Introduction: McKittrick-Wheelock Syndrome (MWS) is a rare condition caused by colorectal tumors, usually benign villous adenomas, that results in diarrhea, electrolyte depletion, and significant fluid losses. Definitive treatment is tumor resection, often surgically. We present a case of MWS in a 69-year-old man who had chronic diarrhea and electrolyte abnormalities that fully resolved after endoscopic polypectomy. Case Description/Methods: A 69-year-old man presented to primary care for worsening hemorrhoids and new onset diarrhea, refractory to loperamide. He was found to have moderate electrolyte abnormalities with K 2.8 mmol/L, Na 133 mmol/L, BUN 25 mg/dL, and Cr 1.1 mg/dL, requiring repletion. He underwent a colonoscopy which revealed a villous rectal polyp 10cm in size, with biopsy showing villous tips of an adenoma. He subsequently underwent a colonoscopy and lower endoscopic ultrasound which confirmed a mucosal polyp measuring 100x62x47mm, occupying the majority of the rectal lumen (Figures 1A-B). Piecemeal endoscopic mucosal resection of the rectal polyp was performed (Figure 1C). Random colon biopsies were obtained and were normal. Pathology of the polyp revealed a tubulovillous adenoma without high grade dysplasia or carcinoma (Figure 1D). At follow-up, he had complete resolution of his diarrhea and normal electrolytes following the polypectomy, confirming the diagnosis of MWS. Discussion: MWS is a rare cause of diarrhea associated with electrolyte abnormalities, renal dysfunction, and fluid depletion due to hypersecretory rectal tumors. Treatment of MWS requires supportive care of the patient's electrolyte disturbances and hypovolemia, as well as resection of the tumor, either surgically or endoscopically. We demonstrate the feasibility of endoscopic resection for the management of MWS.Figure 1.: A, B: Large rectal polyp found on colonoscopy. C: Endosonographic findings demonstrating a 100x62x47mm rectal mass arising from the mucosa. D: Resection area after piecemeal endoscopic mucosal resection. E: Colonic polyp with tubulovillous architecture and low-grade adenomatous dysplasia (high-power view).
Purpose: The gastrointestinal tract is a rare site for lung cancer metastasis. Involvement of the colon is especially rare and is usually symptomatic and discovered after detection of the primary tumor. We report a case of lung cancer metastatic to the colon discovered at screening colonoscopy. Methods: Case report Results: A 71 year old male presented for colonoscopy based on Guaiac positive stool testing performed as part of routine colon cancer screening. Laboratory evaluation showed no anemia. Colonoscopy revealed a transverse colon mass. Biopsy showed colonic mucosa with no evidence of dysplasia. Tumor stains suggested undifferentiated carcinoma, likely metastatic. CT scan of chest, abdomen and pelvis showed a right upper lung lobe soft tissue density. PET scan showed uptake in the right upper lung as well as right paratracheal and left neck areas. Resection was performed and pathology revealed the tumor to be submucosal in location (Fig. 1) with ulceration of overlying mucosa and extension into the subserosa. Immunohistochemical studies performed on representative tumor sections reveal a pattern suggestive of lung origin (Fig. 2). One out of seven lymph nodes showed metastatic carcinoma.FigureFigureThe patient underwent a CT-guided FNA biopsy of the right upper lung nodule. Immunohistochemical stains and morphologic features were similar to the colonic tumor; both were consistent with a lung primary. The patient enrolled in a clinical trial and received Paclitaxel and Carboplatin chemotherapy. Interval chest CT scan 3 months after initiation of chemotherapy showed decrease in the size of the lung mass, but treatment was stopped because of neuropathy. The patient expired 8 months after presentation. Conclusion: To the best of our knowledge this is the first report of lung carcinoma with colon metastasis discovered at screening (FOBT positive) colonoscopy.[figure1][figure2]
