There has been a rapid increase in the incidence of acute pancreatitis (AP) and associated mortality. This mortality is even higher in patients having severe disease (about 30% in contrast to 10% in mild AP). Some of the factors which have proven to lower the mortality are early feeding rather than keeping patient nil per oral (NPO), and aggressive intravenous fluid replacement therapy, especially during the first 12-24 hours. in our study, we investigated the reasons for the increase in incidence and AP-associated mortality as there was no previous study done to focus on these areas.

Introduction: Background: Acute pancreatitis (AP) is one of the most common diseases of the gastrointestinal tract requiring hospitalization in the United States with an annual incidence from 20-40 per 100,000 persons per year. Initial management of a patient with AP may consist of supportive care with analgesics, nutritional support, and closer monitoring. However, aggressive intravenous fluid replacement during the first 12-24 hours is inevitable to reduce AP associated morbidity and mortality. Objectives: 1. To assess the knowledge and practices among medicine and surgery residents at Abington Hospital about early management of AP. 2. Help to formulate a standardized admission order set in the electronic medical records (EMR). Methods: A cross-sectional educational study was performed, all internal medicine (IM) (PGY1 to PGY4) and surgical residents (PGY1-PGY5) were given a detailed questionnaire based upon the American College of Gastroenterology (ACG) guidelines, to assess their knowledge about early management of AP.(Table 1) The poll was created using the SurveyMonkey tool and was sent to all participants via email. Results: Of the 71 participants (n=25 surgery/46 IM), 56% (n=5 surgery/35 IM) completed the questionnaire. Most responses came from IM PGY-1 (42.5%), the least from surgery PGY-2 (2.5%) and no response from surgery PGY-1/PGY-5. About 61% IM PGY-3 provided the correct answers, compared to 58% of IM PGY-2 and 60% of IM PGY-1. (Table 2) Only 20% (N=5) of surgery residents responded to the survey; 46% provided the correct answers. IM and surgical resident comparison of correct answers was 60% vs. 46% (n=35 vs. n=5, respectively). Residents showed lack of knowledge(<50% correct answers) specifically in questions related to diagnosis, initial assessment/risk stratification and role of ERCP/Surgery. However, greater than 50% correct answers were given for fluid resuscitation, the role of antibiotics and nutrition. Conclusion: We observed that patients were not being managed as per standard of care guidelines at our institution due to the lack of knowledge and decreased adherence to the standard recommendations. In the majority of categories of questions, residents performed poor, indicating that education about clinical practice guidelines regarding early management of AP is required. Moreover, a standardized admission order set should be introduced in the EMR systems for patients with AP based on standard guidelines as per the American College of Gastroenterology.41_A Figure 1. Standardized questionnaire to assess knowledge and adherence to ACG Guidelines for AP management41_B Figure 2. Percentages of correct answers for AP management among IM residents

Colonoscopic polypectomy is a relatively simple and easily executed method of reducing the incidence of CRC. Although its benefits are clear and well-established, colonoscopic polypectomy is subject to complications, postpolypectomy bleeding (PPB) being the most frequent which can unfortunately lead to increased cost with regards to further repair and downstream complications. Interestingly, no well-designed controlled trials have been conducted to guide the risk-benefit analysis of this technique for a larger polyp population (>1cm).

Background: Criteria for selecting patients with advanced cancer for palliative surgery (PS) remains poorly defined. Decision making for PS requires realistic treatment goals with well-defined criteria. Here we discuss a 71-year-old Jehovah's Witness with advanced stage renal cell carcinoma (RCC) who presented with profound anemia due to intractable bleeding from gastric metastasis. After repeated attempts with endoscopic and angiographic management, she underwent surgical palliation. Through this case, we developed 10-item evidence-based criteria for selecting patients for PS. Objective: The study objective was to provide a review of pertinent literature for PS and identify evidence-based criteria for patient selection. These criteria were relevant for selecting this patient with metastatic RCC and may prove beneficial for selecting advanced cancer patients for PS. Methods: A MEDLINE search revealed 175 publications relevant to PS. Among these, 17 articles defining patient selection criteria (PSC) were reviewed. A frequency-based analysis of each criterion was performed. Another search returned 30 cases of RCC gastric metastases from 25 published reports. Outcome analysis was determined by the Kaplan-Meier actuarial method. Results: Ten criteria were identified: symptom control, prognosis, preoperative performance status, quality of life (QoL), tumor burden amenable to palliation, procedure-related morbidity and mortality, feasibility of nonsurgical therapies, anticipated hospitalization, requirement for additional palliation, and cost. This patient met all inclusion criteria and underwent a successful gastrectomy. Median survival for patients with RCC gastric metastasis was 20 months. Conclusions: This report illustrates an example of implementation of evidence-based criteria for selecting advanced cancer patients for PS. Validation of these criteria is warranted.

