Digestive and Liver Disease

Editorial Board

2012-06-01

If steatosis is the atherosclerosis of the liver, are statins the “aspirin” for steatosis?

Amedeo Lonardo, Paola Loria — 2012-04-09

With its tremendous impact on public health, non-alcoholic fatty liver disease (NAFLD) has emerged as the most common liver disease in many countries . NAFLD is a complex disorder: although it may follow a progressive course leading to non-alcoholic steatohepatitis (NASH) with or without cirrhosis, liver failure and hepatocellular carcinoma in a proportion of patients, by no means can it be viewed as a condition threatening the health of the liver alone . Indeed it represents a faithful mirror of systemic metabolic derangements, e.g. the inflammatory changes occurring in visceral adipose tissue in the setting of peripheral insulin resistance (IR); furthermore NAFLD is a powerful engine capable of amplifying sub-clinical dysmetabolic and inflammatory states substantially contributing to organ damage (typically: premature atherosclerosis and risk of metabolic decompensation in the course of the follow-up) .

Diagnosis, prevention and treatment of postoperative Crohn's disease recurrence

2012-01-20

Abstract: Ileocolonoscopy remains the gold standard in diagnosing postoperative recurrence. After excluding stricture, wireless capsule endoscopy seemed accurate in small series, but no validated score is available. Ultrasonography is a non-invasive diagnostic method reducing radiation exposure and emerging as an alternative tool for identifying post-operative recurrence. Computed tomography enteroclysis yields objective morphologic criteria that help differentiate between recurrent disease and fibrostenosis at the anastomotic site, but ionising radiation exposure limits its use. Magnetic resonance imaging may be as powerful as ileocolonoscopy in diagnosing postoperative recurrence and in predicting the clinical outcome using specific MR-scores. Biomarkers such as faecal calprotectin and faecal lactoferrin showed promising results, but their specificity in the postoperative period will require further investigation. Numerous medications have been tested to prevent and/or to treat postoperative recurrence. Efficacy of mesalamine is very low and comparable to placebo in most series. Thiopurines have modest efficacy in the postoperative setting and are associated with a high rate of adverse events leading to drug withdrawal. Antibiotics such as metronidazole or ornidazole may be effective, but toxicity and drug resistance prevent their long-term use. Anti-Tumour Necrosis Factor therapy is the most potent drug class to prevent and to treat postoperative recurrence in Crohn's disease.

Mycobacterium avium paratuberculosis in Italy: Commensal or emerging human pathogen?

2012-01-30

Abstract: Background: Specific bacterial infections or alterations of the gut microbiota likely trigger immuno-pathological phenomena associated with Crohn's disease and ulcerative colitis. Mycobacterium avium subspecies paratuberculosis is a candidate etiological agent of Crohn's disease. Definitive causal connection between Mycobacterium avium subspecies paratuberculosis infection and Crohn's disease has not been demonstrated.Aims: To determine the circulation of Mycobacterium avium subspecies paratuberculosis in Crohn's disease patients and water supplies in an Italian region where this bacterium is endemic in cattle farms.Methods: Mycobacterium avium subspecies paratuberculosis screening was performed on biopsies from human patients, and from water samples, using two different PCR procedures.Results: In hospitals where multiple specimens were obtained from different sites in the intestine, the prevalence of Mycobacterium avium subspecies paratuberculosis infection was 82.1% and 40% respectively in Crohn's disease and ulcerative colitis patients; in another hospital, where single specimens were obtained from patients, the bacterium was not detected. Control subjects also harboured Mycobacterium avium subspecies paratuberculosis, but at a lower prevalence. Tap water samples collected in the study area contained Mycobacterium avium subspecies paratuberculosis DNA.Discussion: The results of screenings for Mycobacterium avium subspecies paratuberculosis in humans are deeply influenced by both the number and location of the collected biopsies. There is a wide circulation of the organism in the study area, considering the prevalence in humans and its presence in drinking water.

