Cavernous hemangioma of adult pancreas: A case report and literature review

Pancreatic hemangioma is a rare type of benign vascular tumor.Low clinical suspicion and inability of current cross sectional imaging techniques to differentiate it from other pancreatic lesions,contribute to the difficulty in making the correct diagnosis.Without a definitive diagnosis,and due to concern for malignancy,in many instances,surgery is performed.We report a case of pancreas cavernous hemangioma in an 18-yearold female.The patient presented with three-month history of epigastric pain.Physical examination and routine blood tests were normal.Abdominal Computed Tomography scan revealed a 5 cm × 6 cm complex nonenhancing cystic mass in the head of pancreas.Magnetic resonance imaging,endoscopic ultrasonography(EUS) and EUS guided fine needle aspiration cytology were non-diagnostic.Because of uncontrolled symptoms,the patient underwent surgical resection.Histopathology and Immunohistochemical staining confirmed the diagnosis of cavernous hemangioma of pancreas.

Vertical transmission of hepatitis C virus: Current knowledge and perspectives

Hepatitis C virus(HCV) infection is a major global health issue.Infection by the HCV can cause acute and chronic liver diseases and may lead to cirrhosis,hepatocellular carcinoma or liver failure.The World Health Organization estimates that approximately 3% of the world population have been infected with HCVand the worldwide prevalence is between 1% and 8% in pregnant women and between 0.05% and 5% in children.Following the introduction of blood product screening,vertical transmission becomes the leading cause of childhood HCV infection.The prevalence of pediatric HCV infection varies from 0.05% to 0.36% in developed countries and between 1.8% and 5% in the developing world.All children born to women with antiHCV antibodies should be checked for HCV infection.Though universal screening is controversial,selective antenatal HCV screening on high-risk populations is highly recommended and should be tested probably.Multiple risk factors were shown to increase the possibility of HCV vertical transmission,including coinfections with human immunodeficiency virus,intravenous drug use and elevated maternal HCV viral load,while breastfeeding and HCV genotypes have been studied to have little impact.At present,no clinical intervention has been clearly studied and proved to reduce the HCV vertical transmission risk.Cesarean section should not be recommended as a procedure to prevent vertical transmission,however,breastfeeding is generally not forbidden.The high prevalence of global HCV infection necessitates renewed efforts in primary prevention,including vaccine development,as well as new approaches to reduce the burden of chronic liver disease.Future researches should focus on the interruption of vertical transmission,developments of HCV vaccine and directacting antivirals in infancy and early childhood.

Management of pancreaticobiliary disease using a new intra-ductal endoscope:The Texas experience

AIM:To evaluate a new single-operator mini-endoscope, Spyglass,for its performance,feasibility and safety in the management of pancreaticobiliary disease. METHODS:In a multicenter retrospective analysis of patients undergoing intraductal endoscopy,we evaluated 128 patients(71 men,mean age 57.6 years).Indications were therapeutic(TX)in 72(56%) and diagnostic(DX)in 56(44%). RESULTS:Peroral endoscopy was performed in 121 and percutaneous in seven.TX indications included CBD stones in 41,PD stones in six,and biliary strictures in 25.DX indications included abnormal LFT’s in 15, abnormal imaging in 38 and cholangiocarcinoma staging in three.Visualization of the stone(s)was considered good in 31,fair in six,and poor in four. Advancement of the electrohydraulic lithotripsy probe was not possible in three patients and proper targeting of the lesion was partial in four patients.A holmium laser was used successfully in three patients.Ductal clearance was achieved in 37 patients after one procedure and in four patients after two procedures.Diagnosis of biliary strictures was modified in 20/29 and confirmed to be malignant in 10/23.Of the modified patients,no diagnosis was available in 17.Spyglass demonstrated malignancy in 8/17 and non-malignancy in nine.Suspected pathology by imaging studies and abnormal LFT’s was modified in 43/63(66%).Staging of cholangiocarcinoma demonstrated multicentric cholangiocarcinoma in 2/3.There was no morbidity associated with the use of Spyglass. CONCLUSION:Spyglass Spyscopeis a first generation, single operator miniature endoscope that can evaluate and treat various biliary and pancreatic tract diseases.

