AIDS-related Kaposi’s sarcoma (KS) is a low-grade vascular tumor that occurs in association with human herpesvirus 8 infection. Here we report the case of a 21-year-old male with recently diagnosed cutaneous KS who presented with rectal bleeding and anal pruritus. Initial endoscopic evaluation was nondiagnostic. CT imaging showed diffuse lymphadenopathy including perirectal involvement which was suspicious for metastatic KS. Echoendoscopy with needle biopsies and EchoBrush sampling of the lymph nodes revealed spindle cells confirming metastatic KS. Treatment was initiated with liposomal doxorubicin resulting in rapid improvement of the skin lesions. After treatment completion, repeat CT imaging showed improved lymphadenopathy. No further rectal bleeding or perianal pruritus was reported. Although the EchoBrush has previously been used to aid in the diagnosis of pancreatic lesions, this report describes a novel use of EchoBrush to diagnose KS from perirectal lymph nodes.

BackgroundRadiation exposure to patients and staff during ERCP correlate with total fluoroscopy time. Little data exists concerning the physician, patient, and procedure factors that influence total fluoroscopy time during ERCP.AimThe goal of this study was to investigate multiple factors which may influence the total ERCP fluoroscopy time.MethodsWe reviewed the electronic medical records between Oct 2009 and May 2010 for the following parameters in adult patients (≥18 yrs) undergoing ERCP: age, sex, diagnostic vs therapeutic ERCP, technician, endoscopist, presence of a trainee, total procedure time, type of sedation (general anesthesia vs. conscious sedation), inpatient vs. outpatient, prior sphincterotomy or ERCP, altered anatomy, stents placed or removed, biliary manometry preformed, pre-cut needle knife sphincterotomy performed. All of these variables were examined to see if they influenced the total fluoroscopy time. In all cases the endoscopist directly controlled the amount of fluoroscopy time used during ERCP.Results357 patients were identified undergoing ERCP. Mean age at presentation 58 yrs (SD 15.72-18.22, 95% CI)), 52% female. The factors significantly influencing fluoroscopy time were: endoscopist performing the procedure (P<0.1), (5.1 - 14.1 min fluoroscopy time per case); whether the procedure was diagnostic vs. therapeutic (5.9 vs. 8.1 min, P = .03); and the use of general anesthesia vs. conscious sedation (P<.01, 12.3 vs. 7.2 min). There was significant correlation between fluoroscopy time and total time of ERCP, (kappa = .79). The following factors had no influence on fluoroscopy time: patient age, gender, whether the procedure was performed as outpatient vs. inpatient, technician, presence of a trainee, previous ERCP, previous sphincterotomy, altered anatomy, or performance of individual therapeutic maneuvers.Conclusions1) Performance of therapeutic ERCPs and the use of general anesthesia increased the total fluoroscopy time during ERCP. 2) Fluoroscopy time is significantly effected by the individual endoscopist due to both increased overall procedure time and increased fluoroscopy use during the ERCP procedure. BackgroundRadiation exposure to patients and staff during ERCP correlate with total fluoroscopy time. Little data exists concerning the physician, patient, and procedure factors that influence total fluoroscopy time during ERCP. Radiation exposure to patients and staff during ERCP correlate with total fluoroscopy time. Little data exists concerning the physician, patient, and procedure factors that influence total fluoroscopy time during ERCP. AimThe goal of this study was to investigate multiple factors which may influence the total ERCP fluoroscopy time. The goal of this study was to investigate multiple factors which may influence the total ERCP fluoroscopy time. MethodsWe reviewed the electronic medical records between Oct 2009 and May 2010 for the following parameters in adult patients (≥18 yrs) undergoing ERCP: age, sex, diagnostic vs therapeutic ERCP, technician, endoscopist, presence of a trainee, total procedure time, type of sedation (general anesthesia vs. conscious sedation), inpatient vs. outpatient, prior sphincterotomy or ERCP, altered anatomy, stents placed or removed, biliary manometry preformed, pre-cut needle knife sphincterotomy performed. All of these variables were examined to see if they influenced the total fluoroscopy time. In all cases the endoscopist directly controlled the amount of fluoroscopy time used during ERCP. We reviewed the electronic medical records between Oct 2009 and May 2010 for the following parameters in adult patients (≥18 yrs) undergoing ERCP: age, sex, diagnostic vs therapeutic