Purpose: Anorectal cancer accounts for 1-6% of colon malignancies, of which cloacogenic cancer seen in ˜2% of anorectal malignancies. Cloacogenic cancer is a non keratinizing tumor that originates from the cloacal remnant cells at the level of or below the pectinate line in the region of the anal sphincter. This cancer often accompanies genital cancer as the cloacal cells give rise to the hind gut and the part of the genital system. This cancer has a female preponderance and is frequently seen in the fifth and seventh decade of life. Proposed etiologies include chromosomes 3 and 11 deletions, chronic anorectal disease as is seen in colitis, immunosuppression, human papilloma virus infection and smoking. Patients can present with a wide variety of symptoms that include abdominal discomfort, bloody stools, and diarrhea. Direct visualization with colonoscopy generally reveals plaque like lesion with histopathology leading to the final diagnosis. Polypoidal manifestations are unusual. Colposcopy and prostate cancer screening is recommended to rule out concomitant genital cancer. Full body CT scans help in staging and detecting recurrences and is generally more aggressive than the common squamous cell cancers and adenomas. Management is by local excision with chemoradiation for localized tumors and abdominoperineal resection for more extensive tumors. A 52-year-old woman with a family history of polyps presented with complaints of bloody diarrhea and lower abdominal discomfort for 4 weeks. Review of systems was otherwise negative. She denied any recent travels, but did report having similar symptoms following a trip to Costa Rica 8 to 9 years ago. At this time, she underwent a colonoscopy that was reported normal and her diarrhea responded to antibiotics. She is an ex-smoker and social drinker. Physical exam was significant for tenderness in the left upper and lower quadrants. Rectal exam revealed 1.5 cm rectal polyp, 0-1 cm from the anal verge. Labs were non-revealing. Colonoscopy revealed a 1.5 cm rectal polyp and mild pancolitis. Biopsies were obtained and sent for pathology. Pathology revealed invasive cloacogenic cancer in the polyp and chronic colitis in the remainder of the colon. Colorectal surgery consult was obtained and full body CT scan for staging and chemoradiation is being planned. Conclusion: Cloacogenic cancer is a relatively rare anorectal malignancy and further research on the etiology and pathogenesis may help in proposing effective management strategies. This report also emphasizes biopsying polyps near the anorectal verge. In addition, the close embryologic correlation with genital malignancies may warrant a rethinking for earlier screening if patients are diagnosed with genital malignancies.
Morbid obesity may adversely affect the clinical course of acute pancreatitis (AP); however, there are no inpatient, population-based studies assessing the impact of morbid obesity on AP-related outcomes. We sought to evaluate the impact of morbid obesity on AP-related clinical outcomes and health-care utilization.The Nationwide Inpatient Sample (2007-2011) was reviewed to identify all adult inpatients (≥18 years) with a principal diagnosis of AP. The primary clinical outcomes (mortality, renal failure, and respiratory failure) and secondary resource outcomes (length of stay and hospital charges) were analyzed using univariate and multivariate comparisons. Propensity score-matched analysis was performed to compare the outcomes in patients with and without morbid obesity.Morbid obesity was associated with 3.9% (52,297/1,330,302) of all AP admissions. Whereas the mortality rate decreased overall (0.97%→0.83%, P<0.001), it remained unchanged in those with morbid obesity (1.02%→1.07%, P=1.0). Multivariate analysis revealed that morbid obesity was associated with increased mortality (odds ratio (OR) 1.6; 95% confidence interval (CI) 1.3, 1.9), prolonged hospitalization (0.4 days; P<0.001), and higher hospitalization charges ($5,067; P<0.001). A propensity score-matched cohort analysis demonstrated that the primary outcomes, acute kidney failure (10.8 vs. 8.2%; P<0.001), respiratory failure (7.9 vs. 6.4%; P<0.001), and mortality (OR 1.6, 95% CI 1.2, 2.1) were more frequent in morbid obesity.Morbid obesity negatively influences inpatient hospitalization and is associated with adverse clinical outcomes, including mortality, organ failure, and health-care resource utilization. These observations and the increasing global prevalence of obesity justify ongoing efforts to understand the role of obesity-induced inflammation in the pathogenesis and management of AP.