New serological biomarkers of inflammatory bowel disease

Serological biomarkers in inflammatory bowel disease (IBD) are a rapidly expanding list of non-invasive tests for objective assessments of disease activity, early diagnosis, prognosis evaluation and surveillance. This review summarizes both old and new biomarkers in IBD, but focuses on the development and character-ization of new serological biomarkers (identifi ed since 2007). These include fi ve new anti-glycan antibodies, anti-chitobioside IgA (ACCA), anti-laminaribioside IgG (ALCA), anti-manobioside IgG (AMCA), and antibod-ies against chemically synthesized (∑) two major oligomannose epitopes, Man α-1,3 Man α-1,2 Man (∑Man3) and Man α-1,3 Man α-1,2 Man α-1,2 Man (∑Man4). These new biomarkers serve as valuable complementary tools to existing biomarkers not only in differentiating Crohn's disease (CD), ulcerative colitis (UC), normal and other non-IBD gut diseases, but also in predicting disease involvement (ileum vs colon), IBD risk (as subclinical biomarkers), and disease course (risk of complication and surgery). Interestingly, the prevalence of the antiglycan antibodies, including anti-Saccharomyces cerevisiae antibodies (ASCA), ALCA and AMCA, was found to be associated with single nucleotide polymorphisms (SNPs) of IBD susceptible genes such as NOD2/CARD15, NOD1/CARD4, toll-likereceptors (TLR) 2 and 4, and β-defensin-1. Further-more, a gene dosage effect was observed: anti-glycan positivity became more frequent as the number of NOD2/CARD15 SNPS increased. Other new serum/ plasma IBD biomarkers reviewed include ubiquitination factor E4A (UBE4A), CXCL16 (a chemokine), resistin, and apolipoprotein A-IV. This review also discusses the most recent studies in IBD biomarker discovery by the application of new technologies such as proteomics, fourier transform near-infrared spectroscopy, and mul-tiplex enzyme-linked immunosorbent assay (ELISA)'s (with an emphasis on cytokine/chemokine profiling). Finally, the prospects of developing more clinically use-ful novel diagnostic algorithms by incorporating new technologies in serological biomarker profiling and integrating multiple biomarkers with bioinformatics analysis/modeling are also discussed.

Comparison of the use of wireless capsule endoscopy with magnetic resonance enterography in children with inflammatory bowel disease