ERCP, technician, endoscopist, presence of a trainee, total procedure time, type of sedation (general anesthesia vs. conscious sedation), inpatient vs. outpatient, prior sphincterotomy or ERCP, altered anatomy, stents placed or removed, biliary manometry preformed, pre-cut needle knife sphincterotomy performed. All of these variables were examined to see if they influenced the total fluoroscopy time. In all cases the endoscopist directly controlled the amount of fluoroscopy time used during ERCP. Results357 patients were identified undergoing ERCP. Mean age at presentation 58 yrs (SD 15.72-18.22, 95% CI)), 52% female. The factors significantly influencing fluoroscopy time were: endoscopist performing the procedure (P<0.1), (5.1 - 14.1 min fluoroscopy time per case); whether the procedure was diagnostic vs. therapeutic (5.9 vs. 8.1 min, P = .03); and the use of general anesthesia vs. conscious sedation (P<.01, 12.3 vs. 7.2 min). There was significant correlation between fluoroscopy time and total time of ERCP, (kappa = .79). The following factors had no influence on fluoroscopy time: patient age, gender, whether the procedure was performed as outpatient vs. inpatient, technician, presence of a trainee, previous ERCP, previous sphincterotomy, altered anatomy, or performance of individual therapeutic maneuvers. 357 patients were identified undergoing ERCP. Mean age at presentation 58 yrs (SD 15.72-18.22, 95% CI)), 52% female. The factors significantly influencing fluoroscopy time were: endoscopist performing the procedure (P<0.1), (5.1 - 14.1 min fluoroscopy time per case); whether the procedure was diagnostic vs. therapeutic (5.9 vs. 8.1 min, P = .03); and the use of general anesthesia vs. conscious sedation (P<.01, 12.3 vs. 7.2 min). There was significant correlation between fluoroscopy time and total time of ERCP, (kappa = .79). The following factors had no influence on fluoroscopy time: patient age, gender, whether the procedure was performed as outpatient vs. inpatient, technician, presence of a trainee, previous ERCP, previous sphincterotomy, altered anatomy, or performance of individual therapeutic maneuvers. Conclusions1) Performance of therapeutic ERCPs and the use of general anesthesia increased the total fluoroscopy time during ERCP. 2) Fluoroscopy time is significantly effected by the individual endoscopist due to both increased overall procedure time and increased fluoroscopy use during the ERCP procedure. 1) Performance of therapeutic ERCPs and the use of general anesthesia increased the total fluoroscopy time during ERCP. 2) Fluoroscopy time is significantly effected by the individual endoscopist due to both increased overall procedure time and increased fluoroscopy use during the ERCP procedure.

To establish the incidence of, and identify risk factors associated with, high-risk adenomas in a population undergoing solid organ transplantation evaluation.

test (Roche) was used.To study platelets morphology, the two dimension analysis have been used (ADVIA 2120, Siemens).Results: At day 1 (hospital admission) number of CD41 molecules on platelets was significantly (p<0.01)higher both in M-AP (58595±7322) and S-AP (62213±11740) patients, than in the control (46152±9262).At day 30, the number of CD41 molecules was normalized only in M-AP group.Measurement with TRAP showed significant increase of GPIIb at day 1 and 30, only in S-AP patients.At day 30, platelet reactivity expressed by the number of CD62P was higher than at day 1 (7227±2614 vs 6448±2541) and still significantly higher than in control group (1642±283) (p<0.001).Concentration of b-TG was significantly higher (p<0.001) in the M-AP patients (day 1: 120±74; day 30: 143±85 UI/ml) and S-AP (day 1: 137±54, day 30: 161±64 UI/ml) than in control group (62±14 UI/ml).The population of youngest, most active platelets (L-PLT) was significantly increased in both groups of AP patients (M-AP: 7200/μl±3300; S-AP: 8200/ μl±4600; control: 4500/μl±1700), but at day 30 L-PLT was significantly higher in S-AP patients, than in MAP (9400/μl±6200 vs 6000/μl±1600).Similarly, decrease of MPCcorrelated with platelet degranulation, was more evident in S-AP group at day 1 and day 30 (S-AP: day 1 -23 g/dl±1.5;day 30 -23 g/dl±2.3;MAP: day 1 -24 g/dl±1.2;day 30 -25 g/dl±1,9; control: 28±1.6).Conclusions: At the admission, platelets are highly activated in patients with both, M-AP and S-AP.At the day 30, despite normal resting activity in M-AP, platelets of patients with M-AP and S-AP retained high potential for activation, expressed by increased level of P-selectin (CD62P) after TRAP activation.It is consistent with remained high level of b-TG and increased platelets turnover.