Plasma soluble triggering receptor expressed on myeloid cells-1 in Crohn's disease

2012-02-17

Abstract: Background: No definite conclusions can be drawn from available data on the accuracy of soluble triggering receptor expressed on myeloid cells-1 (sTREM-1) to assess disease activity in Crohn's disease.Aims: Plasma sTREM-1 levels were correlated with disease activity markers in Crohn's disease.Methods: 191 consecutive patients from a single referral centre (Nancy IBD cohort) were prospectively enrolled between June 1, 2005 and December 12, 2008. Plasma sTREM-1 levels were also assessed amongst 20 healthy controls.Results: The sTREM-1 was detectable in 87 Crohn's disease patients (46%). Plasma sTREM-1 level was higher in Crohn's disease patients (interquartile range, 0–356) than in healthy controls (interquartile range, 0–15.1; P=0.01). It was neither correlated with Crohn's disease activity index (r=0.05, P=0.56), C-reactive protein (r=0.06, P=0.53), nor with albumin (r=−0.041, P=0.66). Crohn's disease activity index, C-reactive protein and albumin median levels were similar between patients with positive sTREM-1 levels and those with undetectable sTREM-1 levels. Azathioprine (P=0.06), infliximab (P=0.68) and methotrexate (P=0.56) did not influence sTREM-1 levels.Conclusion: Plasma sTREM-1 does not appear to be an accurate marker of disease activity in Crohn's disease and cannot be recommended for assessing disease activity in these patients.

Socioeconomic position and education in patients with coeliac disease

Ola Olén, Erik Bihagen, Finn Rasmussen, Jonas F. Ludvigsson — 2012-02-16

Abstract: Background and aim: Socioeconomic position and education are strongly associated with several chronic diseases, but their relation to coeliac disease is unclear. We examined educational level and socioeconomic position in patients with coeliac disease.Methods: We identified 29,096 patients with coeliac disease through biopsy reports (defined as Marsh 3: villous atrophy) from all Swedish pathology departments (n=28). Age- and sex-matched controls were randomly sampled from the Swedish Total Population Register (n=145,090). Data on level of education and socioeconomic position were obtained from the Swedish Education Register and the Occupational Register. We calculated odds ratios for the risk of having coeliac disease based on socioeconomic position according to the European Socioeconomic Classification (9 levels) and education.Results: Compared to individuals with high socioeconomic position (level 1 of 9) coeliac disease was less common in the lowest socioeconomic stratum (routine occupations=level 9 of 9: adjusted odds ratio=0.89; 95% confidence interval=0.84–0.94) but not less common in individuals with moderately low socioeconomic position: (level 7/9: adjusted odds ratio=0.96; 95% confidence interval=0.91–1.02; and level 8/9: adjusted odds ratio=0.99; 95% confidence interval=0.93–1.05). Coeliac disease was not associated with educational level.Conclusions: In conclusion, diagnosed coeliac disease was slightly less common in individuals with low socioeconomic position but not associated with educational level. Coeliac disease may be unrecognised in individuals of low socioeconomic position.

Can we shorten the small-bowel capsule reading time with the “Quick-view” image detection system?

2012-01-27

Abstract: Background: The mean small-bowel capsule reading time is about 60min, and shortening this reading time is a major aim.Aim: To evaluate the efficiency of the “Quick-view” detection algorithm.Methods: Multicentre prospective comparative study. One hundred and six small bowel capsule films from 12 centres reviewed in Quick-view mode by 12 experienced readers. Reading time, image relevance, and comparison of Quick-view reading results to results of initial reading. Review of discordant result by 3 experts.Results: The mean reading time in Quick-view mode was of 11.6min (2–27). Concordant negative results were obtained in 41 cases (38.6%) and concordant positive results in 35 cases (33.0%). A discordant result was obtained in 30 (28.3%) cases: 21 false positive cases (initial reading 12 cases, Quick-view reading 9 cases), 14 false negative cases (initial reading 7, Quick-view 7). Four out of 7 lesions missed at Quick-view reading were not present on the Quick-view film (theoretical sensitivity 93.5%).Conclusion: The Quick-view informatic algorithm detected nearly 94% of significant lesions, and Quick-view reading was as efficient as the initial reading and much shorter. These results are to be confirmed by further studies, but suggest an excellent sensitivity for the Quick-view algorithm.

