Ischemic Gastropathic Ulcer Mimics Gastric Cancer

Gastric ulcer due to mesenteric ischemia is a rare clinical finding. As a result, few reports of ischemic gastric ulcers have been reported in the literature. The diagnosis of ischemic gastropathy is seldom considered in patients presenting with abdominal pain and gastric ulcers. In this case report, we describe a patient with increasing abdominal pain, weight loss, and gastric ulcers, who underwent extensive medical evaluation and whose symptoms were resistant to medical interventions. Finally he was diagnosed with chronic mesenteric ischemia, and his clinical and endoscopic abnormalities resolved after surgical revascularization of both the superior mesenteric artery and the celiac trunk

Exploring the Optimal Timing of Endoscopic Ultrasound Performance Post-Acute Idiopathic Pancreatitis

Background: Patients with acute idiopathic pancreatitis (AIP) should undergo further imaging tests such as endoscopic ultrasound (EUS) for further investigation. The time interval between an episode of AIP and EUS performance is still controversial. Aims: We aimed to explore the optimal timing for performing EUS and to reveal parameters that might predict longer intervals needed for performing EUS. Methods: We performed a single-center retrospective study at Galilee Medical Center from January 2015 to January 2020, at which point we included all patients who underwent EUS for further investigation of AIP. Results: Overall, we included 50 patients. The average age of all patients was 54.2 ± 17.6 years (range 22–69 years), and more than half of the study cohort were males (58%). Classifying patients as inflamed vs. normal pancreatic tissue on EUS, we found that among patients with normal pancreatic tissue, EUS was performed 44.7 ± 28.3 days from discharge, while for patients with inflamed pancreatic tissue, it was 48.1 ± 22.3 days (p = 0.37) after discharge. Notably, the CT severity index was significantly associated with inflamed pancreatic tissue on EUS, as it was 2.4 ± 0.74 vs. 1.5 ± 1.3 in the normal pancreatic tissue group (p = 0.03). There were no differences in the Bedside index for severity in acute pancreatitis (BISAP) scores, and there were no differences in the average American Society of Anesthesiologist Physical Status (ASA) scores between the two groups. Notably, 26.3% of patients had inflamed pancreatic tissue when performing EUS at 4 weeks, as compared to 16% who had inflamed pancreatic tissue at EUS performed after 6 weeks. Conclusion: Radiological severity score was the only important factor in determining the time interval of performing EUS after an episode of AIP. Intervals greater than six weeks seem to be needed among patients with higher Balthazar scores

The Utility of Endoscopic Ultrasound Fine Needle Aspiration in Pancreatic Cystic Lesions Diagnosis

The yield of biochemical analysis of pancreatic cysts fluid obtained via fine needle aspiration (FNA) is limited. We aimed to assess whether biochemical cyst analysis correlates with the endoscopic ultra-sonographic (EUS) diagnosis. A retrospective study including patients who underwent EUS-FNA was performed. Agreement level between EUS diagnosis and biochemical analysis was reported. One-hundred-and-eleven patients were included. For cyst CEA level, 42.4% of patients with endoscopic diagnosis of pancreatic mucinous cystic neoplasm (intraductal papillary mucinous neoplasm (IPMN) and mucinous cystic neoplasms (MCN)) had CEA level >192 ng/mL vs. 15.8% of patients who had another endoscopic diagnosis (chi square = 0.03) with poor agreement level (Kappa = 0.130). For the serous cystadenoma (SCA), the levels of amylase and CEA were defined as <250 unit/L and <5 ng/mL, respectively. Eight patients (57.1%) had amylase of <250 unit/L, while 42.9% had >250 unit/L (chi square = 0.007). The agreement level between EUS diagnosis of SCA and amylase level was poor (Kappa = 0.231). For cyst CEA level, 71.4% had CEA level <5 ng/mL vs. 28.6% who had CEA >5 ng/mL (chi square < 0.001) with fair agreement level (Kappa = 0.495). EUS-FNA for pancreatic cystic lesions poorly correlated with the EUS diagnosis. FNA should be considered in the setting of EUS worrisome findings

Fatty Pancreas and Pancreatic Cancer: An Overlooked Association?

Background: fatty pancreas (FP) is an old observation, but a new disease with clinical implications and several associated comorbid conditions, ranging from mild to life-threatening diseases. Herein, we aimed to assess the association between FP and pancreatic cancer (PC) development. Methods: we performed a retrospective cross-sectional study including all patients who underwent endoscopic ultrasound (EUS) for hepatobiliary indications. The study cohort was divided into patients with and without PC. Univariate and multivariate analysis were used to assess the association of several parameters with PC. Results: overall, 519 patients were included in the study. Of them, 48 had PC (PC group), and 471 did not (non-PC group). In univariate analysis, age (OR 1.04, 95% CI 1.01–1.07, p = 0.004), congestive heart failure (CHF) (OR 3.89, 95% CI 1.72–8.79, p = 0.001), ischemic heart disease (IHD) (OR 3.36, 95% CI 1.59–7.05, p = 0.001), hypertension (OR 2.42, 95% CI 1.33–4.41, p = 0.004) and fatty pancreas (FP) (OR 2.62, 95% CI 1.23–5.57, p = 0.01) were significantly associated with PC. In multivariate logistic regression analysis, only FP kept its association (OR 2.35, 95% CI 1.04–5.33, p = 0.04). Conclusion: FP was significantly associated with PC. A follow-up plan should be considered for individuals with FP