The pancreas is the latest focus of the Curbside Consultation series. This clinically oriented series reviews 49 topics in a question-and-answer format. The book is written not only for gastroenterologists, but also for primary care physicians and trainees looking for a supplement to fine tune their management of pancreatic and biliary disease. The aim of this book is to provide concise answers to informal consultation questions frequently asked among colleagues. This soft-cover, glossy-paged book is divided into 7 sections that cover pancreatic as well as some biliary disease: Acute Pancreatitis, Chronic Pancreatitis, Cystic Pancreatic Lesions, Pancreatic Cancer, Other Pancreatic Neoplasms, Biliary, and Miscellaneous (245 pages). Editors Drs Tenner, Brown, and Gress are well-known gastroenterologists with numerous publications focusing on pancreatic disease. For this publication they enlisted 25 co-authors who range from staff gastroenterologists or surgeons to GI fellows and medical students, but nearly all the answers are co-written with an editor allowing for a consistent presentation throughout. Examples of questions and thus chapters are: “When would you use antibiotics in acute pancreatitis, and which antibiotics would you use?” “What is the best approach to staging pancreatic cancer?” “What is the best approach to a cystic lesion in the tail versus head of the pancreas when the diagnosis cannot be clearly established?” and “When should a pancreatic duct stent be placed?” In each section, questions range from those relevant to a trainee or primary care physician to those that a practicing gastroenterologist may use to find a quick answer for the latest management strategies. Summary tables and figures are listed for the vast majority of topics, which are particularly helpful to highlight the reading material. High-quality imaging studies are also included for virtually all subject matter along with both black-and-white and color histologic, pathologic, or endoscopic photographs when appropriate. Given the topic of the pancreas, extensive radiologic images including computed tomography, endoscopic retrograde cholangiopancreatography, and endoscopic ultrasound pictures are included in almost every chapter. The information provided is not meant to be a long or detailed analysis of the pathophysiology of each disease covered, but rather the depth of the material is ideal to answer the question posed with a focus on patient management. Some answers are 2 pages, whereas others are up to 6 pages. For example, the question “Is there a role of pancreatic enzymes to treat pain in patients with chronic pancreatitis?” has an answer just >2 pages long, including a meta-analysis review, whereas the question “When should one suspect autoimmune pancreatitis as a cause of acute or chronic pancreatitis” has an answer >5 pages long and includes sections on diagnosis, laboratory studies, imaging, and histology. Concise bibliographies of <10 references at the end of each question and answer session are well focused, allowing for easy referral if needed. Reading this book in 1 sitting does reveal some overlap of material in the various sections. It is doubtful this will be an issue for most readers, who are likely to thumb to a topic based on a specific clinical question. Overall, the material reviewed is extremely accurate, up-to-date, and easy to read. Many of the responses to the clinically posed questions end in a summary paragraph that is a final combination of the literature's latest recommendation with the authors' personal opinion and interpretation of existing data. Curbside Consultation of the Pancreas: 49 Clinical Questions does carve out its own niche as compared with existing books and texts on the pancreas. This is a book dedicated strictly to the clinical scenarios found by health care providers who treat patients with pancreatic disease. This text does not pretend to thoroughly explain the pathophysiology or basic science of the pancreas, but repeatedly is able, often in a case format, to simply and succinctly explain the common pancreatic diseases and how they are best diagnosed and managed. Bottom Line: A well-recommended book to anyone looking for a user-friendly resource for pancreatic and biliary disease written in a practical and clinically oriented format. Moreover, the layout and wide use of images, charts, and tables make the book an enjoyable source of medical information that is sure to be used repeatedly in every day practice.