Background: Cystic pancreatic lesions are increasingly more frequent detected clinical entities. Mucinous cystic neoplasm (MCN) is a hormone-related pancreatic tumor (HRTP) with a strong predominance in young and middle-aged females.Case presentation: Here, we present the case of a 31-year-old surgically transgendered female-to-male patient with a history of alcoholic pancreatitis, on chronic testosterone therapy. He was found to have a pancreatic MCN and underwent distal pancreatectomy and splenectomy.Conclusion: To our knowledge, this is the first reported case of a transgender patient with a history of hormone replacement therapy (HRT) and pancreatic MCN. We consider possible mechanisms for the pathogenesis to explain this patient's neoplasm.

Introduction: A 67-year-old man with a past history of hypertension and long-standing alcohol abuse was admitted for shortness of breath secondary to new-onset heart failure. His hospital course was complicated by hypertensive emergency and delirium tremens requiring intubation and midazolam drip. An ultrasound of the abdomen was performed to evaluate for cirrhosis and revealed a questionable mass in the uncinate process of the pancreas and a dilated pancreatic duct to 6 mm in the head. At this time GI was consulted for further evaluation. A palpable epigastric mass was noted on physical exam and labs revealed a low albumin, 2.5 g/dL. Liver function tests, amylase, lipase, and coagulation studies were otherwise normal. CT scan of the abdomen demonstrated a 2.8 x 3.2 x 2.8 cm enhancing lesion concerning for a tumor in the area of the pancreatic head and superior mesenteric vein (SMV). Endoscopic ultrasound (EUS) was performed and revealed a dilated SMV to 25 x 21 mm with pseudoaneurysm formation. The EUS also revealed multiple criteria to establish a diagnosis of chronic pancreatitis. Arteriogram was performed and did not show an arteriovenous malformation. The patient was diagnosed with a SMV pseudoaneurysm and discharged in stable condition, remaining asymptomatic upon outpatient follow-up. Pseudoaneurysms are a rare complication of chronic pancreatitis. It is theorized that pancreatic enzymes may erode the peripancreatic vessels and result in the formation of a pseudoaneurysm. Vessels commonly affected include the splenic, hepatic, gastroduodenal, and cystic arteries. Eighty-nine percent of patients with a pseudoaneurysm complain of abdominal pain and complications include thrombosis and bleeding. When bleeding occurs, surgery is complicated and is associated with a high morbidity and mortality. Conservative management with serial abdominal imaging, usually ultrasound, is generally recommended, as 94% of pseudoaneurysms remain stable and a much smaller percentage regress. We found no published cases of SMV pseudoaneurysms mimicking pancreatic cancer. We present a unique case of an asymptomatic patient with SMV pseudoaneurysm from chronic alcoholic pancreatitis masquerading as pancreatic cancer. Vascular pseudoaneurysms must be considered in the setting of chronic pancreatitis, especially when a mass-like lesion is discovered.Figure 1

Hemosuccus pancreaticus (HP) is a rare cause of gastrointestinal bleeding (GIB) that should be considered in a patient with a history of pancreatitis and GIB. A 17-year-old female presented with nausea followed by an episode of hematemesis. Fourteen weeks prior to presentation, she had 3 episodes of vomiting within a week. Six weeks prior to presentation, she developed abdominal pain and was diagnosed with acute idiopathic pancreatitis. Computed tomography (CT) revealed a cystic lesion arising in the gastroduodenal artery (GDA), and coil embolization was performed. There are no reported cases of HP in an adolescent with acute idiopathic pancreatitis.

Introduction: A 66-year-old Hispanic man with hepatitis C (HCV) cirrhosis presented to the emergency department with complaints of several weeks of epigastric/left upper quadrant abdominal pain, night sweats, and an 18-lb weight loss. Physical examination revealed no jaundice, no palpable lymphadenopathy, nor cutaneous stigmata of chronic liver disease. On abdominal examination, there was evidence of tender hepatomegaly with a fullness in the epigastrium and right upper quadrant. A CT scan revealed cirrhotic liver morphology with a 4-cm arterially-enhancing mass in segment 2 of the left hepatic lobe with delayed-phase washout, suspicious for a hepatocellular carcinoma (HCC). In addition, there was a confluent nodular mass in the gastrohepatic space measuring 6.5 x 5 cm with encasement of the celiac trunk, its branches, the portal venous confluence, and splenic vessels. A similar mass was seen in the retroperitoneum with encasement of the renal vessels. Mild ascites was noted with no evidence of portal vein thrombosis. Percutaneous biopsy of the hepatic mass revealed a moderately differentiated HCC. The patient’s alpha-fetoprotein (AFP) was 9.3. A CT scan of the chest and a nuclear medicine bone scan were negative for distant metastases. Due to the CT findings of bulky lymphadenopathy and associated “B symptoms” the patient underwent an endoscopic ultrasound (EUS) to rule out a concomitant lymphoma. The EUS confirmed the presence of widespread malignant-appearing abdominal adeopathy. Fine needle aspiration demonstrated carcinoma that was morphologically identical to the liver pathology, thus confirming a locally advanced metastatic HCC. There was no evidence of lymphoma on flow cytometry. The patient has since been treated with a combination of loco-regional transarterial chemoembolization of the primary hepatic HCC lesion and systemic sorafenib. Given his advanced disease, he was not deemed a suitable liver transplant candidate. Although lymph node metastases may be seen in HCC, the size and isolated extent of abdominal lymphadenopathy seen in this case were distinctly unusual and the presentation mimicked that of a lymphoma.