BACKGROUND Magnetic resonance enterography (MRE) and wireless capsule endoscopy (WCE) are equally accepted modalities for noninvasive screening of small bowel involvement (SBI) in children with Crohn’s disease (CD) and indeterminate colitis (IC) albeit there is a paucity of data comparing the two and thereby guiding the clinician in selecting the ideal diagnostic approach. Therefore, the goal of this study is to provide additional evidence for capsule endoscopy role in the evaluation of established Crohn’s disease exacerbation compared to MRE in relation to Pediatric Crohn's Disease Activity Index (PCDAI), and histological indices. AIM To prospectively compare the findings of MRE and WCE and their agreement with PCDAI or histology in children with CD or IC. METHODS Consecutive patients diagnosed with CD and IC were screened for inclusion. After informed consent, patient’s demographic and clinical data was abstracted. The current pediatric disease activity index (PCDAI) and endoscopic findings were included. Patients underwent MRE and WCE including preprocedural patency capsule within a maximum of 7 d of each other. Pathological presence of active small bowel disease in ileal and duodenal biopsies were collected if the endoscopy was performed within 2 mo of the WCE study. Patients who failed to pass the PC were excluded from the study. WCE was read by two different experienced gastroenterologists (Attard TM and Colombo JM) blinded to each other's findings and to the findings on MRE (Mardis NJ). Agreement between WCE reviewers, WCE and MRE findings and concordance between positive PCDAI and SBI based on MRE compared with WCE was computed. RESULTS Forty-five patients were included in the study, 18 withdrew and 27 (20 males and 20 CD), mean age (standard deviation) 13.46 (2.4) years, completed the study protocol. There were no instances of capsule retention. Concordance between gastroenterologist reviewers was excellent for the diagnosis of small intestinal CD with good correlation between the two Lewis scores (r=0.875, P<0.001). Concordance between WCE and MRE was poor (69%). In CD patients, when both MRE and WCE were compared using PCDAI>10 as the standard reference reflecting active small intestinal CD, the sensitivity of MRE and WCE were 100% and 83% respectively and the specificity of MRE and WCE were 57.14% and 78.6%, respectively. If the histology in ileum or/and duodenum was used as the reference for active small bowel involvement, WCE had a higher specificity as compared to MRE (83.3% vs 50%). In patients with Crohn’s disease, those with a positive PCDAI (>10) were more likely to have a positive WCE as compared to those with a negative PCDAI (83% vs 21%;P=0.018). CONCLUSION We suggest that MRE and WCE have a complementary role in the assessment of SBI in CD. WCE detected SBI with a much higher specificity while MRE had a higher sensitivity.

Unreported complication of Bravo p H capsule dislodged into the pyriform sinus

We report an unexpected, previously unreported complication of Bravo p H capsule dislodgement. During Bravo p H testing of a 44-year-old man with gastroesophageal reflux disease, we were unable to endoscopically visualize the capsule attached to the esophageal wall after deployment. After multiple attempts to detect the capsule, it was visualized in the left pyriform sinus. As there was significant risk for pulmonary dislodgement, ENT and pulmonary physicians were immediately consulted to review options for safe removal. Ultimately, ENT successfully retrieved the capsule with a foreign body removal forceps. The Bravo p H test is generally a well-tolerated diagnostic tool used to confirm the presence of abnormal esophageal acid reflux. While few complications have been reported, technical difficulties can occur, including poor data reception, misplacement, and early dislodgement. Rarely, more serious complications can occur, ranging from esophageal wall trauma to capsule aspiration. Gastroenterologists performing this procedure should be aware of the low, but nontrivial, risk of complications.

The Relationship Between Training Volume and BMI in the Expression of Running Performance in Runners: A Mediation Model

Purpose The relationships between anthropometric and training variables with running performance were previously investi-gated.However,it is possible that through the moderating role of anthropometric variables,the magnitude of the relationship between training and performance may be changed.The purpose of this study was to estimate the mediation role of body mass index(BMI)in the relationship between training volume and running performance among non-professional runners,taking into account sex and age category.Methods The sample comprised 1151 non-professional road runners(61.8%male),aged 18–72 years.Information about sex,age,body mass(kg),body height(cm),running pace,motivation for running,training volume and frequency were obtained through an online questionnaire.Taking into account athletes’age,they were split into two age categories:“until 34 years”(adult runners)and“≥35 years”(master athletes).A mediation analysis was computed in Macro Process(SPSS 26),considering sex and age category.BMI was the mediating variable,while training volume/week was used as independ-ent variable,and running pace was considered as dependent variable.Results For both sexes and age categories,a significant association between training volume on running pace was observed[male adult:β=-0.67;95%CI(-1.04 to-0.53);male master:β=-0.241;95%CI(-0.44 to-0.26);female adult:-0.83;95%CI(-1.25 to-0.41);female master:-0.76;95%CI(-1.09 to-0.44)],as well the association between training volume and BMI;and running BMI and running pace.Except for female adult runners,a mediation effect of BMI was observed.Conclusion The present study showed that BMI mediated the association between training volume and running pace in non-professional runners of different sexes and age categories.On the other hand,a small influence of training volume on the expression of BMI was found.

