Introduction: Neuroendocrine tumors (NETs) are epithelial tumors that arise from neuroendocrine cells of the digestive system. Within the digestive system, the majority occur in small intestine (45%). Diagnosis is usually made accidentally during a routine workup or from the patient experiencing symptoms from the tumor. We report a difficult-to-diagnose unsuspected NET of the ileum in a young, otherwise healthy individual. Case Description/Methods: A 57-year-old female with a history of hypertension and hyperlipidemia presented to the emergency department with multiple episodes of dark stools one day prior to admission. A CT angiogram showed high density fluid in the small bowel with no active bleeding. Overnight, the patient had a near syncopal episode. A repeat CT angiogram showed active bleeding within the small intestine. However, on angiogram, no active bleeding was noted. The following day, an MR enterography showed thickening of the segment of the small intestine that had shown active bleeding on the repeat CT angiogram. During laparoscopy, the surgeon identified what felt to be a tumor in the distal ileum. Pathology revealed a well-differentiated neuroendocrine tumor (Figure 1). Discussion: NETs are the most common type of small bowel neoplasms. They are divided into duodenal NETs and distal NETs of the jejunum and ileum. Lymph node metastasis occurs in about 60% of cases of duodenal NET. Liver metastasis occurs in less than 10% of duodenal NET cases and about 20% of cases of distal NET of the jejunum and ileum. The stage of the disease has a large impact on prognosis. The 10-year survival rate is 95% for patients with localized NETs and 10% for those with distant metastasis. Distal NETs of the jejunum and ileum have a poorer prognosis because of their tendency to metastasize. The annual incidence of NETs has increased over the past five years to forty to fifty cases per million, largely due to better diagnostic tools. For duodenal NETs, upper gastrointestinal endoscopy with biopsy is the most sensitive diagnostic test. Several genetic markers are being evaluated as diagnostic tools. Treatment depends on the size of the NET. Small (≤ 1 cm) duodenal NETs can be resected endoscopically. Larger duodenal NETs (≥ 2 cm) or lymph node metastasis should be treated surgically. Systemic chemotherapy is not recommended for well-differentiated NETs. In conclusion, this case describes difficulties in diagnosing NETs of the ileum and highlights the need for improvements in diagnosis and management of NETs.Figure 1.: Ulcerated submucosal mass in distal small bowel measuring 2.8x1.8 cm.
Introduction: Acute hepatitis B is caused by infection with hepatitis B virus (HBV). The incubation period from the time of exposure to the onset of symptoms is 6 weeks to 6 months. Most infections in adults are caused by exposure to contaminated blood. Other potential sources are semen, vaginal secretions, and open wound exudate. Acute infection ranges from asymptomatic or mild disease to, rarely, fulminant hepatitis. Disease is more severe among adults aged >60 years. The fatality rate among acute cases reported to Center for Disease Control (CDC) is 0.5-1%. Case Report: Here, we describe a case of acute hepatitis B infection in a healthy South Asian female from possible exposure at an urban pedicure facility. A 35-year-old, previously healthy but unvaccinated Indian woman was seen in a gastroenterology clinic for acute jaundice. Her initial blood work showed AST 550 U/l, ALT 1745 U/L, total bilirubin 9.3 mg/dL, direct bilirubin 7.3 mg/dL, and ALP 196 U/l. Previous liver function tests were normal. An ultrasound of her abdomen showed normal-appearing liver without gallstones or biliary dilatation. Her serologies showed positive hepatitis A IgG antibody, negative hepatitis A IgM antibody, positive hepatitis B surface antigen, positive hepatitis B core IgM antibody, negative hepatitis C antibody, hepatitis B DNA 81300 IU/mL, and negative hepatitis B surface antibody. Her creatinine was 0.59 mg/dL and prothrombin time/ INR 1.1. She had no features of encephalopathy or hepatic decompensation. Her husband and children were immune for hepatitis B from previous vaccination. She was taking no other medications at the time of her illness. She had no other risk factors except a visit to an urban pedicure facility in downtown San Jose, 2 months prior to her acute illness. She remembered having a cut and a bruise after her nails were done, and her feet were washed in a bowl that was used to wash other customers’ feet. She was managed conservatively with no antiviral medications. Follow-up blood work revealed normalization of liver enzymes in about 3 months with AST 31 U/l, ALT 56 U/l and total bilirubin 0.4 mg/dL. She achieved seroconversion 3 months after presentation with negative hepatitis B surface antigen and reactive hepatitis B surface antibody, and undetectable hepatitis B virus. She remains asymptomatic and clinically well. Conclusion: Acute hepatitis B infection can be caused from contamination of blood from open cuts/bruise and stains that can happen at a pedicure facility. The Center for Disease Control recommends any blood spills, including dried blood, which can still be infectious for about 7 days, be cleaned using 1:10 dilution of 1 part household bleach to 10 parts of water for disinfecting the area.