Direct examination of the pancreaticobiliary system permits mucosal inspection, detection of stones or mucin, and directed tissue sampling. 1 Takekoshi T. Maruyama M. Sugiyama N. Retrograde pancreatocholangioscopy. Gastroenterol Endosc. 1975; 17: 678-683 Google Scholar , 2 Kodama T. Tatsumi Y. Kozarek R.A. et al. Direct pancreatoscopy. Endoscopy. 2002; 34: 653-660 Crossref PubMed Scopus (17) Google Scholar , 3 Ringold D.A. Shah R.J. Peroral pancreatoscopy in the diagnosis and management of intraductal papillary mucinous neoplasia and indeterminate pancreatic duct pathology. Gastrointest Endosc Clin N America. 2009; 19: 601-613 Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar , 4 Riemann J.F. Kohler B. Endoscopy of the pancreatic duct: value of different endoscope types. Gastrointest Endosc. 1993; 39: 367-370 Abstract Full Text PDF PubMed Scopus (43) Google Scholar , 5 Chen Y.K. Preclinical characterization of the SpyGlass peroral cholangiopancreatoscopy system for direct access, visualization, and biopsy. Gastrointest Endosc. 2007; 65: 303-311 Abstract Full Text Full Text PDF PubMed Scopus (122) Google Scholar , 6 Howell D.A. Dy R.M. Hanson B.L. et al. Endoscopic treatment of pancreatic duct stones using a 10F pancreatoscope and electrohydraulic lithotripsy. Gastrointest Endosc. 1999; 50: 829-833 Abstract Full Text Full Text PDF PubMed Scopus (76) Google Scholar , 7 Attwell A.R. Brauer B.C. Chen Y.K. et al. ERCP with per oral pancreatoscopy for calcific chronic pancreatitis using endoscope and catheter-based pancreatoscopes: a 10-year single center experience. J Pancreas. 2013; (In press) Google Scholar Although peroral pancreatoscopy (POP) is typically performed via the major papilla, the main pancreatic duct (PD) may be inaccessible because of acquired obstruction of the ventral PD (“pseudodivisum”) from strictures or stones. To access the dorsal duct by ERCP in this setting, we and others have reported the technique of minor papilla endotherapy in patients without divisum with patent accessory ducts that communicate with the upstream PD. 8 Song M.H. Kim M.H. Lee S.K. et al. Endoscopic minor papilla interventions in patients without pancreas divisum. Gastrointest Endosc. 2004; 59: 901-905 Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar , 9 Shah R.J. Chen Y.K. Antillon M.R. et al. Minor papilla endotherapy in patients without pancreas divisum: identification and management [abstract]. Gastrointest Endosc. 2005; 61: AB196 Abstract Full Text Full Text PDF Google Scholar However, it is largely unknown whether pancreatic endotherapy with POP via the minor papilla is technically feasible because of the less-stable duodenoscope position in the more proximal duodenum. We report our experience of dorsal duct pancreatoscopy (DDP) via the minor papilla.

