Gastroenterol. Insights, Volume 8, Issue 1 (May 2017) – 15 articles

Desmoid tumors are unique mesenchymal neoplasm. They are able to spread to proximal tissues but tend not to metastasize. Our case presents a 66-year-old female referred for evaluation of the prominent, palpable mass located into the left abdomen. Imaging studies revealed a tumor up to 22 cm, extending below the diaphragm to the retroperitoneal and intra-abdominal cavity. Contrast enhanced ultrasound showed strong inhomogeneous arterial hyper-enhancement followed by persistent enhancement in a venous phase. Histology obtained with trucut needle biopsy established desmoid tumor, with overall proliferating activity (Ki-67 expression) of 20%. The lesion had been identified as sporadic and unresectable. During the patient’s follow-up a slow but continuous elevation of serum creatinine was registered eventually led to anuria, requiring emergent hemodialysis. The non-obstructing nephropathy is an unusual complication of the disease course, therefore we briefly reviewed the published data on abdominal desmoid tumors and critically analyzed the relation with kidney injury. Full article

Hepatic hemangiomas are benign tumors of the liver which are often found incidentally. We present a 34-years-old man with a two-month history of upper abdominal pain and incidental finding of multiple hepatic masses. The patient sought medical attention at several healthcare facilities where he posed a diagnostic dilemma before he was referred to us. Computed tomographic scan revealed four hypodense hepatic nodules of varying sizes. The nodules demonstrated peripheral enhancement with progressive centripetal filling till they were totally filled during the delayed phase. Abdominal ultrasonography confirmed the four hepatic lesions. The largest lesion was in the left lobe measuring 73×72 mm while the smallest was in the right lobe (24×20 mm). All the masses demonstrated increased vascularity on color Doppler imaging. The paucity of reported cases of hepatic hemangioma in Nigeria, the multiplicity of the tumor and the giant size of one of them make this case remarkable and reportable. Full article

Large spontaneous portosystemic shunts in cirrhosis are implicated in recurrent and/or chronic persistent hepatic encephalopathy. In long standing cases, these shunts lead to portal vein thrombosis and hepatic dysfunction. Balloon-occluded retrograde transvenous obliteration (BRTO) is an endovascular technique that is usually employed for shunt closure in the patients manifesting the features of chronic hepatic encephalopathy. There are several reports documenting systemic and portal vein thrombosis as a part of the procedure. We report first time a patient in whom the difficult and partial BRTO procedure led to the extensive thrombosis of the large splenorenal shunt itself without sclerosant instillation. Full article

Fistulating cholecystocutaneous abscess is a known rare complication of chronic gallstones disease. In these modern days, this complication is exceedingly rare due to early diagnosis with radiological imaging, use of broad spectrum antibiotics and early surgical management of biliary tract disease. Here we present a case of an 89-yearold with cholecystocutaneous abscess that was mistaken for simple subcutaneous abscess. The management include initial control of subcutaneous abscess and use of antibiotics followed by definitive surgical excision of gall bladder and the fistula tract. Full article

A 61-year-old Punjabi female patient presented with six months history of mild abdominal discomfort with bloody diarrhea. She did not have underlying chronic medical illness; she neither took steroid nor immunosuppressant. She was found anemic, thrombocytosis, and elevated C-reactive protein. Colonoscopy showed moderate left sided colitis, with histopathology evidence of ulcerative colitis (UC) with cytomegalovirus (CMV) infection. Her serum anti-CMV IgM antibody was detected. She was treated with intravenous ganciclovir, together with 5-ASA and tapering dose of steroid. Anemia was corrected. Subsequent clinic reviews and follow up endoscopies showed dramatically improvement. CMV colitis should be considered for the patients presenting with moderate to severe UC. Early prescription of antiviral would be beneficial in the treatment of flare of UC. Full article

