Mahmoud Ali

Institut national de recherche en informatique et en automatique

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Sorin V. Pislaru

Mayo Clinic

Patricia A. Pellikka

Mayo Clinic

Anish V. Patel

San Antonio Military Medical Center

Kevin L. Greason

Mayo Clinic

Vuyisile T. Nkomo

Mayo Clinic

Renuka Jain

Aurora St. Luke's Medical Center

Mostafa Jahanifar

University of Warwick

Ayesha Azam

University Hospitals Coventry and Warwickshire NHS Trust

David Snead

University Hospitals Coventry and Warwickshire NHS Trust

Emily Hero

University Hospitals Coventry and Warwickshire NHS Trust

Cooperative Institutions

Aurora St. Luke's Medical Center

Mayo Clinic

Aurora Health Care

Mayo Clinic in Arizona

Johnson University

Rutgers, The State University of New Jersey

WinnMed

Mayo Clinic in Florida

Mansoura University

University of Wisconsin–Madison

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S4025 Bleeding GIST Suggestive of Undiagnosed Neurofibromatosis Type 1

The American Journal of Gastroenterology (2023)

Zhuo Justin Ping He Mahmoud Ali Anish V. Patel Keerthana Kesavarapu

Introduction: Neurofibromatosis type 1 (NF1) is one of the most common autosomal dominant genetic disorders. Patients with NF1 have a higher risk of developing gastrointestinal stromal tumors (GISTs). We describe a case of a jejunal GIST discovered during endoscopic evaluation for severe gastrointestinal (GI) bleeding in a young adult. Case Description/Methods: A 28-year-old man with a history of iron deficiency anemia and obscure GI bleeding presented with one day of profuse hematochezia and hemodynamic instability. CT revealed active contrast extravasation in the proximal jejunum and multiple neurofibromas along the posterior pelvis. Physical exam revealed multiple café-au-lait macules and subcutaneous nodules, which were overall concerning for undiagnosed NF1. Prior endoscopic evaluation included EGD and colonoscopy performed one year ago for melena, which revealed gastritis. Due to ongoing anemia, repeat EGD and video capsule endoscopy had also been performed and were nondiagnostic. Therefore, we performed a push enteroscopy which demonstrated a large submucosal mass with focal ulceration in the proximal jejunum (Figure 1A). Cold forceps biopsies revealed fragments of small bowel mucosa with acute and chronic inflammation. The patient underwent laparoscopic resection of a segment of proximal jejunum containing the 3.8 cm mass with nodules distal and proximal to it. Pathology was consistent with a low-risk, multifocal, spindle cell type GIST (Figure 1B). Without further GI bleeding, the patient was discharged and referred for genetic counseling. Discussion: While NF1 is most commonly recognized by café-au-lait macules and cutaneous neurofibromas, up to 25% of patients have GI manifestations that are often underappreciated in routine clinical practice. GISTs associated with NF1 are often diagnosed in middle age, multifocal, located in the small intestine ( >70%), have spindle cells with low mitotic rates, and lack the PDGFRA and KIT mutations typically seen in sporadic GIST. Patients with wild-type GIST occurring at a younger age should be examined for neurocutaneous markers and a complete family history. Our patient had been experiencing significant GI bleeding and anemia for over a year prior to his diagnosis, highlighting the under recognition of NF1 features and the importance of GI findings in identifying patients with undiagnosed NF1. GISTs in NF1 may not be apparent on routine endoscopy. Thorough small bowel evaluation including enteroscopy, video capsule endoscopy and enterography should be considered.Figure 1.: Push enteroscopy demonstrates a large GIST in the proximal jejunum (A). Histology reveals spindle cells with a low mitotic rate (B).

Hematochezia

Melena

Esophagogastroduodenoscopy

Gastrointestinal bleeding

Jejunum

Enteroscopy

Stromal tumor

10.14309/01.ajg.0000965740.05415.73

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Charcoal Heart

JACC Case Reports (2021)

Mahmoud Ali Amina Adil Rahul Sawlani Sana Jeffreys Omar Cheema

A 59-year-old woman with history of skin melanoma and complete excision presented with palpitations. Transthoracic echocardiogram revealed right atrial mass attached to interatrial septum. Cardiac magnetic resonance was suggestive of metastatic melanoma. Laboratory tests revealed elevated liver enzymes. Liver ultrasonography showed a large mass positive for metastatic melanoma by biopsy. (Level of Difficulty: Intermediate.).