Epidemiology and management of oesophageal coin impaction in children

2012-02-10

Abstract: Objective: The epidemiology of oesophageal coin impaction in children is poorly understood. We aimed to assess characteristics of patients with coin impaction and identify predictors of type of coin impacted and management strategies.Methods: Cases of coin impaction from 2002 to 2009 were identified by querying a tertiary care centre's billing, clinical, and endoscopy databases for the International Classification of Diseases, 9th Revision code “935.1 – foreign body in the oesophagus.” Charts were reviewed to confirm case status and to extract pertinent data.Results: Of 113 patients with oesophageal coin impaction (55% male; 45% Caucasian; mean age 2.9 years), 65 (58%) swallowed a penny, 85 (80%) had the impaction in the proximal oesophagus, and 103 (91%) required a procedure. Thirty-five (34%) patients had an upper endoscopy performed by a gastroenterologist and 68 (66%) had a laryngoscopy or oesophagoscopy performed by an otolaryngologist. Only 2 minor complications were noted. There was no significant relationship between the coin type and location of impaction, but 99% of cases performed by otolaryngologists were for proximally impacted coins, compared to 49% for gastroenterologists (p<0.001).Conclusions: Oesophageal coin impaction disproportionately affected young children and extraction was frequently required. Whilst pennies were the most commonly impacted coin, there were no clear predictors on impaction based on coin type.

Non-invasive assessment of hepatic fibrosis in a series of patients with Wilson's Disease

Margherita Sini, Orazio Sorbello, Alberto Civolani, Mauro Liggi, Luigi Demelia — 2012-01-19

Abstract: Background/aims: Liver biopsy has always represented the standard of reference in hepatic fibrosis assessment. Recently, blood markers and instrumental methods have been proposed for non-invasive assessment.The aim of this study was to validate transient elastography and other non-invasive tests compared to liver histology in Wilson's Disease.Methods: Liver stiffness in 35 Wilson's Disease patients was evaluated by Fibroscan, serum fibrosis markers (AST-to-platelet-ratio index and FIB-4) and biopsy.Results: Compared to liver histology, the FibroScan values increased proportionally with progression of the histological fibrosis stage. Significant fibrosis could be predicted with a Fibroscan cut-off value of 6.6kPa. Advanced fibrosis could be predicted with a FibroScan cut-off value of 8.4kPa. Serum fibrosis marker values gave good correlation with hepatic stage.Conclusions: A FibroScan value of 6.6kPa was found to be a significant separation limit for differentiating significant fibrosis stages from milder stages and a fibroscan value of 8.4kPa was found to be a significant separation limit for differentiating advanced fibrosis stages from milder stages. FibroScan values are clinically useful for predicting fibrosis stages and helpful in managing chronic therapy in Wilson's Disease patients.

Atorvastatin improves disease activity of nonalcoholic steatohepatitis partly through its tumour necrosis factor-α-lowering property

2012-01-24

Abstract: Background: We have previously found that atorvastatin decreases liver injury markers in patients with nonalcoholic steatohepatitis. However, how atorvastatin treatment ameliorates the disease activity in nonalcoholic steatohepatitis patients remains unknown.Aims: We examined here which anthropometric, metabolic and inflammatory variables were improved and related with amelioration of disease activity in atorvastatin-treated nonalcoholic steatohepatitis patients.Methods: Forty-two biopsy-proven nonalcoholic steatohepatitis patients with dyslipidemia were enrolled. Patients were treated with atorvastatin (10mg/day) for 12 months.Results: Atorvastatin significantly decreased liver transaminase, γ-glutamyl transpeptidase, low-density lipoprotein-cholesterol, triglycerides, type IV collagen, and tumour necrosis factor-α levels, whilst it increased adiponectin and high-density lipoprotein-cholesterol. Atorvastatin improved nonalcoholic fatty liver disease activity score and increased liver to spleen density ratio. Multiple stepwise regression analysis revealed that γ-glutamyl transpeptidase, tumour necrosis factor-α and liver to spleen density ratio (inversely) were independently associated with nonalcoholic fatty liver disease activity score. Aspartate aminotransferase, low-density lipoprotein-cholesterol and nonalcoholic fatty liver disease activity score were independent determinants of decreased liver to spleen density ratio.Conclusion: The present study suggests that atorvastatin improves the disease activity of nonalcoholic steatohepatitis partly via its tumour necrosis factor-α-lowering property.