Helicobacter pylori (H. pylori) can cause a wide variety of illnesses such as peptic ulcer disease, gastric adenocarcinoma and mucosa-associated lymphoid tissue (MALT) lymphoma. The diagnosis and eradication of H. pylori are crucial. The diagnosis of H. pylori is usually based on the rapid urease test (RUT) and gastric antral biopsy for histology. The aim of this study is to evaluate the numbers of needed biopsies and their location (antrum/fundus) to obtain optimal result for the diagnosis of H. pylori. Three hundred fifty consecutive patients were recruited, 210 fulfill the inclusion criteria and had nine gastric biopsies for the detection of H. pylori infection: two antral for the first RUT (RUT1), one antral and one fundic for the second (RUT2), one antral for the third (RUT3) and two antral with two fundic for histology (HES, Giemsa, PAS). The reading of the 3 types of RUT was performed at 1 hour, 3 hours and 24 hours and biopsies were read by two experienced pathologists not informed about the result of RUT. Results of RUT were considered positive if H. pylori was found on histology of at least one biopsy. The RUT1 at 1h, 3h and 24h has a sensitivity of 72%, 82% and 89% and a specificity of 100%, 99% and 87% respectively. The positive predictive value (PPV) was 100%, 99% and 85% respectively and the negative predictive value (NPV) of 81%, 87% and 90%. The RUT2 at 1h, 3h and 24h, respectively, had a sensitivity of 86%, 87% and 91% and a specificity of 99%, 97% and 90%. The PPV was 99%, 96% and 88% and NPV of 89%, 90%, 94%. The RUT3 at 1h, 3h and 24h, respectively, had a sensitivity of 70%, 74% and 84% and a specificity of 99%, 99% and 94%. The PPV was 99%, 99% and 92% and NPV of 79%, 81% and 87%. The best sensitivity and specificity were obtained for RUT1 read at 3h, for RUT2 read 1h and 3h, and the RUT3 read at 24h.This study demonstrates that the best sensitivity and specificity of rapid test for urease is obtained when fundic plus antral biopsy specimens are used with a reading time at 3 hours. Full article

In Lebanon, hepatitis C virus (HCV) prevalence is estimated to 0.2% among all ages, with genotype 1 the most common genotype. The age distribution shows 2 peaks reflecting 2 probable mode of transmission of HCV in Lebanon: 20-39 years and more than 40 years. The burden of HCV-related complications on the health system in Lebanon is expected to increase in the upcoming years. The number and prevalence per age group and the fibrosis stage of HCV infections is required to better estimate the burden of the disease in Lebanon. We calculated the prevalence per age group. Concerning fibrosis stage, patients recently diagnosed with HCV and never been treated previously were included and were divided into three groups according to their age Concerning the prevalence by age group, the lowest was seen in the group less than 20 years and the highest in the population aged more than 60. Concerning the fibrosis by age group, the majority of patients less than 40 years had low fibrosis stage, while in the group of more than 60 years F3 and F4 represent respectively 15.07% and 68.49%. Female gender had more significant fibrosis and cirrhosis than male gender. There is an exponential increase of significant fibrosis with age In Lebanon, the highest prevalence of hepatitis C is seen in the age group more than 60 years. In the 2 age groups (40-59 years and >60 years), we noted an advanced fibrosis stage and the majority of patient more than 60 years were cirrhotic at the time of diagnosis, which can reflect the burden of the disease in these groups. Full article

Pancreaticopleural fistula is an extremely rare complication of chronic pancreatitis. Interestingly it may present without any symptoms of pancreatitis per se. The diagnosis requires a high index of suspicion due to the predominant thoracic symptoms. Cases with massive, rapidly refilling, refractory pleural effusion in the setting of pancreatitis (symptomatic or asymptomatic) should be suspected of having a pancreaticopleural fistula. We report two cases of pancreaticopleural fistula. One of the patient also had pancreatic divisum and to the best of our knowledge this is the first case report of pancreatic divisum with pancreaticopleural fistula in the literature. Full article

Mycobacterium tuberculosis can affect any organ of the body. Gastrointestinal tubercular involvement is fairly common. Esophageal tuberculosis though is uncommon. Esophageal tuberculosis accounts for only 0.3% of gastrointestinal tuberculosis. It presents with dysphagia, retrosternal pain, cough or constitutional symptoms. Complications like hemorrhage from the ulcer and development of fistulas like esophagomediastinal fistula is extremely uncommon. We report a case of a 27 years old female who presented with retrosternal pain, dysphagia and hematemesis. The patient had esophageal ulcer secondary to erosion of the esophagus by the subcarinal lymph nodes. Imaging was suggestive of esophagomediastinal fistula. Esophageal ulcer biopsy showed chronic tubercular infection. Culture from the esophageal biopsy confirmed the presence of tubercular bacilli. Patient responded to anti-tubercular therapy. Spontaneous dysphagia resolution prior to starting therapy was likely due to the rupture of the lymph node into the esophagus, which was compressing it initially. Esophageal tuberculosis presenting with hematemesis and fistula is extremely uncommon. Full article

The circadian system has a role in regulating gastrointestinal physiology. Perturbation of this system is associated with gastrointestinal tract dysfunction. Shiftwork and poor sleep quality are associated with functional gastrointestinal disorders among many professional groups. This study compared bowel habits between trainee nurses with regular and irregular patterns of shiftwork. Male and female nursing students, enrolled on the first year (regular shifts; n=49) and the fourth year (irregular shifts, n=48) of a nursing degree course were surveyed. Questionnaires were used to assess functional diarrhea and constipation over a three month period. The prevalence of functional constipation among regular shift workers was lower than that found among irregular shift workers; 31.3% and 61.2%, respectively. There was no difference between the two groups in relation to the prevalence of diarrhea. This suggests an association between shiftwork and functional constipation, but not with functional diarrhea. Full article

