Endoscopic Imaging of Pancreatic Cysts

Pancreatic cystic lesions (PCLs) have been diagnosed with increasing frequency likely due to the widespread use of cross-sectional imaging. A precise diagnosis of the PCL is important because it helps identify patients in need of surgical resection and those who can undergo surveillance imaging. A combination of clinical and imaging findings as well as cyst fluid markers can help classify PCLs and guide management. This review focuses on endoscopic imaging of PCLs including endoscopic and endosonographic features and fine needle aspiration. We then review the role of adjunct techniques, such as microforceps, contrast-enhanced endoscopic ultrasound, pancreatoscopy, and confocal laser endomicroscopy.

Accuracy of virtual chromoendoscopy in differentiating gastric antral vascular ectasia from portal hypertensive gastropathy: A proof of concept study

BACKGROUND

Accurate detection of gastric antral vascular ectasia (GAVE) is critical for proper management of cirrhosis-related gastrointestinal bleeding. However, endoscopic diagnosis of GAVE can be challenging when GAVE overlaps with severe portal hypertensive gastropathy (PHG).

AIM

To determine the added diagnostic value of virtual chromoendoscopy to high definition white light for real-time endoscopic diagnosis of GAVE and PHG.

METHODS

We developed an I-scan virtual chromoendoscopy criteria for diagnosis of GAVE and PHG. We tested our criteria in a cross-sectional cohort of cirrhotic adults with GAVE and PHG when high-definition white light endoscopy (HDWLE) diagnosis was in doubt. We then compared the accuracy of I-scan vs HDWLE alone to histology.

RESULTS

Twenty-three patients were included in this study (65.2% Caucasians and 60.9% males). Chronic hepatitis C was the predominant cause of cirrhosis (43.5%) and seven adults (30.4%) had confirmed GAVE on histology. I-scan had higher sensitivity (100% vs 85.7%) and specificity (75% vs 62.5%) in diagnosing GAVE compared to HDWLE. This translates into a higher, albeit not statistically significant, accuracy of I-scan in detecting GAVE compared to HDWLE alone (82% vs 70%). I-scan was less likely to lead to an accurate diagnosis of GAVE in patients on dialysis (P < 0.05) and in patients with elevated creatinine (P < 0.05). I-scan had similar accuracy to HDWLE in detecting PHG.

CONCLUSION

This pilot work supports that virtual chromoendoscopy may obviate the need for biopsies when the presence of GAVE is in doubt. Larger studies are needed to assess the impact of virtual chromoendoscopy on success of endoscopic therapy for GAVE.

Gossypiboma Masquerading as Small Bowel Malignancy

Gossypiboma refers to inadvertently retained foreign objects after surgical operations. High body mass index and emergency surgery are risk factors of the condition. Presenting symptoms are usually non-specific and it may result in serious complications such as bowel obstruction. Removal can be attempted with endoscopic or surgical approaches depending on the site and presence of complications. This case highlights the need for considering gossypiboma in patients presenting with abdominal symptoms after recent abdominal surgery. Herein we report the case of a 30-year-old woman with abdominal pain two months after mini-gastric bypass surgery. Cross-sectional imaging showed a hyperdense area in the small bowel concerning for malignancy. However, upper endoscopy revealed a 10 × 40 cm retained surgical gauze in the afferent loop that was successfully retrieved. Although rare, retained foreign body should be considered in the differential diagnosis of postoperative abdominal pain.

Minimal change disease associated with balsalazide therapy for ulcerative colitis

Introduction: 5-aminosalicylic acid (5-ASA) compounds have been used in the management of ulcerative colitis for decades. Nephrotoxicity has been previously described in patients treated with 5-ASA compounds and usually manifests as interstitial nephritis, however a few cases of nephrotic syndrome have been reported. Balsalazide is a pro-drug composed of 5-ASA linked to an inert carrier. Case Presentation: Here we report the case of a 74-year-old man with a history of ulcerative proctosigmoiditis treated with balsalazide who presented to our clinic with bilateral lower extremity edema three months after initiation of balsalazide. Laboratory workup showed nephrotic range proteinuria without an apparent secondary etiology. Given worsening proteinuria and renal function despite cessation of balsalazide, the patient underwent renal biopsy that revealed minimal change disease. High dose steroids were started and complete remission of proteinuria was achieved one month into therapy which was slowly tapered over the next five months. Eventual resolution of edema and return of creatinine back to patient’s baseline level was achieved. Conclusion: To our knowledge, this is the first report of nephrotic syndrome manifesting soon after initiation of balsalazide therapy. Our work highlights the importance of maintaining a high clinical suspicion for nephrotoxicity when using balsalazide.

Abstract 5279: Prevalence and correlates of perceived harmfulness and addictiveness to traditional and alternative tobacco products among US adults

Purpose: Beliefs about addictiveness and harmfulness of tobacco products are associated with intentions to use them. This study aimed to (1) evaluate perceived harmfulness and addictiveness patterns towards multiple tobacco products and (2) examine sociodemographic variables that influence those perceptions.