Primary care-based interventions are associated with increases in hepatitis C virus testing for patients at risk

2012-02-20

Abstract: Background: An estimated 3.2 million persons are chronically infected with the hepatitis C virus (HCV) in the U.S. Effective treatment is available, but approximately 50% of patients are not aware that they are infected. Optimal testing strategies have not been described.Methods: The Hepatitis C Assessment and Testing Project (HepCAT) was a serial cross-sectional evaluation of two community-based interventions designed to increase HCV testing in urban primary care clinics in comparison with a baseline period. The first intervention (risk-based screener) prompted physicians to order HCV tests based on the presence of HCV-related risks. The second intervention (birth cohort) prompted physicians to order HCV tests on all patients born within a high-prevalence birth cohort (1945–1964). The study was conducted at three primary care clinics in the Bronx, New York.Results: Both interventions were associated with an increased proportion of patients tested for HCV from 6.0% at baseline to 13.1% during the risk-based screener period (P<0.001) and 9.9% during the birth cohort period (P<0.001).Conclusions: Two simple clinical reminder interventions were associated with significantly increased HCV testing rates. Our findings suggest that HCV screening programs, using either a risk-based or birth cohort strategy, should be adopted in primary care settings so that HCV-infected patients may benefit from antiviral treatment.

Platelet count/spleen diameter ratio for non-invasive diagnosis of oesophageal varices: Is it useful in compensated cirrhosis?

2012-02-10

Abstract: Aim: To assess the diagnostic accuracy of the platelet count/spleen diameter ratio for identification of oesophageal varices and/or hypertensive gastropathy in patients with compensated cirrhosis.Methods: Platelet count/spleen diameter ratio was calculated in 87 consecutive patients with compensated cirrhosis. A new cut-off with the highest sensitivity and specificity for the presence/absence of oesophageal varices and/or hypertensive gastropathy was identified. Performance of the platelet count/spleen diameter ratio considering previously reported cut-off values were then tested in our population.Results: A platelet count/spleen diameter ratio <936.4 had the best sensitivity and specificity for the diagnosis of oesophageal varices and for all endoscopic findings of portal hypertension. A value lower than 936.4 allowed identification of 64.5% of patients with oesophageal varices and 66.7% of patients with any sign of portal hypertension; a value higher than 936.4 excluded oesophageal varices in 64.3% of patients and any sign of portal hypertention in 68.6% of patients.Conclusions: In patients with compensated cirrhosis, the platelet count/spleen diameter ratio is not a useful parameter to avoid unnecessary upper endoscopy, independently of the cut-off.

Colorectal stenting as a bridge to surgery reduces morbidity and mortality in left-sided malignant obstruction: a predictive risk score-based comparative study

2012-01-24

Abstract: Background: The Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity model, and its Portsmouth and colorectal modifications are used to predict postoperative mortality and morbidity after colorectal surgery.Aims: To compare stent placement as a bridge to surgery vs. emergency surgical resection in patients with acute left-sided colorectal cancer obstruction using P-POSSUM and CR-POSSUM.Methods: From January 2008 to December 2009, the physiological and operative scores, morbidity and mortality predicted by the P-POSSUM and CR-POSSUM scores were collected in all consecutive patients with LCCO who underwent surgical resection directly (Group A) or after stent placement (Group B).Results: Eighty-six patients were enrolled (Group A-41 and Group B-45). The observed 30-day mortality rate was 9.8% (4/41) in Group A and 2.4% (1/45) in Group B. The 30-day morbidity rate was 61% (25/41) in Group A and 29% (13/45) in Group B. The mean values of P-POSSUM morbidity (A=70.5% vs. B=34.3%; p=0.001), P-POSSUM mortality (A=13.6% vs. B=2.4%; p=0.001) and CR-POSSUM mortality (A=15.1% vs. B=4.9%; p=0.001) were significantly lower in the Group B patients than in the Group A patients.Conclusions: Bridge to surgery strategy reduces the surgical risks in LCCO, and P-POSSUM and CR-POSSUM scores represent a good tool for comparing the two strategies.