A 69-year-old female with no significant past history presented to the emergency room with throat pain and difficulty swallowing.On the day of her visit, she took her daily pills without putting on her glasses.Immediately, she felt something get stuck in her throat.In the emergency room, an X-ray of the neck showed an ovoid soft tissue structure near the cervicothoracic junction.Subsequent endoscopy revealed a pill in its blister pack lodged in the upper esophagus.The pill was extracted using biopsy forceps.This case describes foreign body impaction in an otherwise healthy individual and highlights the significance of early recognition and immediate endoscopic intervention to prevent complications.
Purpose: To quantify, compare, and correlate non-invasive and invasive diagnostic assays for assessing degrees of H. pylori infection for use in antibiotic development. Methods: Volunteers (N = 152, 100%) were screened for circulating IgG antibodies to H pylori using the QuickVue H. pylori gII test and, if positive (N = 42,27.6%), further screened with13 C urease breath test (UBT) (N = 20, 13.2%). UBT data were obtained at baseline, 15, 30, 45, and 60 min. post po administration of 13C; fifteen patients were positive (9.9%). Urease activity was calculated as umolesof 13CO2 formed/minute at time points (15, 30,45, 60 min). Urease activity was highest at 30 min., consistent with previously published reports. Volunteers with positive results for both screening tests underwent endoscopy (N = 4, 2.6%). Six biopsy samples were obtained, two each from the lesser and greater curvatures of the antrum (GA, LA, 2 cm and 4 cm from pylorus), and two samples from the greater curvature of the corpus (GC, 3 and 5 cmproximal to angulus). Within 2 hours, biopsy samples were homogenized, serially diluted and plated on on Skirrow's agar for H. pylori colony forming units (cfu). H. pylori colonies were counted on Day 3 after plating and cfu/biopsy site was calculated. Correlation analysis was used to relate cfu obtained per biopsy site to urease activity. Results: We report here the preliminary findings of this study which demonstrate good correlation (r2 = 0.93, p = 0.023) between log cfu at biopsy location GA-4cm and 30 minute urease activity rate. However, no correlation with the 30 minute urease activity rate was found with other biopsy sites. Conclusions: A correlation was observed between log cfu and urease activity at 30 minutes on UBT at one of six biopsy sites in this limited sample. We speculate that either inadequate sample size or uneven distribution of H. pylori infection may explain the lack of correlation at other sites. This may be useful in antibiotic therapy development by providing an early indicator of bacterial kill, which could guide the dosing and sequence of component administration in combination therapies. This warrants further study.
Helicobacter pylori is a ubiquitous bacterial pathogen that has evolved to chronically infect the gastric mucosal surface, evade host immune clearance, and cause peptic ulcer disease or gastric neoplasia in a significant minority of infected individuals. Understanding the colonization, persistence, and virulence determinants of the bacterium as well as the innate and adaptive immune responses of the host are critically important if we are to develop novel treatment strategies for eradication of infection and prevention of H. pylori-induced gastroduodenal disease.Substantial progress has been made in understanding the role of CagA in altering gastric epithelial cell signaling pathways. Intracellular CagA has been shown to activate the Ras/MEK/ERK mitogen activated protein kinase cascade and to associate with epithelial tight-junction scaffolding protein ZO-1. CagA was shown to regulate cellular responses and possibly contribute to gastritis by phosphorylation-dependent pathways. A phosphorylation-independent mechanism for CagA intracellular effects has also been proposed. The potential for CagA to disrupt the apical junctional barrier and for the outer membrane protein oipA to promote IL-8 secretion and gastric inflammation have also been explored. A number of different mechanisms by which H. pylori escapes and evades host immune attack to cause chronic indolent inflammation have been uncovered. Meanwhile, the examination and development of new adjuvants and vaccine delivery mechanisms to induce mucosal immune responses against key bacterial antigens has been a continuing focus of investigation in both animal and human studies.H. pylori induces gastritis through production of a variety of antigens, virulence factors, and soluble mediators. The bacterium also dysregulates, disarms, and evades host immune responses to maintain chronic colonization of the gastric mucosa. Understanding the mechanisms of its growth and survival in the human stomach are essential for the development of an effective vaccine and other novel eradication strategies.