Thiopurines are negatively associated with anthropometric parameters in pediatric Crohn's disease

AIM To determine the distribution of anthropometric parameter(AP)-z-scores and characterize associations between medications/serum biomarkers and AP-z-scores in pediatric Crohn's disease(CD).METHODS CD patients [< chronological age(CA) 21 years] were enrolled in a cross-sectional study. Descriptive statistics were generated for participants' demographic characteristics and key variables of interest. Paired t-tests were used to compare AP-z-scores calculated based on CA(CA z-scores) and bone age(BA)(BA z-scores) for interpretation of AP's. Linear regression was utilized to examine associations between medications and serum biomarkers with AP-z-scores calculated based on CA(n = 82) and BA(n = 49). We reported regression coefficients as well as their corresponding p-values and 95% confidence intervals.RESULTS Mean CA at the time of the study visit was 15.3 ± 3.5(SD; range = 4.8-20.7) years. Mean triceps skinfold(P = 0.039), subscapular skinfold(P = 0.002) and midarm circumference(MAC)(P = 0.001) BA z-scores were higher than corresponding CA z-scores. Medications were positively associated with subscapular skinfold [adalimumab(P = 0.018) and methotrexate(P = 0.027)] and BMI CA z-scores [adalimumab(P = 0.029)]. Azathioprine/6-mercaptopurine were negatively associated with MAC(P = 0.045), subscapular skinfold(P = 0.014), weight(P = 0.002) and BMI(P = 0.013) CA z-scores. ESR, CRP, and WBC count were negatively associated, while albumin and IGF-1 BA z-scores were positively associated, with specific AP z-scores(P < 0.05). Mean height CA z-scores were higher in females, not males, treated with infliximab(P = 0.038). Hemoglobin(P = 0.018) was positively associated, while platelets(P = 0.005), ESR(P = 0.003) and CRP(P = 0.039) were negatively associated with height CA z-scores in males, not females. CONCLUSION Our results suggest poor efficacy of thiopurines and a possible sex difference in statural growth response to infliximab in pediatric CD. Prospective longitudinal studies are required.

Assessing disease activity using the pediatric Crohn’s disease activity index:Can we use subjective or objective parameters alone?

BACKGROUND The pediatric Crohn’s disease activity index(PCDAI)is used as a standard tool to assess disease activity in clinical trials for pediatric Crohn’s disease.AIM To examine which items on the PCDAI drive assessment of disease activity,and how subgroups of subjective and objective items reflect change in disease state over time.METHODS Selective raw data from three prospectively collected datasets were combined,including 703 children with full PCDAI data at baseline,at 3-mo(Q1,n=670),and 1-year(Q4,n=474).Change in individual PCDAI scores from baseline to Q1 and to Q4 were examined using the non-weighted PCDAI.RESULTS Abdominal pain,well-being,weight,and stooling had the highest change scores over time.Objective indicators including albumin,abdominal exam,and height velocity followed.Change scores for well-being and abdominal exam did not explain significant variance at Q1 but were significant predictors at Q4(P<0.001 and P<0.05).Subjective and objective subgroups of items predicted less variance(18%and 22%)on total PCDAI scores at Q1 and Q4 compared to the full PCDAI,or a composite scale(both 32%)containing significant predictors.CONCLUSION Although subjective items on the PCDAI change the most over time,the full PCDAI or a smaller composite of items including a combination of subjective and objective components classifies disease activity better than a subgroup of either subjective or objective items alone.Reliance on subjective or objective items as stand-alone proxies for disease activity measurement could result in misclassification of disease state.

How do we manage post-OLT redundant bile duct?