Purpose: Wall thickening in the lower GI tract is a common finding on computed tomography (CT) and raises the concern for neoplasia. Patients often undergo colonoscopy to evaluate these findings, but the yield of significant findings is not known. Methods: We performed a retrospective study of patients with WTLGIT discovered on CT scan between 2008 and 2011. A database was constructed with clinical information using electronic medical records (EMR). Significant findings were defined as the following: polyps measuring >1 cm, masses, ulceration, edema, erythema, infectious colitis, and diverticulitis. Results: Two hundred twenty-seven of 2,641 (8.6%) CT scans described wall thickening in the lower GI tract. The mean age was 54.8±19.6 years, 124 (54.6%) were females, 128 (56.4%) were African American, and 74 (32.6%) were Caucasian. Ninety two of 227 (40.5%) patients underwent diagnostic investigations; 77/227 (33.9%) had colonoscopy and 15/227 (6.6%) had surgery. Fifty six of 92 (60.9%) patients had correlative thickening (terminal ileum 2; right colon 12; left colon 28; or multiple areas 14) based on colonos-copy and surgery. Correlating findings included: 8 (8.7%) adenocarcinomas, four (4.3%) new diagnoses of IBD, 18 (19.6%) presumed infectious colitis, seven (7.6%) ischemic colitis, three (3.2%) ulcerations, 9 (9.8%) diverticulitis, and seven (7.6%) with other causes. Patients with correlating findings were significantly older (55.2±18.5 years) than those without (46.8±19.1 years; p=0.001). African Americans (37/53; 69.8%) were more likely to have correlating findings than Caucasians (11/27; 40.7%; p=0.016). No one symptom predicted the presence of correlating findings. Weight loss (6/8; 75%) was more common in patients with cancer than in those without (5/52; 9.6%) who underwent an intervention (p=0.0002). Patients who did not undergo an intervention were more likely to have a presumed or diagnosed infectious cause (91/135 [67.4%] vs. 46/92 [50.0%]; p=0.013). Radiologists indicated the need to rule out malignancy in 50/227 (22.0%) of the CT reads. Of these, 27 (54.0%) underwent an intervention and 13/27 (48.0%) had a correlating finding. Five of 27 (18.5%) patients were diagnosed with a malignancy. Conclusion: Sixty percent of patients with wall thickening in the lower GI tract have correlating findings on colonoscopy and surgery. Nine percent of patients with wall thickening in the lower GI tract have malignancy. The presence or lack of certain symptoms does not appear to be useful in clinical decision making. Fifty nine percent of patients did not undergo further evaluation of wall thickening in the lower GI tract. If able, patients should undergo diagnostic evaluation for wall thickening in the lower GI tract.

Purpose: To determine why those who have HIV are less likely to undergo a screening colonoscopy compared to the general population and to improve screening in this subset. Methods: Patients at the ID clinic, Drexel University College of Medicine who are HIV-positive and at least the age of 50 years were asked to fill out a survey. The survey includes questions such as age, gender, religion, sexual orientation, education level, patient's knowledge of colonoscopy, if they have been referred for such a screening test, and the reasons for declining. The faculty and fellows at the clinic have also been given a survey to assess their knowledge about colorectal cancer screening. This information is now being used to overcome these barriers tailored to the results of both surveys. The results are being compared to patients at Drexel University's outpatient internal medicine clinic to determine whether or not the same barriers exist between individuals who have HIV compared to those who do not. Results: Thus far, 200 surveys have been collected. Over one-third of the patients who completed a questionnaire have not had a screening colonoscopy. More than half of those patients were never referred for such a procedure. The most common reasons given for refusing a colonoscopy was fear of the procedure, followed by time constraints, and finally viewing the procedure as being unimportant. The major difference that has been noted thus far between the groups of those that have been scoped in the past as compared to those who have not, is education level (higher education level is directly correlated with likelihood of being scoped). Currently these results are being compared to barriers to screening in those who do not have HIV. Conclusion: Over one-third of patients who are at least the age of 50 and have HIV have not been screened. More than half of those who have not been screened have never been referred, and those who declined have stated that fear and importance are the main reasons. The next step in this study entails analyzing the results of colonoscopies of those who have been scoped and to offer a colonoscopy to those who have not been. The results of these procedures will then be analyzed and the incidence/prevalence of polyps and neoplastic lesions be assessed. Age, viral load, CD4 count, and co-morbidities will be analyzed. The goal is to determine whether or not patients who have HIV are at a higher risk of developing pre-malignant and malignant lesions as compared to the general population. There are no screening guidelines for those who are infected with HIV, and if there is a statistical difference then guidelines will have to be implemented. Currently, educational videos and pamphlets about colorectal cancer screening are being developed.