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Introduction: To delineate predictive factors differentiating groove pancreatitis (GP) from other lesions involving the head of the pancreas (HOP). Methods: A case-control study of patients over a 10-year period was performed comparing patients with GP to other surgically resected HOP lesions. Results: Thirteen cases of GP (mean age: 51.9±10.5 years; 11 [84.6%] male), all with a history of smoking (mean 37.54±17.8 pack-years) were identified. Twelve (92.3%) had history of heavy alcohol drinking (heavy EtOH). Mean lesion size was 2.6±1.1 cm and the CA 19-9 was elevated (>37 IU/mL) in 5 (45.5%) patients. Most common histopathology was duodenal wall cyst with myofibroblastic proliferation and changes of chronic pancreatitis (CP) in the HOP. Univariate analysis revealed decreasing age, male gender, weight loss, nausea/vomiting, heavy EtOH, smoking, and history of CP were predictive of GP. A multivariate analysis among smokers demonstrated that weight loss (p=0.006; odds ratio OR] 11.96; 95% confidence interval [CI] 2.1-70.2), and heavy EtOH (p<0.001; OR 82.2; 95% CI 9.16-738.1) were most predictive of GP. Compared to pancreatic adenocarcinoma (n=183), weight loss and heavy EtOH remained predictive of GP. Conclusion: GP (localized CP) in the HOP is associated with history of heavy EtOH and weight loss. In the absence of these symptoms, it is essential to rule out a malignant lesion.Figure 1: (A) Computed tomography (CT) scan of the abdomen showing peripancreatic edema, duodenal wall thickening with cystic (2.4 x 1.6 cm) dysplastic degeneration suggestive of groove pancreatitis. (B) Follow-up CT Scan 3 months following conservative management showing a decreased size (1.7 x 1.1 cm) and resolution of acute inflammatory changes. (C) Upper endoscopy showing a subepithelial bulging mass in the duodenal bulb. (D) Endosonography demonstrated a duodenal intramural cyst (26 x 13 mm) within a thick wall. There were findings of chronic pancreatitis in the pancreas. (E) Representative H&E sections (4x) show dilated cysts lined by bland benign epithelium. The cyst wall contains chronic inflammation and fibrosis. (F) Representative H&E section at 10x.
Chronic pancreatitis (CP) is a common gastrointestinal illness, which affects the quality of life with substantial morbidity and mortality. The management includes medical, endoscopic and surgical approaches with the need for interaction between various specialties, calling for a concerted multidisciplinary approach. However, at the time of this publication, guidelines to establish care of these patients are lacking. This review provides the reader with a comprehensive overview of the studies summarizing the various treatment options available, including medical, surgical and endoscopic options. In addition, technological advances such as endoscopic retrograde cholangiopancreatogrophy, endoscopic shock wave lithotripsy and endoscopic ultrasound can now be offered with reasonable success for pancreatic decompression, stricture dilatation with stent placement, stone fragmentation, pseudocyst drainage, and other endoscopic interventions such as celiac plexus block for pain relief. We emphasize the endoscopic options in this review, and attempt to extract the most up to date information from the current literature. The treatment of CP and its complications are discussed extensively. Complications such as biliary strictures. pancreatic pseudocysts, and chronic pain are common issues that arise as long-term complications of CP. These often require endoscopic or surgical management and possibly a combination of approaches, however choosing amongst the various therapeutic and palliative modalities while weighing the risks and benefits, makes the management of CP challenging. Treatment goals should be not just to control symptoms but also to prevent disease progression. Our aim in this paper is to advocate and emphasize an evidence based approach for the management of CP and associated long term complications.