Palpitations

Interatrial septum

10.1016/j.jaccas.2021.08.012

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Foreign Body Granuloma Induced by Submucosal Lifting Agent Mimicking Adenoma or Colorectal Carcinoma

North American Journal of Medicine and Science (2021)

Mahmoud Ali Nell Maloney-Patel Zhongren Zhou

Foreign bodies used during surgeries and endoscopy procedures may elicit inflammatory reactions and granuloma formation. The resultant lesion may mimic polyps or tumors, which require cautious interpretation. Here we reported that 69-year-old patient with history of treated rectal cancer underwent surveillance colonoscopy where a tubular adenoma was found in the cecum. A follow-up endoscopy found a flat polyp at the ileocecal valve. Right hemicolectomy was performed. On examining the specimen, two lesions were identified in the wall of the ileocecal valve area. Microscopically, there were foreign body giant cell granulomas filled with eosinophilic amorphous material which is consistent with an inflammatory reaction caused by submucosal lifting material injection used during colonoscopy for polypectomy. The granulomas mimicked recurrence of colorectal carcinoma. Therefore, surgeons and pathologists should be aware of the inflammatory reaction elicited by the new lifting agents that may resemble polyps or tumors. [N A J Med Sci. 2021;1(1):001-003. DOI: 10.7156/najms.2021.1401001]

Ileocecal valve

Polypectomy

Cecum

Foreign body granuloma

Tubular adenoma

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Surgical Loupe at 4.0× Magnification in Pancreaticoduodenectomy—Does It Affect the Surgical Outcomes? A Propensity Score–Matched Study

Surgical Innovation (2018)

Mohamed El Shobary Ayman El Nakeeb Ahmed Sultan Mahmoud Ali Mohamed El Dosoky

Background. There is paucity of data about the impact of using magnification on rate of pancreatic leak after pancreaticoduodenectomy (PD). The aim of this study was to show the impact of using magnifying surgical loupes 4.0× EF (electro-focus) on technical performance and surgical outcomes of PD. Patients and Method. This is a propensity score–matched study. Thirty patients underwent PD using surgical loupes at 4.0× magnification (Group A), and 60 patients underwent PD using the conventional method (Group B). The primary outcome was postoperative pancreatic fistula. Secondary outcomes included operative time, intraoperative blood loss, postoperative complications, mortality, and hospital stay. Results. The total operative time was significantly longer in the loupe group ( P = .0001). The operative time for pancreatic reconstruction was significantly longer in the loupe group ( P = .0001). There were no significant differences between both groups regarding hospital stay, time to oral intake, total amount of drainage, and time of nasogastric tube removal. Univariate and multivariate analyses demonstrated 3 independent factors of development of postoperative pancreatic fistula: pancreatic duct <3 mm, body mass index >25, and soft pancreas. Conclusion. Surgical loupes 4.0× added no advantage in surgical outcomes of PD with regard to improvement of postoperative complications rate or mortality rate.

Affect

10.1177/1553350618812322

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Carpal Tunnel Syndrome: Correlating Preoperative Diagnostic Tools with Intraoperative Findings

Deleted Journal (2023)

Omar Elgazzar Mahmoud Ali Mohamed Abdel Shaheed Ahmed Zayed Ebrahim El Tnany

Background: There is no universally accepted gold standard for decision-making regarding the choice of surgery for carpal tunnel syndrome.A combination of clinical examination and electrophysiological studies has been commonly used for the diagnosis of CTS and grading its severity with the recent introduction of ultrasonographic examination as a reliable diagnostic tool.In severe cases of CTS, carpal tunnel release surgery is usually done, while patients with mild or moderate degree of the disease usually start with conservative treatment.Knowing which diagnostic test more accurately reflects the severity of CTS is mandatory for proper decision-making regarding management.Objective: To correlate preoperative diagnostic tools (clinical presentation, Nerve conduction study, and US) findings with intraoperative findings to find out which one of these preoperative diagnostic tools plays the greatest role in the decision-making process regarding the choice of surgery.Method: Surgically treated 18 patients diagnosed with carpal tunnel syndrome (CTS) were included in the study.A correlation between clinical, electrophysiological, and ultrasonographic data and intraoperative findings was done.Results: Statistical analysis shows positive correlation between clinical, electrophysiological and ultrasonographic data, and intraoperative findings with electrophysiological studies being the best and only statistically significant predictor of severity. Conclusion:Electrophysiological studies provide the best predictor of the severity of CTS but more studies are needed to test the accuracy of these results.