Wall thickening in the Lower GI tract (WTLGIT) commonly presents a challenge to clinicians as there is the concern for neoplasia.1Wolff J.H. Rubin A. Potter J.D. Waymon L. Resnick M.B. et al.Clinical Significance of Colonoscopic Findings Associated With Colonic Thickening on Computed Tomography Is Colonoscopy Warranted When Thickening is Detected?.J Clin Gastroenterol. 2008; 42: 472-475Crossref PubMed Scopus (53) Google Scholar, 2Stermer E. Lavy A. Rainis T. Goldstein O. Keren D. Zeina A.-R. et al.Incidental Colorectal Computed Tomography Abnormalities: Would You Send Every Patient For A Colonoscopy?.Can J Gastroenterol. 2008; 22: 758-760Crossref PubMed Scopus (11) Google Scholar, 3Moraitis D. Singh P. Jayadevan R. et al.Colonic wall thickening on computed tomography scan and clinical correlation Does it suggest the presence of an underlying neoplasia?.Am Surg. 2006; 72: 269-271Crossref PubMed Google Scholar, 4Cai Q. Baumgarten D.A. Affronti J.P. et al.Incidental findings of thickening luminal gastrointestinal organs on computed tomography: an absolute indication for endoscopy.Am J Gastroenterol. 2003; 98: 1734-1737Crossref PubMed Scopus (36) Google Scholar, 5Rockey D.C. Halvorsen Jr, R.A. Higgins J.L. et al.Prospective evaluation of patients with bowel wall thickening.Am J Gastroenterol. 1995; 90: 99-103PubMed Google Scholar We hypothesize that majority of the patients that have thickening are unlikely to have significant findings on colonoscopy. This is a retrospective study performed from October 2008 to December 2010. A clinical database was constructed for individuals that had WTLGIT in CT scan reports from the radiological database. Our endoscopic database was used to assess patients who had WTLGIT. Significant colonoscopy findings were defined as following: Polyps >1cm/masses, ulceration, edema, erythema, infectious colitis and diverticulitis. 207/2505 (8.1%) of CT scans reports described new WTLGIT. The mean age was (54.7 ± 19.0y) and 111(54%) were females. 109 (53%) were African American and 70 (34%) were Caucasian. 69/207 (33%) patients underwent colonoscopy and 10/207 (3.7%) underwent surgery. 48/79 (61%) had correlative thickening (4 terminal ileum, 7 right colon, 26 left colon and 11 multifocal). Of these, 4 (5.1%) had colorectal adenocarcinoma and 7(9.0%) had large villous/adenomatous polyps. In 3 patients (3.8 %), a new diagnosis of IBD was made, 13 (16.5%) had presume diagnoses infectious colitis based on symptoms/colonoscopy findings, 7(10.1%) had presumed diverticulitis with medical management, while 3 (3.8%) diagnosed with diverticulitis had surgery. 7 (8.9%) had ischemic colitis, 1 (1.3%) perforation, 1 (1.3%) pseudomembrane colitis, 1 (1.3%) volvulus, 1 (1.3%) eosinophilic colitis that correlated with WTLGIT. Of those diagnosed with adenocarcinoma or IBD 7/9 (77%) presented with anemia, weight loss and/or hypoalbunemia compared to others 9/29 (31%) without IBD or adenoCA that underwent colonoscopy, p=0.02. 8 (11.6%) of colonoscopies performed discovered incidental adenomas that did not correlate with WTLGIT on CT scans. Patients with a correlating colonoscopy finding were significantly older (58.5 ± 18.2y) than those without (48.5 ± 18.9y); p=0.029. The majority of patients with WTLGIT had significant correlating colonoscopic findings. Patients with significant correlative pathological finding on colonoscopy for WTLGIT tended to be older compared to patients with no findings. The presence of symptoms, sex, and race did not correlate with significant GI pathology and cannot be utilized to stratify patients with WTLGIT. Among the patients who were diagnosed with IBD or adenocarcinoma, the majority demonstrated anemia, weight loss, and /or hypoalbunemia. As such, WTLGIT in patients with these features should be investigated more urgently by colonoscopy. No prior studies have demonstrated these trends before.

Purpose: We report a rare case of severe non-cirrhotic portal hypertension causing an upper gastrointestinal bleeding secondary to extensive thrombosis of portal, inferior mesenteric and splenic veins with cavernous formation of unclear etiology. Non-cirrhotic portal hypertension is characterized by varices of esophagus, stomach, or duodenum, and splenomegaly in the absence of liver cirrhosis or risk factors for chronic liver disease. A 35-year-old AA female with medical history of depression, chronic anemia presented with c/o epigastric pain, black colored stools and vomittings mixed with blood clots since 3 days. She felt very weak, lightheaded and dizzy. She denied alcohol or smoking but used Motrin regularly since past three months for headaches. She had a Hb/Hct of 6.3/18.6 with normal platelets, electrolytes and LFTs. She used oral contraceptives briefly 19 years ago. EGD showed grade II non-bleeding varices in the distal 1/3 of esophagus, multiple localized large varices in the cardia and fundus of stomach, and duodenum with non-bleeding erosions. EUS confirmed the presence of varices in the duodenum, stomach, and esophagus in association with the absence of the splenic vein and partial thrombosis of portal vein. It also showed a large number of venous collaterals in the portal and splenic regions consistent with non-cirrhotic portal hypertension. A CT scan of abdomen showed a grossly normal liver, chronic portal venous thrombosis with occlusion of the superior mesenteric and splenic veins. A cavernous transformation of the porta hepatis was noted and there were multiple perisplenic, perigastric, and mesenteric venous collaterals. An angiogram confirmed the findings. She was treated with PPI, Octreotide, PRBC transfusion and stabilized. Evaluation for etiological factors like autoimmune disease, occult malignancy, myeloproliferative disorders and hypercoagulable state was begun as she didn't have any evidence for cirrhosis of liver. Her labs were only singificant for (+) ANA titers at 1/40, AT III level of 75%, and negative Factor V Leiden mutation. She was discharged on PPI and nadolol, evaluation for hypercoagulable state would be continued and antcoagulated once the erosions heal.Figure: No Caption available.