Chylous Ascites: A Rare Adverse Effect of Methimazole Treatment for Grave’s Disease—A Case Report and Review of the Literature

A 40-year-old woman was admitted due to an urticarial rash that was attributed to recent onset of methimazole treatment for a diagnosis of Grave’s disease. The patient had no prior significant medical history and used no medications, including over-the-counter or herbal medications. Her sister had Grave’s disease. On admission, the patient received corticosteroids with improvement in her rash. On the second day of the hospitalization, the patient complained of abdominal discomfort. Abdominal ultrasound revealed a large amount of new onset ascites. Peritoneal tap yielded a milky fluid with high triglyceride level (12.2 mmol/L or 1080 mg/dL), consistent with chylous ascites. After discontinuation of the methimazole, the ascites disappeared. The patient later underwent therapeutic thyroidectomy, after which all features of thyrotoxicosis had improved

Exploring the Optimal Timing of Endoscopic Ultrasound Performance Post-Acute Idiopathic Pancreatitis

Background: Patients with acute idiopathic pancreatitis (AIP) should undergo further imaging tests such as endoscopic ultrasound (EUS) for further investigation. The time interval between an episode of AIP and EUS performance is still controversial. Aims: We aimed to explore the optimal timing for performing EUS and to reveal parameters that might predict longer intervals needed for performing EUS. Methods: We performed a single-center retrospective study at Galilee Medical Center from January 2015 to January 2020, at which point we included all patients who underwent EUS for further investigation of AIP. Results: Overall, we included 50 patients. The average age of all patients was 54.2 ± 17.6 years (range 22–69 years), and more than half of the study cohort were males (58%). Classifying patients as inflamed vs. normal pancreatic tissue on EUS, we found that among patients with normal pancreatic tissue, EUS was performed 44.7 ± 28.3 days from discharge, while for patients with inflamed pancreatic tissue, it was 48.1 ± 22.3 days (p = 0.37) after discharge. Notably, the CT severity index was significantly associated with inflamed pancreatic tissue on EUS, as it was 2.4 ± 0.74 vs. 1.5 ± 1.3 in the normal pancreatic tissue group (p = 0.03). There were no differences in the Bedside index for severity in acute pancreatitis (BISAP) scores, and there were no differences in the average American Society of Anesthesiologist Physical Status (ASA) scores between the two groups. Notably, 26.3% of patients had inflamed pancreatic tissue when performing EUS at 4 weeks, as compared to 16% who had inflamed pancreatic tissue at EUS performed after 6 weeks. Conclusion: Radiological severity score was the only important factor in determining the time interval of performing EUS after an episode of AIP. Intervals greater than six weeks seem to be needed among patients with higher Balthazar scores

A Novel Clinical Score Predicting the Presence of Fatty Pancreas

Background: Fatty pancreas (FP) has become an increasingly encountered entity in recent years. Several studies have shown an association with several disease states. Aims: we aimed to generate a simple non-invasive scoring model to predict the presence of FP. Method: We performed a retrospective cross-sectional analysis at Galilee Medical Center. Inclusion criteria included patients who underwent endoscopic ultrasound (EUS) for hepatobiliary indications and who had either hyperechogenic pancreas consistent with FP or no sonographic evidence of fatty pancreas. Results: We included 569 patients. Among them, 78 patients had FP by EUS and 491 patients did not have FP. On univariate analysis, obesity (odds ratio (OR) 5.11, p < 0.0001), hyperlipidemia (OR 2.86, p = 0.0005), smoking (OR 2.02, p = 0.04), hypertension (OR 2.58, p = 0.0001) and fatty liver (OR 5.94, p < 0.0001) were predictive of FP. On multivariate analysis, obesity (OR 4.02, p < 0.0001), hyperlipidemia (OR 2.22, p = 0.01) and fatty liver (OR 4.80, p < 0.0001) remained significantly associated with FP. We developed a diagnostic score which included three parameters that were significant on multivariate regression analysis, with assignment of weights for each variable according to the OR estimate. A low cut-off score of ≤1 was associated with a negative predictive value (NPV) of 98.1% for FP, whereas a high cut-off score of ≥2 was associated with a positive predictive value (PPV) of 35–56%. Conclusion: We recommend incorporating this simple score as an aid to identify individuals with FP

Bloating, Diarrhoea and Maldigestion in Patients with Metabolic Syndrome: Are Fatty Pancreas and Pancreatic Exocrine Insufficiency the Missing Pieces of the Puzzle?

Pancreatic exocrine insufficiency (PEI) is a disorder causing symptoms such as maldigestion, malnutrition, diarrhoea, bloating, vitamin deficiency and weight loss [...