The pancreas is the latest focus of the Curbside Consultation series. This clinically oriented series reviews 49 topics in a question-and-answer format. The book is written not only for gastroenterologists, but also for primary care physicians and trainees looking for a supplement to fine tune their management of pancreatic and biliary disease. The aim of this book is to provide concise answers to informal consultation questions frequently asked among colleagues. This soft-cover, glossy-paged book is divided into 7 sections that cover pancreatic as well as some biliary disease: Acute Pancreatitis, Chronic Pancreatitis, Cystic Pancreatic Lesions, Pancreatic Cancer, Other Pancreatic Neoplasms, Biliary, and Miscellaneous (245 pages). Editors Drs Tenner, Brown, and Gress are well-known gastroenterologists with numerous publications focusing on pancreatic disease. For this publication they enlisted 25 co-authors who range from staff gastroenterologists or surgeons to GI fellows and medical students, but nearly all the answers are co-written with an editor allowing for a consistent presentation throughout. Examples of questions and thus chapters are: “When would you use antibiotics in acute pancreatitis, and which antibiotics would you use?” “What is the best approach to staging pancreatic cancer?” “What is the best approach to a cystic lesion in the tail versus head of the pancreas when the diagnosis cannot be clearly established?” and “When should a pancreatic duct stent be placed?” In each section, questions range from those relevant to a trainee or primary care physician to those that a practicing gastroenterologist may use to find a quick answer for the latest management strategies. Summary tables and figures are listed for the vast majority of topics, which are particularly helpful to highlight the reading material. High-quality imaging studies are also included for virtually all subject matter along with both black-and-white and color histologic, pathologic, or endoscopic photographs when appropriate. Given the topic of the pancreas, extensive radiologic images including computed tomography, endoscopic retrograde cholangiopancreatography, and endoscopic ultrasound pictures are included in almost every chapter. The information provided is not meant to be a long or detailed analysis of the pathophysiology of each disease covered, but rather the depth of the material is ideal to answer the question posed with a focus on patient management. Some answers are 2 pages, whereas others are up to 6 pages. For example, the question “Is there a role of pancreatic enzymes to treat pain in patients with chronic pancreatitis?” has an answer just >2 pages long, including a meta-analysis review, whereas the question “When should one suspect autoimmune pancreatitis as a cause of acute or chronic pancreatitis” has an answer >5 pages long and includes sections on diagnosis, laboratory studies, imaging, and histology. Concise bibliographies of <10 references at the end of each question and answer session are well focused, allowing for easy referral if needed. Reading this book in 1 sitting does reveal some overlap of material in the various sections. It is doubtful this will be an issue for most readers, who are likely to thumb to a topic based on a specific clinical question. Overall, the material reviewed is extremely accurate, up-to-date, and easy to read. Many of the responses to the clinically posed questions end in a summary paragraph that is a final combination of the literature's latest recommendation with the authors' personal opinion and interpretation of existing data. Curbside Consultation of the Pancreas: 49 Clinical Questions does carve out its own niche as compared with existing books and texts on the pancreas. This is a book dedicated strictly to the clinical scenarios found by health care providers who treat patients with pancreatic disease. This text does not pretend to thoroughly explain the pathophysiology or basic science of the pancreas, but repeatedly is able, often in a case format, to simply and succinctly explain the common pancreatic diseases and how they are best diagnosed and managed. Bottom Line: A well-recommended book to anyone looking for a user-friendly resource for pancreatic and biliary disease written in a practical and clinically oriented format. Moreover, the layout and wide use of images, charts, and tables make the book an enjoyable source of medical information that is sure to be used repeatedly in every day practice.