Purpose: ‘Mycosis Fungoides' (MF) is an indolent T cell lymphoma, involving primarily skin with rare extracutaneous, or visceral involvement occurring in advanced stages of the disease. Gastrointestinal system involvement is very rare and it is associated with significant morbidity and mortality secondary to various complications. We are describing a case of “Peripheral T-Cell Lymphoma” involving the rectum and the colon diagnosed on a screening colonoscopy in a patient with a history of Mycosis Fungoides. A 66-year-old AA man with h/o of HTN, dyslipidemia, and mycosis fungoides was referred by his dermatologist for a screening colonoscopy. He denied any symptoms including weight loss, rectal bleeding, melena, hematemesis or altered bowel movements. His physical exam was notable for diffuse hypopigmented and hyperpigmented patches over the skin, primarily hands and feet. There was no evidence of splenomegaly or lymphadenopathy. He was lost to follow up for five years after a decade of stable disease. He was started on clobetasol topical ointment and narrow band UVB therapy. Colonoscopy showed a large ulcerated mass with greenish black exudate occupying 50-74% of the circumference of the rectum, extending 5cm from entry site up to 17cm. The biopsy showed colonic mucosa diffusely infiltrated by large atypical lymphoid cells with varied size, hyperchromatic nuclei and small nucleoli. Flow cytometry showed abnormal clonal T cell proliferation and stained positive for CD3, CD4, CD5 and rarely for CD8 suggestive of peripheral T cell lymphoma. A molecular study for TCR Gamma rearrangement performed on the previous lymph node biopsy and the current rectal specimen showed identical clonal peaks indicating that the process in the rectum likely represents transformation of the patient's cutaneous T cell lymphoma. A month later, he was admitted to the hospital with severe pain and swelling in his right lower extremity. He was found to be having a diffuse systemic involvement of T cell lymphoma of plural fluid, right thigh, inguinal lymphnodes, and CNS. His prognosis was assessed to be very poor and he was sent to hospice care based on his wishes for comfort care.Figure: No Caption available.

A 73-year-old woman with blindness, hypertension, and diabetes was diagnosed with new-onset atrial fibrillation requiring anticoagulation with dabigatran. During the admission, she had painless hematochezia and a decrease in her hemoglobin levels requiring transfusion with 3 U of packed red cells. She denied a history of anemia, and she had never had a colonoscopy. A colonoscopic evaluation revealed a 1.5-cm ulcerated, raised up, submucosal lesion in the transverse colon (Figure A) . At the biopsy examination of the lesion, there was profuse bleeding requiring hemostasis with the placement of several endoscopic clips. Microscopic examination revealed an infiltrating tumor composed of vascular channels and endothelial cells that were reactive to the endothelial marker (CD31), consistent with an angiosarcoma (Figure B, C). An imaging work-up for metastatic disease was negative. She underwent a right hemicolectomy with complete tumor resection; there was no evidence of metastatic disease. An angiosarcoma is a rare, malignant subtype of sarcoma that describes an aggressive neoplasm that originates in blood vessels and the linings of various blood-filled organs. It recurs locally and metastasizes quickly through the lymphatic system. Gastrointestinal angiosarcomas are exceedingly rare, occurring primarily in the stomach and small bowel. Angiosarcomas typically present with bleeding and anemia. In 1949, Steiner and Palmer1Steiner C.A. Palmer L.H. Angiosarcoma of the colon: with case report.Ann Surg. 1949; 129: 538-542Crossref PubMed Google Scholar first described a colonic angiosarcoma in a 46-year-old woman who presented with left lower-quadrant pain, a palpable mass, and a partial bowel obstruction. The patient had a sigmoid resection and was found to have a 3.5-cm angiosarcoma with peritoneal metastasis. Eight months later, metastatic disease to the cervix was identified. She had adjuvant radiation therapy and survived for 21 months postoperatively. With only 14 cases described in the literature, the prognosis is extrapolated from more common angiosarcomas. Older age (>50 y), larger tumor size (>4.5 cm), and metastatic disease have been associated with a poor clinical outcome.2Bardwil J.M. Mocega E.E. Butler J.J. et al.Angiosarcomas of the head and neck region.Am J Surg. 1968; 116: 548-553Abstract Full Text PDF PubMed Scopus (122) Google Scholar Age was shown as a key prognostic factor by Smith et al,3Smith J.A. Bhathal P.S. Cuthbertson A.M. Angiosarcoma of the colon Report of a case with long-term survival.Dis Colon Rectum. 1990; 33: 330-333Crossref PubMed Scopus (28) Google Scholar who reported the case of a 16-year-old girl with angiosarcoma of the colon who survived for 36 months despite having peritoneal metastases, a high tumor burden, incomplete resection, and lack of adjuvant therapy. She is the youngest patient reported to date. In published cases of colonic angiosarcoma, the age ranged from 16 to 77 years, with a mean of 59 years. Eight of 14 patients were identified after the sixth decade of life, and 75% of these patients survived fewer than 6 months.4Brown C.J. Falck V.G. MacLean A. Angiosarcoma of the colon and rectum: report of a case and review of the literature.Dis Colon Rectum. 2004; 47: 2202-2207Crossref PubMed Scopus (47) Google Scholar Tumor size greater than 4.5 cm is another poor prognostic marker, with a majority of patients surviving fewer than 6 months. Anticoagulation caused our patient's bleeding, allowing us to identify the tumor at an early stage. Despite being older, she had a low tumor burden without metastasis at initial diagnosis. Her remaining hospital stay was without incident, and she was feeling great at her 6-month follow-up evaluation.