AIM: To address endoscopic outcomes of post-Orthotopic liver transplantation (OLT) patients diagnosed with a "redundant bile duct" (RBD). METHODS: Medical records of patients who underwent OLT at the Liver Transplant Center, University Texas Health Science Center at San Antonio Texas were retrospectively analyzed. Patients with suspected biliary tract complications (BTC) underwent endoscopic retrograde cholangiopancreatography (ERCP). All ERCP were performed by experienced biliary endoscopist. RBD was defined as a looped, sigmoid-shaped bile duct on cholangiogram with associated cholestatic liver biomarkers. Patients with biliary T-tube placement, biliary anastomotic strictures, bile leaks, bile-duct stonessludge and suspected sphincter of oddi dysfunction were excluded. Therapy included single or multiple biliary stents with or without sphincterotomy. The incidence of RBD, the number of ERCP corrective sessions, and the type of endoscopic interventions were recorded. Successful response to endoscopic therapy was defined as resolution of RBD with normalization of associated cholestasis. Laboratory data and pertinent radiographic imaging noted included the pre-ERCP period and a follow up period of 6-12 mo after the last ERCP intervention. RESULTS: One thousand two hundred and eighty-two patient records who received OLT from 1992 through 2011 were reviewed. Two hundred and twenty-four patients underwent ERCP for suspected BTC. RBD was reported in each of the initial cholangiograms. Twentyone out of 1282 (1.6%) were identified as having RBD. There were 12 men and 9 women, average age of 59.6 years. Primary indication for ERCP was cholestatic pattern of liver associated biomarkers. Nineteen out of 21 patients underwent endoscopic therapy and 2/21 required immediate surgical intervention. In the endoscopically managed group: 65 ERCP procedures were performed with an average of 3.4 per patient and 1.1 stent per session. Fifteen out of 19 (78.9%) patients were successfully managed with biliary stenting. All stents were plastic. Selection of stent size and length were based upon endoscopist preference. Stent size ranged from 7 to 11.5 Fr (average stent size 10 Fr); Stent length ranged from 6 to 15 cm (average length 9 cm). Concurrent biliary sphincterotomy was performed in 10/19 patients. Single ERCP session was sufficient in 6/15 (40.0%) patients, whereas 4/15 (26.7%) patients needed two ERCP sessions and 5/15 (33.3%) patients required more than two (average of 5.4 ERCP procedures). Single biliary stent was sufficient in 5 patients; the remaining patients required an average of 4.9 stents. Four out of 19 (21.1%) patients failed endotherapy (lack of resolution of RBD and recurrent cholestasis in the absence of biliary stent) and required either choledocojejunostomy (2/4) or percutaneous biliary drainage (2/4). Endoscopic complications included: 2/65 (3%) post-ERCP pancreatitis and 2/10 (20%)non-complicated post-sphincterotomy bleeding. No endoscopic related mortality was found. The medical records of the 15 successful endoscopically managed patients were reviewed for a period of one year after removal of all biliary stents. Eleven patients had continued resolution of cholestatic biomarkers (73%). One patient had recurrent hepatitis C, 2 patients suffered septic shock which was not associated with ERCP and 1 patient was transferred care to an outside provider and records were not available for our review. CONCLUSION: Although surgical biliary reconstruction techniques have improved, RBD represents a postOLT complication. This entity is rare however, endoscopic management of RBD represents a reasonable initial approach.