Methods: Weighted multivariate ordinal logistic regression analyses were performed on 5,474 US adults aged ≥18 years who participated in the 2015 and 2017 cycles of the Health Information National Trends Survey-FDA. The two primary outcomes were perceived harmfulness and addictiveness of traditional (cigarette, cigar, and pipe filled with tobacco) vs alternative tobacco (e-cigarette, hookah, and “roll your own” cigarettes). All models were adjusted for age, gender, race/ethnicity, education, household income, census region, and smoking status.

Results: Overall, 7.9% of adults in the U.S. perceived alternative tobacco as “not harmful at all” compared to 2.4% for the traditional products. Similarly, 16.2% of adults perceived alternative tobacco as “not addictive at all” compared to 13.6% for the traditional products. Beliefs about the harmfulness and addictiveness of traditional and alternative tobacco products differed by sociodemographic characteristics and smoking status: Those who believed traditional and alternative tobacco products are more harmful were more likely to be female, older (compared with those aged 18-34), Black (compared with White), former or never smokers (compared with current smokers), and adults living in West (compared with Northeast). Similarly, those who believed traditional and alternative tobacco products are more addictive were more likely to be female, older, Black, and adults living in West. However, no association between smoking status and perceived addictiveness was noted.

Conclusion: Adults in U.S. perceive tobacco harmfulness and addictiveness differently based on their sociodemographic characteristics and smoking status. These findings are potential areas for targeted behavioral interventions to increase individuals' perceived risk of harm and addiction to all forms of tobacco products in the United States.

Citation Format: Kahee A. Mohammed, Martin W. Schoen, Nosayaba Osazuwa-Peters, Ahmad M. Al-Taee, Gebran W. Khneizer, Lauren D. Arnold, Leslie Hinyard, Thomas E. Burroughs. Prevalence and correlates of perceived harmfulness and addictiveness to traditional and alternative tobacco products among US adults [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 5279.

Autologous Graft-Versus-Host Disease of the Gastrointestinal Tract in Patients With Multiple Myeloma and Hematopoietic Stem Cell Transplantation

Multiple myeloma (MM) is the most common indication for autologous hematopoietic stem cell transplantation (HSCT) in North America. Despite occurring in up to 50% of patients undergoing allogeneic HSCT, the incidence of graft-versus-host disease (GVHD) after autologous HSCT is reportedly only 5-20%. Gastrointestinal involvement with graft-versus-host disease (GI GVHD) is a common and serious complication of allogeneic HSCT. GI GVHD after autologous transplant, which is referred to as autologous GVHD (auto-GVHD), has also been described. Auto-GVHD is usually less severe than allogeneic GVHD, and it can be one of the manifestations of engraftment syndrome with release of inflammatory cytokines and infiltration of auto-reactive T cells into affected tissue. Seventy-nine percent of patients respond well to corticosteroids without evidence of recurrence. However, cases of severe auto-GVHD lacking good response to corticosteroids have been reported, most notably in MM patients. Here we present two cases of autologous GI GVHD in recipients of autologous HSCT for treatment of MM. Our cases demonstrate two distinct clinical and endoscopic presentations of this uncommon entity. In the first case, the patient had more severe clinical symptoms accompanied by radiographic, endoscopic, and pathologic findings. The hospital course was complicated by cryptosporidium enteritis and acute cholecystitis in the setting of increased immunosuppression with a corticosteroid for presumed auto-GVHD. In contrast, the second case presented a patient with normal radiologic and endoscopic findings. Pathology revealing frequent apoptotic bodies led to auto-GVHD as a diagnosis. Both our patients received similar courses of chemotherapy prior to autologous HSCT (four cycles of a proteasome inhibitor, lenalidomide, and dexamethasone). Our work highlights the importance of maintaining a high level of clinical suspicion for auto-GVHD in patients presenting with GI symptoms after autologous HSCT, as it is a potentially treatable pathology that may be easily confused with other conditions. Health care providers should be aware of the potential complications of auto-GVHD after autologous HSCT and should be suspicious of auto-GVHD if GI symptoms occur, especially in patients receiving immunomodulatory therapy for MM, even in the absence of gross endoscopic findings.

Diagnosis and Classification of Chronic Renal Failure Utilising Intelligent Data Mining Classifiers

This paper presents a new clinical decision support system for diagnosing patients with Chronic Renal Failure (CRF) which is not yet thoroughly explored in literature. This paper aims at improving performance of a previously reported CRF diagnosis system which was based on Artificial Neural Network (ANN), Decision Tree (DT) and Naïve Bayes (NB) classifying algorithms. This is achieved by utilizing more efficient data mining classifiers, Support Vector Machine (SVM) and Logistic Regression (LR), in order to: (i) diagnose patients with CRF and (ii) determine the rate at which the disease is progressing. A clinical dataset of more than 100 instances is used in this study. Performance of the developed decision support system is assessed in terms of diagnostic accuracy, sensitivity, specificity and decisions made by consultant specialist physicians. The open source Waikato Environment for Knowledge Analysis library is used in this study to build and evaluate performance of the developed data mining classifiers. The obtained results showed SVM to be the most accurate (93.14%) when compared to LR as well as other classifiers reported in the previous study. A complete system prototype has been developed and tested successfully with the aid of NHS collaborators to support both diagnosis and long-term management of the disease.