Simplified identification of Lynch syndrome: A prospective, multicenter study

2012-04-05

Abstract: Background: Recommended strategies to screen for Lynch syndrome in colorectal cancer are not applied in daily practice and most of Lynch cases remain undiagnosed.Aims: We investigated in routine conditions a strategy that uses simplified clinical criteria plus detection of MisMatch Repair deficiency in tumours to identify Lynch carriers.Methods: Colorectal cancer patients that met at least one of three clinical criteria were included: (1) colorectal cancer before 50 years, (2) personal history of colorectal or endometrial cancer, (3) first-degree relative history of colorectal or endometrial cancer. All tumours underwent an MisMatch Repair test combining microsatellite instability analysis and MisMatch Repair immunohistochemistry. Patients with an MisMatch Repair-deficient tumour were offered germline testing.Results: Of the 307 patients fulfilling the clinical criteria, 46 (15%) had a MisMatch Repair-deficient tumour. Amongst them 27 were identified as Lynch carriers (20 with germline mutation: 12 MLH1, 7 MSH2, 1 MSH6; 7 highly suspected cases despite failure of genetic testing). The simplified clinical criteria selected a population whose MisMatch Repair-deficient status was highly predictive (59%) of Lynch syndrome.Conclusion: This bio-clinical strategy based on simplified clinical criteria combined with an MisMatch Repair test efficiently detected LS cases and is easy to use in clinical practice, outside expert centres.

What is the probability of being too old for salvage transplantation after hepatocellular carcinoma resection?

2012-03-05

Abstract: Background: The strategy of salvage transplantation for patients with hepatocellular carcinoma is based on the premise that tumour recurrence will be still transplantable at the time of recurrence. However, patients can not only present non-transplantable recurrence but can also be over the age limit accepted for transplantation.Aims: To measure the risk of being too old for salvage transplantation of patients resected for hepatocellular carcinoma within Milan criteria.Methods: A Markov simulation model was developed on the basis of published literature.Results: The risk of being too old for salvage transplantation depends on the time-span between age at hepatic resection and age limit, and the expected median waiting-time. Patients resected at an age 2 or 3 years below the age limit carry a risk of being too old that overcomes the probability of receiving transplantation. Salvage strategy can cause harm that depends on the tumour characteristics and degree of portal hypertension, becoming maximal for patients with multiple tumours, clinical signs of portal hypertension and increased bilirubin levels.Conclusions: The best strategy to adopt should be balanced between the risk of being too old and the expected transplant benefit, but salvage strategy could be pursued if it did not turn into significant harm in comparison to primary transplantation.

Prevalence of coeliac disease in healthy blood donors: A study from north India

2012-04-12

Abstract: Background: Blood donor screening can help predict prevalence of coeliac disease in population.Methods: Between December 2010 and June 2011, healthy blood donors were screened using anti-tissue glutaminase antibodies. Those positive underwent duodenoscopy. Their age, gender, body mass index and haemoglobin and histological changes were recorded.Results: Of the 1610 blood donors screened, 1581 (98.2%) were males. The mean age of donors was 31.51±9.66 years and the mean body mass index was 22.12±4.24kg/m2. Nine (0.56%) men were seropositive. Endoscopic features included reduced fold height (9), scalloping (8), grooving (7) and mosaic mucosal pattern (3). Eight had Marsh IIIa changes whilst one had IIIb change. The prevalence of coeliac disease was 1:179 (0.56%, 95% confidence interval 1/366–1/91, 0.27–1.1%). None of the 9 patients had any symptoms. Their mean haemoglobin and body-mass index was similar to rest of the cohort.Conclusion: The prevalence of coeliac disease amongst apparently healthy blood donors was 1:179 (0.56%).