Introduction: Metastatic spread to the upper gastrointestinal tract is rare. Typically, the stomach is more often affected than the duodenum. The most common primary cancers found in the upper gastrointestinal tract include lung cancer, breast cancer, and melanoma. Metastasis to the ampulla of Vater (ampulla) is rare with only 33 cases reported. Affected patients commonly present with abdominal pain, jaundice, pruritus and upper GI bleeding. We present a case of acute blood loss anemia and melena from metastatic renal cell carcinoma to ampulla. Case Description/Methods: A 77-year-old female with history of stage IV, clear-cell renal cell carcinoma (RCC) status post right nephrectomy and partial left nephrectomy 3 years prior, complicated by stable metastatic spread to the spine and lungs, actively on pembrolizumab, presented with a week of shortness of breath, fatigue, and dark stools. Her hemoglobin was 5.1mg/dl, down from a baseline of 11mg/dl. CT scan of the abdomen revealed stable metastatic disease. Esophagogastroduodenoscopy was significant for hematin in the stomach and a large fungating mass with bleeding was found at the ampulla (Figure A). Biopsy results returned positive for renal cell carcinoma (Figure B and C) Discussion: We present a case of acute anemia due to metastatic renal cell carcinoma that had spread to the ampulla, 4 years after initial nephrectomy. Of the 33 cases of metastatic spread to the ampulla reported in the literature, 39% were renal carcinoma, 30% melanoma, and 12% breast cancer. Bone, ovary, uterus, bladder, and larynx primary cancers have also been reported. The time interval between the diagnosis of RCC and ampullary metastasis can be as high as 10 years. In our case, the patient had active disease in lungs, and given all her comorbidities, resection of all lesions was not possible. As the treatment of cancer rapidly progresses with advances in genetically guided therapeutics as well as immunotherapy, patients presenting with what today is considered a rare complication as a site of metastatic disease will become more common and recognizing such rare complications can aid in a faster diagnosis and therapy.Figure 1.: Figure A: ampullary mass oozing actively as visualized on Endoscopy ; Figure B: H&E staining of biopsied tissue. Ulcerated tissue with loose, infiltrative cells within the edematous stroma and enlarged nuclei noted; Figure C: Vimentin positive staining.
Introduction: Gastric submucosal lesions are a common finding during endoscopy. However, they rarely present as or cause any symptoms. We present an interesting and rare case of a gastric submucosal lesion causing symptoms Case Description/Methods: An 82-year-old woman with multiple comorbidities presented with worsening nausea and abdominal pain and early satiety. Physical examination had no findings of abdominal tenderness or a palpable mass. A contrast enhanced computed tomography (CT) scan was then performed, and a 6.2cm x 4.9 cm gastric mass was noted. (Figure a) An upper endoscopy revealed an extrinsic compression in the gastric antrum. An endoscopic ultrasound(EUS) examination was then performed, and on EUS, a large perigastric mass in the distal stomach was noted. The lesion appeared hypoechoic and measured 4.6 x 4.9cm with minimal amount of vascularity under EUS-doppler. (Figure b) Transgastric biopsies were obtained. Final pathology revealed spindle cell neoplasm with myxoid stroma, most consistent with schwannoma. The immunohistochemical profile was consistent with schwannoma (Figure c). The patient then underwent surgical resection (Figure d) and pathology confirmed a gastric schwannoma Discussion: Schwannomas are spindle cell mesenchymal tumors originating from the Schwann cell sheath. Gastric schwannomas arise from the gastrointestinal neural plexus. Gastric schwannomas are typically benign and incidentally found, but rarely can have malignant transformation. The tumors are predominantly found in middle-aged females. Gastric schwannoma usually presents in the gastric body. It is important to distinguish these tumors from the two other types of mesenchymal tumors, such as gastrointestinal stromal tumors and leiomyoma. Schwannomas typically have a spindle cell pattern with vague nuclear palisading and peritumoral lymphoid cuff without encapsulation with S100 positive staining and negative for CD34 and CD117, which differentiates them from gastrointestinal stromal tumors and autonomic nerve tumors. Schwannomas stain negatively for actin, unlike leiomyomas. Treatment is typically surgery with recurrence rarely described. The type of surgical approach is dependent on tumor size and location. Due to the excellent outcomes, some endoscopic options are also considered safe Our patient did well and on follow had resolution of all prior symptoms. This case report illustrates the importance of the consideration of schwannomas in the differential diagnosis of perigastric and submucosal lesionsFigure 1.: a: CT scan appearance of the perigastric mass; b: Mass as seen on EUS; c: Pathology with S100 staining; d: Resected specimen.
