Incidental diagnosis of intestinal spirochetosis in a patient with chronic hepatitis B: A case report

BACKGROUND

Intestinal spirochetosis (IS) is caused by Brachyspira colonization of the gastrointestinal tract. Some patients are asymptomatic, while others present with gastrointestinal complaints such as abdominal pain, diarrhea, or gastrointestinal bleeding. However, the clinical significance of asymptomatic IS is unclear, and guidelines are lacking regarding decision to treat.

CASE SUMMARY

A 73-year-old male with peptic ulcer disease and gastroesophageal reflux was evaluated for elevated liver enzymes. He was diagnosed with chronic hepatitis B virus and prescribed entecavir. Additionally, he was leukopenic and had stage 4 liver fibrosis on transient elastography. After 5 mo, the patient returned for esophagogastroduodenoscopy and screening colonoscopy. He denied any gastrointestinal symptoms at that time. Findings included grade I distal esophageal varices, mild portal hypertensive gastropathy, and patchy nodular gastric antral mucosa. On colonoscopy, several polyps were removed. Hematoxylin and eosin stain of mucosa adjacent to the polyps revealed a “false brush border,” and Steiner stain identified spirochetes adherent to the mucosa. These pathology findings confirmed the diagnosis of IS. He was managed conservatively with careful observation and without antibiotic therapy via a multidisciplinary approach between gastroenterology and infectious disease. He remained asymptomatic at the 7-wk follow-up.

CONCLUSION

This case reports the finding of incidental, asymptomatic IS in a leukopenic patient with hepatitis B virus. Conservative management was appropriate.

Radiopaque Short Pancreatic Stents Reliably Migrate in Nearly All Patients When Inserted for Prevention of Pancreatitis

Placement of a pancreatic duct (PD) stent for prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP)^1-3 often necessitates a second procedure for stent removal, generally within 2-4 weeks to avoid stent occlusion or injury to the duct.⁴ These procedures are associated with increased costs and may result in procedure-related complications. Stents without internal anchoring flaps were developed to allow spontaneous migration into the duodenum,⁵ thus obviating the need for a repeat procedure. However, radiographic confirmation of a migrated stent can be challenging.⁶.

Multidisciplinary diagnostic and therapeutic approaches to pancreatic cystic lesions

Pancreatic cystic lesions are commonly encountered today with the routine use of cross-sectional imaging modalities such as computed tomography (CT) and magnetic resonance imaging (MRI). The majority of patients discovered to have a pancreatic cyst are completely asymptomatic; yet the presence of such a finding instills fear in the minds of both patient and physician, as the concern for malignant transformation to pancreatic cancer is great despite the relatively low overall likelihood of cyst progression. Not all cysts in the pancreas represent pancreatic cystic neoplasms (PCNs), and not all PCNs have significant malignant potential. Mucinous PCNs are the most concerning, as these lesions have the greatest potential for cancerous transformation to adenocarcinoma. Within the group of mucinous PCNs, intraductal papillary mucinous neoplasms (IPMNs) involving the main pancreatic duct are the most worrisome, and surgical resection should be pursued if the patient has appropriate operative risks. IPMN lesions involving the branch ducts, and mucinous cystadenomas, have a lower likelihood for malignancy, and they may be closely followed for the development of any worrisome or high-risk features. Surveillance of known PCNs is performed with a combination of CT, MRI and endoscopic ultrasound (EUS). EUS-guided fine-needle aspiration (EUS-FNA) may be used to assess cyst fluid cytology, and also to detect cyst fluid amylase level, carcinoembryonic antigen level, and DNA molecular analysis in certain cases. The presence or absence of specific cyst morphological features, as well as the cyst fluid analysis, is what enables the physician to guide the patient towards continued surveillance, versus the pursuit of surgical resection.