic difficulties usually arise in patients with tubercular splenic abscess because of its non-specific presentation. We report an elderly male who presented with cough and fever and had pulmonary infiltrates suspicious of tuberculosis. Bronchoalveolar lavage microbiology including XpertMTB/Rif assay was non-contributory. Contrast enhanced computed tomography scan of abdomen revealed multiple non-enhancing lesions in the spleen. Ultrasound guided splenic aspirate revealed pus that was positive for Mycobacterium tuberculosis in XpertMTB/Rif assay confirming the diagnosis of tuberculosis.

Rasmussen's aneurysm masquerading as mass lesion

Haemoptysis is an often encountered respiratory symptom. The amount of haemoptysis varies from mild to life-threatening severity and may indicate the underlying pulmonary disorder. Herein, we report a 50-year-old male smoker who presented with occasional streaky to mild haemoptysis for last 1 year. He had pulmonary tuberculosis 10 years ago and had received adequate treatment. Chest radiograph was suspicious of a mass lesion in left upper lung. Contrast-enhanced CT scan of thorax revealed pulmonary artery pseudoaneurysm suggestive of Rasmussen's aneurysm. Unlike this case, Rasmussen's aneurysm usually manifests as life-threatening haemoptysis and portends a high mortality.

Effect of Iodinated Contrast Media on Serum Electrolyte Concentrations in Patients Undergoing Routine Contrast Computed Tomography Scan Procedure

Background and Objectives:

Being hypertonic solutions, iodinated contrast media such as iohexol can cause a shift of fluids and electrolytes between different compartments of the body, but there is an ongoing discrepancy in data and current studies as to the effect of iodinated contrast media on serum electrolytes. Hence, this hospital-based prospective clinical observational study was carried out with objectives of evaluating the changes in serum electrolyte concentrations with intravenous iodinated contrast media administration in adult population and to correlate the changes in electrolyte concentrations, if any, with the demographic profile of the patients.

Materials and Methods:

We analyzed 103 numbers of adult patient samples over a period of 2 months by collecting blood both before administration of contrast and after 24 h of the contrast-enhanced computed tomography scan procedure. Serum concentrations of sodium, potassium, chloride, and ionized calcium were measured using Eschweiler Combiline analyzer based on ion-selective electrode principle.

Results:

The mean age of the study population in our study was 40.11 ± 20.51 years. We found that changes in serum sodium and chloride concentration after administration of contrast media are significant (sodium: 136.29 ± 3.53 vs. 132.49 ± 6.36 mmol/L and chloride: 100.03 ± 0.70 vs. 97.53 ± 0.70 mmol/L). Sodium concentration shows more decrease in females compared to males after administration of iodine contrast. The most probable reason for this decrease in serum electrolytes was secondary changes to hemodilution due to high osmolality of the contrast.

Conclusions:

Attending physicians must be alert for such possibilities of changes in electrolytes after contrast administration and be prepared to treat any adversity if one occurs.

Multifocal Balo's Concentric Sclerosis in Children: Report of a Case and Review of Literature

Balo's concentric sclerosis (BCS) is a rare demyelinating lesion considered to be a variant of multiple sclerosis (MS). On magnetic resonance imaging (MRI) Balo's concentric sclerosis shows the typical concentric pattern. We report a case of 10 year old child with BCS who presented as post infectious acute disseminated encephalomyelitis (ADEM). He is asymptomatic and had no relapse after 6 years of follow-up.

Endovascular biopsy in Takayasu arteritis

Takayasu arteritis is a chronic inflammatory arteriopathy of the large vessels, mainly the aortic arch and its branches. The disease progression varies, ranging from a rapid progression to quiescence reached within 2 years. The activity of the disease is evaluated by biochemical markers, but at times, there is a discrepancy between the clinical picture and biochemical markers. Histopathology helps in assessing the disease activity, but it is not included in the antemortem diagnosis because of the invasiveness of the procedure and the availability of noninvasive vascular imaging. However, it may be performed simultaneously with angioplasty. Here we present a case of endovascular aortic biopsy conducted to detect active inflammation in the aortic wall.