Duodenal involvement in multiple myeloma

Won Sohn, Byung Chul Yoon, Byeong-Bae Park, Chan Kum Park — 2012-03-14

A 48-year-old man presented with a 1-week history of epigastric pain and dyspepsia. Multiple myeloma with monoclonal gammopathy was diagnosed 1 year previously, and he was treated with chemotherapy and autologous bone marrow transplantation. Until recently, he had received high dose oral dexamethasone and his disease was in remission according to all clinical and laboratory data. Esophago-gastro-duodenoscopy showed a huge ulcerative mass in the second portion of the duodenum (Fig. 1A). A biopsy was performed: on light microscopy, there was diffuse infiltration of atypical plasma cells in the duodenal mucosa that mimicked malignant lymphoma histologically (Fig. 2A, H & E, ×400). On immunohistochemical staining, the neoplastic plasma cells were diffusely positive for CD138 (Fig. 2B) and negative for CD20 and CD3. Abdominal computer tomography demonstrated a huge mass in the second duodenal portion (Fig. 1B; arrow) and multiple lymphadenopathies in the periduodenal, portocarval, peripancreatic, and aortocaval areas. Duodenal involvement of multiple myeloma with lymphadenopathy was diagnosed, and radiotherapy and chemotherapy were initiated.

Biliary cast syndrome in a non-transplant patient with acute pancreatitis

Katarzyna Kusnierz, Ewa Nowakowska-Dulawa, Joanna Pilch-Kowalczyk, Pawel Lampe — 2012-02-27

We have read with great interest the paper by Zimmer et al. in Digestive and Liver Disease describing biliary cast syndrome (BCS) in sclerosing cholangitis after orthotopic heart transplantation . We agree with the authors that cases of BCS are difficult to treat and often require liver transplantation. The occurrence of BCS in the livers of non-transplant patients is extremely rare, with fewer than ten cases described in the literature. Herein, we describe a 37-year-old patient with BCS. Similar to the patient described in Digestive and Liver Disease, our patient presented symptoms of cholangitis, cholestasis and acute pancreatitis (laboratory tests revealed amylase levels of 1550U/L and lipase levels of 6423U/L). Magnetic resonance cholangiopancreaticography showed a diffusely destroyed biliary system with multiple filling defects, intrahepatic duct dilation and bile-duct irregularities. Endoscopic retrograde cholangiopancreatography confirmed irregular contours of the biliary duct with strictures and dilations as well as the presence of deposits and biliary sludge. Because of the inability to remove the deposits, a prosthesis and a nasobiliary drainage were inserted into the right and left hepatic ducts respectively. An abdominal CT confirmed the diagnosis of acute pancreatitis with necrosis and abscesses. Due to the serious condition associated with severe acute necrotizing pancreatitis, the first surgical intervention involved only cast removal () and biliary tract drainage. The abscess and other fluid collections were evacuated and drained, and the necrotic tissue was removed. Morganella morganii and Candida albicans were cultured from the bile. Four months after the operation, during which the patient complained about cholangitis, he was admitted again. Due to destruction of the bile duct, the second surgery, a Roux-en-Y hepaticojejunostomy, was performed. Because changes in the type of biliary cast also include small intrahepatic bile ducts, a recurrence of cholangitis is possible, and a liver transplantation may be necessary.