Introduction: Walled-off pancreatic necrosis (WOPN) interventions have shifted over recent years, now favoring non-surgical methods. While this has reduced morbidity, there remains variation in single- vs dual-approach, being endoscopist- or institution-dependent. Dual-modality drainage (DMD) consisting of percutaneous drain(s) in conjunction with endoscopically-placed transmural stent(s) has been shown to be safe and effective by providing drainage via 2 conduits. Endoscopic drainage has since evolved, now with wider caliber stents and earlier aggressive per-oral debridement. We aim to assess efficacy of index endoscopic drainage and define characteristics associated with need for steP-up to DMD. Methods: A retrospective single center medical record review was performed among patients who received endoscopic ultrasound (EUS)-guided transmural drainage for symptomatic WOPN between 1/2017 - 10/2022. Patients were categorized DMD if a percutaneous drain was later placed; all others were Endoscopic Approach Only (EAO). Demographics, WOPN characteristics, and details of clinical care were recorded. Outcomes were assessed over 30 days. Intergroup differences were compared using Chi square, independent t-tests and Fishers Exact test. The primary outcome was need for steP-up percutaneous drainage. Results: Fifty-six patients (32.1% women; median 54.5 years) were included, all who received initial EUS-drainage: 37 (66.1%) remained EAO. Lumen-apposing metal stents (LAMS) were utilized in similar proportions and there was equal distribution of disconnected tail in about half the patients (Table 1). The DMD patients had larger collection(s): 16.4 cm DMD vs 11. 5cm EAO (P=0.013), with more frequent pericolic extension (42.1% vs 13.5%, P=0.043). Gastric outlet obstruction (GOO) was also more common in the DMD group than EAO (84.2% vs 56.8.2%, P=0.040). DMD had longer LOS and required twice as many Cat scans. LAMS indwell time was similar between groups (24.2 days in DMV vs 28.7 days in EAO, P=0.515). Low rates of procedure-related adverse events were observed in both groups. Conclusion: In patients receiving initial EUS drainage, the rate of steP-up to DMD was 33.9%, highlighting that 2/3 of those with WOPN (even ranging up to 25cm in our EAO group) can be successfully managed by endoscopic means alone, and avoid a percutaneous drain. GOO, pericolic extension, and large size were associated with need for steP-up, and such features may be useful in identifying patients who may benefit from early dual approach. Table 1. - Baseline Patient Characteristics & Patient Outcomes According to Study Group Study sample Endoscopic Approach Only (EAO)N=37 Dual-Modality Drainage (DMD)N=19 P-value Demographic characteristics Mean Age in Years (SD) 56.2 (14.6) 50.3 (16.0) 0.172a Gender n (%) n (%) 0.560b Male 24 (64.9%) 14 (73.7%) Female 13 (35.1%) 5 (26.3%) Risk behaviors n (%) n (%) Used alcohol w/in 30 days (2 Unknown - Endo) 12 (32.4%) 7 (36.8%) 0.557c Smoked w/in 30 days (3 Unknown - Endo) 5 (13.5%) 4 (21.1%) 0.371c Clinical Characteristics Etiology of pancreatitis n (%) n (%) 0.100c Alcohol 10 (27.0%) 8 (42.1%) Gallstones 13 (35.1%) 3 (15.8%) Idiopathic 11 (29.7%) 4 (21.1%) Iatrogenic 2 (5.4%) 2 (10.5%) Hypertriglyceridemia 1 (2.7%) 2 (10.5%) Type of Initial Stent n (%) n (%) 0.917c AXIOS20 x 10mm 7 (18.9%) 4 (21.1%) AXIOS15 x 10mm 27 (73.0%) 14 (73.7%) Double pigtail stents (DPS) only 3 (8.1%) 1 (5.3%) Location of transmural stent n (%) n (%) 0.288c Cystgastrostomy 33 (89.2%)* 19 (100.0%) Cystduodenostomy 4 (10.8%)* 0 (0.0%) Mean size of largest collection (SD) (cm) 12.1 (4.85) 16.4 (6.17) 0.013 a Median size of largest collection (cm) 11.5 15.1 Range (cm) 6.2-25.0 5.9-28.0 Mean # Collections (SD) 1.39 (0.69) 2.1 (1.65) 0.108a Median # Collections (range) 1 (0-4) 2 (1-8) n (%) n (%) Pericolic/pelvic extension 5 (13.5%) 8 (42.1%) 0.043 c GOO 21 (56.8%) 16 (84.2%) 0.040 c ERCP at index drainage 2 (5.4%) 2 (10.5%) 0.598b Evidence of disconnected tail 20 (54.1%) 10 (52.6%) 0.920c Study outcomes Mean LOS after EUS-drainage (SD) 7.0 (6.9) 25.6 (19.8) < 0.001a Median LOS after EUS-drainage (range) 5 (1-27) 22 (1-76) Mean # of days LAMS in place^ (SD) 28.7 (33.2) 24.2 (16.9) 0.515 a Median # of days LAMS in place^ (Range) 23 (0-204) 20 (0-57) Number of readmissions at 1 month n (%) n (%) 0.236c None 22 (59.5%) 7 (36.8%) 1 12 (32.4%) 8 (42.1%) 2 3 (8.1%) 2 (10.5%) 3 0 1 (5.3%) 4 0 1 (5.3%) (Range) (0-2) (0-4) n (%) n (%) Number of patients with readmission at 1 mo 15 (40.5%) 12 (63.2%) 0.191c Procedure-Related Adverse Events n (%) n (%) Intraprocedural Bleeding 2 (5.4%) 1 (5.3%) 1.000b Delayed bleeding 3 (8.1%)# 0 (0) 0.544b Perforation 0 (0) 4 (21.1%)$ 0.011 b Stent migration 5 (13.5%) 4 (21.1%) 0.470b Mean # of endoscopy sessions (SD) 3.3 (1.45) 4.7 (2.08) 0.010 a Median # of endoscopy sessions (Range) 3 (1-8) 4.0 (2-9) Mean # of IR drainage procedures N/A 3.4 (2.50) -- Mean # of perc drains N/A 2.4 (2.2) -- Mean # of total procedures (SD) 3.3 (1.46) 7.3 (2.9) < 0.001 a Mean # of days b/w EUS and IR drainage (Range) N/A 6 (2-48) -- Mean # of IR drain exchanges N/A 0.5 (0-4) -- Mean # CT scans 3.9 (2.2) 8.1 (4.2) < 0.001 a Mean # of MRI 0.51 (0.8) 0.74 (1.1) 0.390a Mean # Necrosectomies at 1 month (SD) 1.51 (1.3) 2.16 (1.5) 0.125 Median # Necrosectomies at 1 month (range) 1 (0-6) 2 (0-5) Developed exocrine deficiency 21 (56.8%) 12 (63.2%) 0.654c Need for surgical debridement 1 (2.7%) 2 (10.5%) 0.263c Death 1 (2.7%) 0 (0.0%) 1.00c *One patient completed both cystoduodenostomy & cystogastrostomy at initial EUS.#One of the patients with delayed bleeding required IR-embolization.^Only patients who received LAMS were included in this analysis $Confirmed perforations through imaging a Independent samples t-test (2 tailed) b Fisher’s Exact test (2 tailed) c Chi Square (2 tailed).
Techniques of tissue sampling at endoscopic retrograde cholangiopancreatography (ERCP) have been underutilized due to technical demands, low yield, and lack of immediate intraprocedural diagnosis. The objective of this study was to describe a new inexpensive, highly efficient ERCP tissue processing, and interpretation technique to address these issues.A retrospective, institutional review board approved, single-center study was done at a tertiary-care medical center. Between June 2004 and February 2009, 133 patients (age 38-95 years; men 53%) with suspicious biliary strictures underwent ERCP with tissue sampling using a new technique. Small forceps biopsy specimens were forcefully smashed between two dry glass slides, immediately fixed, stained with rapid Papanicolaou, and interpreted by an on-site pathologist during the procedure (Smash protocol).Of the 117 proven to have cancer, true-positive Smash preps included pancreatic cancer 49/66 (74%), cholangiocarcinoma 23/29 (79%), metastatic cancer 8/15 (53%), and other 4/7 (57%). The median number of Smash biopsies to diagnosis was 3 (range 1-17). Suspicious or atypical results were considered to be negative in this study. There were no false positives and no complications. Smash had an overall sensitivity of 89/117 (76%) for all cases. The true-positive yield of immediate Smash prep cytology, combined with ERCP fine needle aspirate (FNA) and forceps biopsy histology was 77/95 (81%) for primary pancreaticobiliary cancers.Immediate cytopathologic diagnosis at ERCP was established in 72% of patients presenting with suspected malignant biliary obstruction using a new cytological preparation of forceps biopsies. This approach to ERCP tissue sampling permits immediate diagnosis and avoids the need for subsequent procedures, adds little cost and time, and is safe to perform.