Myeloid Sarcoma is a rare tumor composed of myeloblasts occurring at an extramedullary site like bones, or various soft tissues. Myeloid sarcoma may involve the gastrointestinal tract very rarely either solitarily, or occurring simultaneously with acute myeloid leukemia. Its diagnosis is challenging and needs biopsy and immunohistochemical staining. We are describing a case of myeloid sarcoma which presented as a painful anal ulcer mimicking an atypical fissure. Its appearance resembled crohn’s disease on sigmoidoscopy. A biopsy of the ulcer along with histochemical staining led to the diagnosis of myeloid sarcoma. Our case demonstrates the need for aggressive evaluation of any common gastrointestinal complaint with an atypical presentation.

BackgroundAs HIV infected patients live longer, colonoscopies for both screening and symptomatic patients are performed more often. Compared to controls, non-AIDS defining malignancies are more prevalent in HIV patients. It is not known if the development of colonic neoplasia occurs at a higher rate or at a younger age in HIV infected patients.MethodsWe conducted a retrospective study to investigate the prevalence of polyps in HIV patients detected on colonoscopy from 2000-10 at an inner city tertiary care center. These patients underwent colonoscopy either for screening, surveillance or symptoms. Age, sex, symptoms and CD4 count were recorded. Size and histology of both benign and neoplastic polyps were collected. Advanced neoplasms were defined as an adenoma >10mm or any lesion with high-grade dysplasia(HGD), villous histology or carcinoma. A mixed control group without HIV was used for comparison.ResultsA total of 319 HIV patients underwent colonoscopy; the mean age of these patients was 51.5 y and 92 were over 50y. There were 209 men and 110 women. 31 of 209 men and 14 of 110 women had polyps(17.4% vs. 12.7%, p= 0.73). The overall neoplastic polyp detection rate in HIV patients was 6.6%, compared to 27.9% in the control group(p=<0.01 ). Advanced neoplastic lesions were seen in 11 HIV patients(3.5%). In the subgroup of those patients with neoplastic lesions, 52.4%(11/21) had advanced neoplasms, including 4 cancers and 1 HGD. In comparison, the control group had 15/48 advanced neoplasms(31.3%, p=0.11). A total of 93 polyps were found in 47 individuals. Of those individuals with any lesion found on colonoscopy, 32% were women and 68% were men(p=0.74). 23.4% of neoplasms were found to be advanced neoplasms in the HIV patients compared to 18.3% in the control group(p=0.33). The rate of neoplasia detection among patients over 50(n=148, mean= 56.7y) was 22.9%. The rate of neoplasia detection in the under 50 group (n=137, mean= 43 y) was 9.4%. The preparation was poor for 75 of the 319(23.5%) HIV patients that had colonoscopy in comparison to 9 of 172 (5.2%) patients without HIV (p<0.0001). In a subgroup analysis of patients followed in an HIV specialty care clinic, only 29 of 503 patients(5.7%) over 50 received screening colonoscopy.ConclusionsThe frequency of polyp detection in HIV patients is not greater than in the control population. However, a greater proportion of advanced neoplasms were seen in HIV infected patients and HIV infected men had more polyps compared to women, although this was not statistically significant. Amongst HIV patients, a low rate of screening and a high rate of poor preparation were observed in our study. Both of these observations are potential areas for quality improvement. BackgroundAs HIV infected patients live longer, colonoscopies for both screening and symptomatic patients are performed more often. Compared to controls, non-AIDS defining malignancies are more prevalent in HIV patients. It is not known if the development of colonic neoplasia occurs at a higher rate or at a younger age in HIV infected patients. As HIV infected patients live longer, colonoscopies for both screening and symptomatic patients are performed more often. Compared to controls, non-AIDS defining malignancies are more prevalent in HIV patients. It is not known if the development of colonic neoplasia occurs at a higher rate or at a younger age in HIV infected patients. MethodsWe conducted a retrospective study to investigate the prevalence of polyps in HIV patients detected on colonoscopy from 2000-10 at an inner city tertiary care center. These patients underwent colonoscopy either for screening, surveillance or symptoms. Age, sex, symptoms and CD4 count were recorded. Size and histology of both benign and neoplastic polyps were collected. Advanced neoplasms were defined as an adenoma >10mm or any lesion with high-grade dysplasia(HGD), villous histology or carcinoma. A