Egypt has the highest prevalence of hepatitis C virus (HCV) worldwide. Most of data came from lower Egypt regions (Cairo and northern to it). So, we decided to study risk factors and prevalence of HCV transmission in our governorate. In this cross sectional study, we recruited 631 blood donors from April, 2011 to March 2012 who were tested for anti-HCV, HBs Ag, anti- HBc and anti-HIV. Fifty seven donors were excluded as they are HBs Ag and anti-HBc positive. We found 138 (24%) HCV seropositive participants. Logistic regression final model demonstrated that endoscopy, hospital admission, socioeconomic status, IV drug use and age made a significant contribution to prediction (P=0.0001). The level of education also made significant contribution to prediction (P=0.014). In conclusion, it is wise to determine high HCV prevalence areas and risk factors for its seropositivity then build up a governorate suitable infection control program concentrating upon prevention more than treatment of HCV patients. Also, the introduction of pre-test and post-test counseling in blood banks will help in better donor selection and early detection of patients. Full article

Small-for-size liver syndrome and posthepatectomy liver failure remain a major challenge for surgeons. Recently, updates in literature points to describe this two syndrome as two face of the same coin. These syndromes are characterized by hyperbilirubinemia, coagulopathy, hyper-GGT, high portal pressure and flow in liver remnant, occurring within the first postoperative week. It can lead to post-operative sepsis and bleeding, increasing mortality and morbidity. Despite the large experience in the field of transplantation, few studies are focused on small-for-size syndrome after major hepatectomy. For years, scientists were focused on the size of liver remnant, supposing a small liver remnant, in relation with the primary liver size, was the cause of the syndrome. The strategies used to prevent it after transplantation, have however shown a predominant role of high portal pressure and flow, leading to an alteration in functional regeneration of liver parenchyma, as the prevalent mechanism. According to these evidences, we suggest adopting another nomenclature for the two syndromes: small-for-flow-liver failure. In this article, we analyze and summarize different experiences, proposing our inward algorithm, including the role of portal flow and pressure measurements. This review seeks to be an operative instrument for surgeons and hepatologists in an effort to find a common point of view regarding small for flow liver failure and its management strategies. Full article

Serum cholinesterase levels are closely correlated with the severity of liver disease. The aim of the paper was to assess the value of serum cholinesterase in evaluating liver reserve function in cirrhotic patients. 90 patients with liver cirrhosis and thirty healthy control group were included. Liver cirrhosis patients were classified according to child score into three equal groups: Child A liver cirrhosis, Child B liver cirrhosis and Child C liver cirrhosis. Patients were subjected to clinical evaluation, laboratory analysis, abdominal U/S. Measuring serum cholinesterase, and Calculation of both Child and model of end stage liver disease (MELD) scores. The level of serum cholinesterase was higher in control group than the three groups of liver cirrhosis with median (IQR) 17,410 (12,111-21,774), 7528 (5200-9856), 6021 (4500-7542), 3828.5 (1541-6060), respectively P<0.001). And the level of serum cholinesterase was higher in Child A more than Child B and Child C and the level of serum cholinesterase was higher in Child B more than Child C with very strong negative correlation between serum Cholinesterase level and Child score (r=-0.9, P<0.001). Also strong negative correlation between serum Cholinesterase level and MELD score (r=- 0.85, P=0.001), and positive correlation with prothrombin concentration (r=0.554, P=0.009), and serum albumin levels (r=0.582, P=0.0002). Serum cholinesterase is a good biomarker of cirrhosis. Since it distinguishes decompensated from compensated cirrhosis well, low levels in cirrhosis may serve as a useful prognostic marker of advanced liver disease. Full article

Intramural duodenal hematomas (IDH) have been rarely associated with pancreatic diseases. Conservative treatment is recommended, but course of disease can be life threatening, serious complications may occur (i.e. duodenal perforation) with imperative surgery. The management of diagnostic and treatment in IDH has improved over the years. Computed tomography (CT) and endoscopic ultrasound are excellent tools for diagnosis and follow up of IDH. We report a case of a 31-year-old alcoholic who presented with vomiting, exsiccosis, hypochondriac pain and positive shock index. Esophagogastroduodenoscopy showed gastric outlet obstruction caused by obliterating tumor of bulbus duodeni. Initial suspicion was malign tumor of the duodenum confirmed by native CT and histology. Further diagnostic using EUS-guided aspirate resulted in IDH. By conservative management with nasogastric decompression and digestive rest the patient recovered. In course of disease the hematoma got smaller, but parts were still seen in CT 6 month later. Full article