Background: The increased incidence of malignancy and specifically colorectal cancer after solid organ transplantation has been documented. However, the incidence of colorectal adenomas and advanced adenomas in transplant populations have not yet been well characterized. Aim: The goal of this investigation was to compare the adenoma and cancer incidence of solid organ transplant recipients to an age and sex matched screening population. Methods: Over a 15 year period we reviewed 320 patients with solid organ transplants who underwent colonoscopy and 1134 patients in an average risk colorectal screening population who underwent colonoscopic examinations. We compared the incidence of adenomatous polyps, advanced adenomas (adenomas >= 10 mm, villous histology, serrated adenomas, high grade dysplasia), and cancers in these groups. Results: In the solid organ transplant group there were 105 females and 215 males (mean age 56.3). In the age and sex matched control group there were 400 females and 734 males (mean age 56.2). There was a statistically significant difference (p<0.01) in the number of patients with advanced lesions in the transplant group (35 patients out of 320) compared with the control group (70 patients out of 1134). A total of 123 adenomas were found in the transplant group while 470 were found in the screening group (p=0.34). There was a statistically significant difference in the number of cancers detected in the transplant group (9 patients) compared with 3 patients in the screening group(p<0.01). Conclusions: 1) The incidence of advanced lesions and colon cancer was significantly higher in solid organ transplant recipients compared with an average risk screening population.2) No difference was found in the overall occurrence of adenomas between these groups. 3) This suggests a faster progression of adenomas in transplant patients and a need for more frequent colorectal cancer screening than the average. population.

Background: Diarrhea is common in solid organ transplant recipients with the incidence ranging from 13 to 43%. Colonoscopy with random biopsies is frequently performed in the diagnostic evaluation of the post-transplant population with diarrhea. Aim: To determine the yield of colonoscopy in the diagnosis and management of diarrhea in the solid organ transplant recipient. Methods: From October 1996 to June 2008, 88 patients were identified who had undergone solid organ transplantation and subsequently underwent colonoscopy for an indication of “diarrhea”. Endoscopic findings at time of colonoscopy and any subsequent pathology were reviewed to determine the impact of these studies on the management of the patient's diarrhea. Results: 88 patients (mean age 54 years, 65% male) underwent colonoscopy a mean of 69 months after transplantation (31 kidney, 26 liver, 21 heart, 6 kidney-pancreas, 3 lung, 1 lung-kidney, 1 pancreas). Stool studies including evaluation for clostridium difficile, ova and parasites and stool culture were performed in only 28.1% of patients prior to colonoscopy. Abnormal endoscopic findings were seen in 16/88 (18.2%). Pathology was abnormal in 17/80 (21.3%). In total, only 9/88 (10%) had findings on colonoscopy or pathology that led to a change in management for the diarrhea. Four of 9 patients that had a change in management had findings that could have been diagnosed with flexible sigmoidoscopy. Therefore, overall only 6% (5/88) of all patients had management affected by colonoscopic investigation. There was 1 serious complication (perforation) associated with colonoscopy. No difference in colonoscopy/pathology findings was seen based upon diarrhea duration (acute vs. chronic). Conclusion: The use of colonoscopy with biopsy in the evaluation of post solid organ transplant recipients with diarrhea rarely shows pathologic disease and is unlikely to change patient management in the vast majority of cases. In the absence of other indications, colonoscopy should be reserved for continued diarrhea after negative stool studies and sigmoidoscopy.

BACKGROUND & AIMS: The aim of this study is to evaluate the findings on optical colonoscopy (OC) after a positive CT colonography (CTC) exam and characterize the type of polyps seen on OC but not reported by CTC.METHODS: Over an 18-month period a total of 159 asymptomatic adults had polyps seen on computed tomography colonography examination and subsequently underwent planned therapeutic optical colonoscopy. The colonoscopists were aware of the findings on CT colonography prior to further evaluation of the colon. Characteristics of polyps and adenomas seen on subsequent optical colonoscopy but not seen or reported on CT colonography were examined.RESULTS: The adenoma miss rate for CT colonography overall was 18.9% (25/132) including 6.2% (4/65) for polyps >9 mm and 18.2% (8/44) for polyps 6-9 mm. Three of the adenomas >9 mm not seen on CTC were sessile, and two were found in patients with technically difficult CT colonography studies due to poor colonic distention. No adenomas with advanced pathology <6 mm were found on optical colonoscopy but not reported on CT colonography. False-positive CTC referral where no polyp was seen on colonoscopy was 5.0%.CONCLUSIONS: CT colonography has adenoma miss rates similar to miss rates historically found with optical colonoscopy, with most missed adenomas being <10 mm and sessile in shape.