Comment to “Prevention of paracentesis-induced circulatory dysfunction in cirrhosis: Standard vs half albumin doses”

Alexandre Pariente — 2012-03-05

Alessandria et al. should be commended for their excellent pilot study suggesting that one can halve the dose of albumin infused after large volume paracentesis without increasing the risk of paracentesis-induced circulatory dysfunction, morbidity or 6-month mortality, in stable cirrhotic patients. Although reported as “not significantly different”, the rate of paracentesis after discharge and the dose of albumin that these patients received after the first week were not described in detail. Indeed, the subgroup of patients needing frequent paracentesis could develop progressive deterioration if the half-dose albumin regimen were maintained over time. This point should be specifically addressed when future, large-scale studies are conducted to confirm/dispute the presented data.

Colonic metastasis from a primary adenocarcinoma of the lung presenting with acute abdominal pain

Paolo Pozzato, Angela Salerno, Alessandra Cancellieri, Maurizio Ventrucci — 2012-01-31

A 62-year-old man presented with acute abdominal pain due to intestinal subobstruction. He had previously been treated by radiotherapy for pulmonary adenocarcinoma. The patient underwent a colonoscopy revealing an ulcerated polypoid lesion, 3cm in diameter, in the left flexure (Fig. 1). Histology revealed adenocarcinoma which, at immunohistochemistry, was positive for thyroid transcription factor-1 (TTF-1) [A] and cytokeratin 7 (CK-7) [B], and negative for caudal-related homeobox transcription factor 2 (CDX-2) [C], sinaptofisin and cytokeratin 20 (CK-20) [D] (Fig. 2). Accordingly, the lesion was interpreted as metastatic from the lung. The patient was referred to the Oncology Unit for additional chemotherapy.

An unusual cause of haematemesis: Left-sided portal hypertension due to a large pancreatic tumour

Yen-Dun Tony Tzeng, Shiuh-Inn Liu, Cheng-Chung Tsai — 2012-02-10

A 28 year-old woman presented to our hospital after several episodes of bloody vomitus for 1 day. The physical examinations showed pale conjuctiva and a palpable mass over left upper quadrant of abdomen without tenderness. The laboratory tests revealed white-cell count of 11,980/Cumm with 80% neutrophils and haemoglobin of 6.6g/dL. An upper gastrointestinal panendoscopy showed isolated gastric varices and external compression of stomach from posterior wall of body (Fig. 1). A contrast enhanced computed tomographic scan of the abdomen revealed a huge cystic mass, 18cm×11cm×12cm, over the pancreatic tail and budding the splenic hilum. The splenic vein was anteriorly displaced and compressed (Fig. 2A, arrow). Distal pancreatectomy and splenectomy were performed (Fig. 2B). The pathological diagnosis was confirmed with mucinous cystadenoma of pancreas. The patient recovered well and discharged in good health 5 days after the operation. She received an upper gastrointestinal panendoscopy 1 year later for regular follow-up and no gastric varices were presented.

‘Volcano sign’ and endoscopic mucosal resection of a villous adenoma arising from the appendix

Dimitri Coumaros, Georgios Mavrogenis, Yves Anselm, Alain Billing — 2012-03-05

A 74-year-old patient was referred for polypectomy of a 1.5cm diameter sessile cecal polyp, located on a mound. During close inspection, a transparent discharge was secreted by a central orifice corresponding to the appendiceal orifice ( a). The lesion was removed by endoscopic mucosal resection (EMR). After en-bloc resection of the ‘top of the mound’, an 8mm orifice secreting a viscous fluid was revealed, followed by prolapse of villous tissue (b). The orifice was closed with application of 5 clips. Histological examination disclosed a villous adenoma with low-grade dysplasia extending into the appendiceal canal, without any accumulation of mucous. Retrospective examination of a previous abdominal computed tomography scan showed that the appendix was retrocecal and enlarged to a diameter of 1.5cm. Appendectomy was then performed, and examination of the specimen showed engorgement of the appendix by villous tissue. Histopathologically, the lumen of the appendix was covered by a villous adenoma with low grade and focally high grade dysplasia (). Endoscopic resection of a pedunculated appendiceal polyp was reported recently . However, in our case the lesion extended into the appendix, so the EMR was completed with appendectomy. Three months later, colonoscopy revealed a 0.5cm residual sessile adenomatous polyp and the patient underwent cecal resection.