10.21608/ejprs.2023.319963

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S3967 A Case of Post-COVID Eosinophilic Enteritis Presenting as Protein-Losing Enteropathy

The American Journal of Gastroenterology (2023)

Ping He Brittany Muhlgeier Mahmoud Ali Anish V. Patel

Introduction: Eosinophilic enteritis (EE) is a chronic inflammatory disorder characterized by infiltration of eosinophils into the mucosa, submucosa, or muscularis propria. Its prevalence is between 0.5-5 per 100,000 people. The exact cause is unknown, but believed to be a reaction to environmental allergens. Symptoms include abdominal pain, diarrhea, vomiting, weight loss, and anemia. Diffuse mucosal involvement can lead to protein-losing enteropathy (PLE) characterized by hypoproteinemia and edema. Case Description/Methods: A 35-year-old woman with no medical history presented to the hospital with severe abdominal pain, nausea, vomiting and diarrhea for 2 weeks. Symptoms started 10 days after COVID-19 infection. Physical exam was significant for periorbital swelling, pitting edema in all extremities, abdominal distention with diffuse abdominal tenderness. Labs were significant for hypoproteinemia (total protein 3.2) and hypoalbuminemia (Alb 1.9). Autoimmune serology including ANA, anti-mitochondrial antibody, anti-smooth muscle antibody, ANCA, celiac panel were negative. Urinalysis was negative for proteinuria. Gastrin level was normal. Abdominal ultrasound and CT revealed normal liver, bowel and mesenteric vasculature. Stool studies were negative for infection, but fecal alpha-1-antitrypsin returned elevated at 916 mg/dL consistent with PLE. Small bowel enteroscopy revealed segmental inflammation with ulcerations in the third and fourth parts of duodenum and proximal jejunum (Figure 1A) with sparing of the proximal duodenum. Biopsies showed chronic enteritis with increased lamina propria eosinophils in a patchy distribution, ranging between 30-60 per hpf (Figure 1B). This was consistent with a diagnosis of EE with PLE. She was started on a high protein diet with low dose furosemide. And then treated with a 14-day course of budesonide with complete resolution of clinical and endoscopic findings on follow-up. Discussion: EE is diagnosed by endoscopic biopsies showing increased eosinophil count. The segmental nature of lesions and microscopic increase in eosinophils despite normal endoscopic appearance can make the diagnosis of EE easy to miss. Although a rare disease, EE cases after COVID infection or vaccination has been reported in literature. T-Helper 2 cell (Th2) response activation occurs in both EE and severe COVID infection, suggestive of a link between COVID infection and EE in our patient. This case demonstrates the importance of thorough small bowel evaluation including enteroscopy in the workup of PLE.Figure 1.: A: Segmental inflammation in the distal duodenum with ulcerations, biopsied on small bowel enteroscopy. B: chronic enteritis with increased lamina propria eosinophils in a patchy distribution, ranging between 30-60 per hpf.

Hypoproteinemia

Hypoalbuminemia

Lymphangiectasia

Lamina propria

Protein losing enteropathy

10.14309/01.ajg.0000965508.27434.3a

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Ultrasound-assisted catheter-directed thrombolysis versus anticoagulation alone for management of submassive pulmonary embolism

Journal of Cardiology (2022)

Sarah Gorgis Sagger Mawri Mohammed Dabbagh Lindsey Aurora Mahmoud Ali

Demographics

10.1016/j.jjcc.2022.04.008

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WHEN LESS IS MORE: CLINICAL DECISION MAKING WITH CORONARY-BRONCHIAL FISTULA

Journal of the American College of Cardiology (2021)

Haroon Zubair Mahmoud Ali Joaquı́n Solı́s

Clinical Decision Making

10.1016/s0735-1097(21)03867-5

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P2964Paravalvular leak following surgical and transcatheter aortic valve replacement: comparative outcomes and the defining role of STS score

European Heart Journal (2017)

Ratnasari Padang Mahmoud Ali Kevin L. Greason Christopher G. Scott C. Rihal

Cluster Groups and Hospitalizations Conclusion:The combination of atmospheric conditions with low temperature, dry weather and increased inhalable particles resulted in a marked increase of hospital admissions due to MI.

Valve replacement

10.1093/eurheartj/ehx504.p2964

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A Rare Finding of Gastric Metastasis From Tonsillar Squamous Cell Carcinoma

Gastro Hep Advances (2022)

Anish V. Patel Mahmoud Ali

Melena

Tonsil

10.1016/j.gastha.2022.04.010

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