mixed control group without HIV was used for comparison. We conducted a retrospective study to investigate the prevalence of polyps in HIV patients detected on colonoscopy from 2000-10 at an inner city tertiary care center. These patients underwent colonoscopy either for screening, surveillance or symptoms. Age, sex, symptoms and CD4 count were recorded. Size and histology of both benign and neoplastic polyps were collected. Advanced neoplasms were defined as an adenoma >10mm or any lesion with high-grade dysplasia(HGD), villous histology or carcinoma. A mixed control group without HIV was used for comparison. ResultsA total of 319 HIV patients underwent colonoscopy; the mean age of these patients was 51.5 y and 92 were over 50y. There were 209 men and 110 women. 31 of 209 men and 14 of 110 women had polyps(17.4% vs. 12.7%, p= 0.73). The overall neoplastic polyp detection rate in HIV patients was 6.6%, compared to 27.9% in the control group(p=<0.01 ). Advanced neoplastic lesions were seen in 11 HIV patients(3.5%). In the subgroup of those patients with neoplastic lesions, 52.4%(11/21) had advanced neoplasms, including 4 cancers and 1 HGD. In comparison, the control group had 15/48 advanced neoplasms(31.3%, p=0.11). A total of 93 polyps were found in 47 individuals. Of those individuals with any lesion found on colonoscopy, 32% were women and 68% were men(p=0.74). 23.4% of neoplasms were found to be advanced neoplasms in the HIV patients compared to 18.3% in the control group(p=0.33). The rate of neoplasia detection among patients over 50(n=148, mean= 56.7y) was 22.9%. The rate of neoplasia detection in the under 50 group (n=137, mean= 43 y) was 9.4%. The preparation was poor for 75 of the 319(23.5%) HIV patients that had colonoscopy in comparison to 9 of 172 (5.2%) patients without HIV (p<0.0001). In a subgroup analysis of patients followed in an HIV specialty care clinic, only 29 of 503 patients(5.7%) over 50 received screening colonoscopy. A total of 319 HIV patients underwent colonoscopy; the mean age of these patients was 51.5 y and 92 were over 50y. There were 209 men and 110 women. 31 of 209 men and 14 of 110 women had polyps(17.4% vs. 12.7%, p= 0.73). The overall neoplastic polyp detection rate in HIV patients was 6.6%, compared to 27.9% in the control group(p=<0.01 ). Advanced neoplastic lesions were seen in 11 HIV patients(3.5%). In the subgroup of those patients with neoplastic lesions, 52.4%(11/21) had advanced neoplasms, including 4 cancers and 1 HGD. In comparison, the control group had 15/48 advanced neoplasms(31.3%, p=0.11). A total of 93 polyps were found in 47 individuals. Of those individuals with any lesion found on colonoscopy, 32% were women and 68% were men(p=0.74). 23.4% of neoplasms were found to be advanced neoplasms in the HIV patients compared to 18.3% in the control group(p=0.33). The rate of neoplasia detection among patients over 50(n=148, mean= 56.7y) was 22.9%. The rate of neoplasia detection in the under 50 group (n=137, mean= 43 y) was 9.4%. The preparation was poor for 75 of the 319(23.5%) HIV patients that had colonoscopy in comparison to 9 of 172 (5.2%) patients without HIV (p<0.0001). In a subgroup analysis of patients followed in an HIV specialty care clinic, only 29 of 503 patients(5.7%) over 50 received screening colonoscopy. ConclusionsThe frequency of polyp detection in HIV patients is not greater than in the control population. However, a greater proportion of advanced neoplasms were seen in HIV infected patients and HIV infected men had more polyps compared to women, although this was not statistically significant. Amongst HIV patients, a low rate of screening and a high rate of poor preparation were observed in our study. Both of these observations are potential areas for quality improvement. The frequency of polyp detection in HIV patients is not greater than in the control population. However, a greater proportion of advanced neoplasms were seen in HIV infected patients and HIV infected men had more polyps compared to women, although this was not statistically significant. Amongst HIV patients, a low rate of screening and a high rate of poor preparation were observed in our study. Both of these observations are potential areas for quality improvement.

Peroral pancreatoscopy (POP) is utilized for managing benign and malignant pancreatic diseases. The main pancreatic duct (PD) may be inaccessible via the major papilla due to congenital pancreas divisum or acquired obstruction of the main PD (“pseudo-divisum”). ERCP via the minor papilla is an established therapy in this setting but there is limited data on POP of the dorsal duct (DP). We report our experience with DP.