Post-infantile giant cell hepatitis:A single center’s experience over 25 years

BACKGROUND Giant cell hepatitis in the adult population remains very poorly defined with only 100 case reports published in the literature over the last three decades.AIM To present our center’s experience in an attempt to learn about the predisposing factors,outcomes and efficacy of proposed therapeutic interventions for giant cell hepatitis.METHODS A retrospective chart review was conducted through the electronic records of the University of Pittsburgh Medical Center.We queried 36726 liver biopsy reports from January 1,1991 to December 6,2016.Our search yielded 50 patients who were identified as carrying a definite diagnosis of post-infantile giant cell hepatitis(PIGCH)by pathology.The data collected included demographic information,laboratory data(liver function tests,autoimmune markers)and transplant status.In order to better analyze patient characteristics and outcomes,subjects were separated into a non-transplant(native)liver group and a post-liver transplant(allograft)group.RESULTS The incidence of PIGCH was approximately 0.14%of all biopsies queried in the 25-year period.The mean age was 48 years with 66%females.Liver function tests were classified as 38.2%cholestatic,35.3%hepatocellular and 26.5%mixed.Autoimmune hepatitis was found to be the most prevalent predisposing factor leading to PIGCH constituting 32%of cases.Management consisted mainly of immunosuppression,viral targeted therapy,supportive care and in six cases liver transplantations.CONCLUSION The diagnosis of PIGCH remains clinically challenging and requires a high index of suspicion as well as a thorough history,physical examination,serological workup and liver biopsy.Treatment of the underlying cause can result in clinical stability in a large number of cases.

对1例胆管闭锁患婴行肝门肠吻合修复术获成功

We present a case report of a boy with biliary atresia who,after hepatoportoenterostomy performed on day 21 of life, had immediate resolution of cholestasis and remained anicteric until 3.5 months of age. He then abruptly developed acholic stools.Nuclear medicine imaging study showed no excretion. Broadspectrum antibiotics and corticosteroids were administered but did not lead to clinical improvement; a surgical revision of the original anastomosis was undertaken at 4 months of age. At 14 months of age, the child is anicteric and growing well. In this case, successful revision of hepatoportoenterostomy averted the need for liver transplantation.

内镜下电灼联合金属夹闭合慢性胃-皮肤瘘管

Background: Chronic gastrocutaneous fistula with intermittent drainage is a common outcome after removing long-standing gastrostomy tubes. The standard treatment is surgery with laparotomy and excision of the fistula tract. This study describes the results of an endoscopic closure technique by using a combination of electrocautery and metal clips. Methods: Three patients with gastrocutaneous fistulas (duration 3 months to 3 years) after gastrostomy tube removal were treated endoscopically by electrocautery of the tract and application of metal clips. Observations: Treatment resulted in complete fistula closure in two patients and partial closure in a third patient. Conclusions: Combined endoscopic therapy with electrocautery and clipping may be an alternative to surgical closure of chronic gastrocutaneous fistulas.

青春前期Alagille综合征患儿的静息时能量消耗没有增加

Increased resting energy expenditure (REE) is a possible explanation for the negative energy balance seen in children with Alagille syndrome (AGS).We evaluated 16 subjects with AGS and 37 healthy controls and did not find a significant difference in REE (101%±12%,105%±13%,respectively).

炎症性肠病中胶原性结肠炎的形成:两例报告并文献复习

The occurrence of collagenous colitis(CC)in patients with pre-existing inflammatory bowel diseases(IBD)is rare,with only seven cases reported in the past.Herein,we report two IBD cases who developed CC after successful treatment of their IBD with two different tumor necrosis factor(TNF)-a inhibitors,which have been previously reported to successfully treat refractory CC.This report highlights the need to do random biopsies of the colon for CC diagnosis in IBD patients with symptoms of diarrhea after complete mucosal healing.The report also reviews plausible mechanisms as to how CC may develop,including the role of multiple medications.

Altered gut-liver axis in liver diseases

Chronic liver diseases have become a major global health prob-lem and its prevalence has been rapidly rising during the last decade.Extensive studies have identified the major causes for the progression of these diseases including chronic viral infections,ge-netic mutations,excessive alcohol consumption,metabolic dis-eases,cholestatic liver injury and toxic effects of medications.1e3 Regardless of the aetiology,multiple common mechanisms,espe-cially the gut-liver-axis,are associated with the pathogenesis and fibrotic disease progression of chronic liver injury.However,it re-mains challenging to develop effective therapeutics due to our limited understanding of these mechanisms.In this special issue,we are excited to present seven review articles and one original research paper.With this collection,we have provided the recent advances in understanding the roles of the gut-liver-axis in the development of a variety of liver diseases.