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Acute pancreatitis caused by Anisakis
At the Focal Point
DISCLOSURE All authors disclosed no financial relationships relevant to this publication. Maryconi M. Jaurigue, MD,* Palaniappan Manickam, MD, MPH, Division of Gastroenterology and Hepatology, Department of Medicine, Mitual Amin, MD,y Department of
Pathology, Mitchell S. Cappell, MD, PhD,* Division of Gastroenterology and Hepatology, Department of Medicine, William Beaumont Hospital, Royal Oak, Michigan, USA *Drs Jaurigue and Cappell contributed equally to this article. yDr Amin is the author for pathology. http://dx.doi.org/10.1016/j.gie.2013.10.047
Commentary As if one needed one more reason not to smoke! Osteoclast-like giant cell tumor of the pancreas (OGTP) is an extremely rare, undifferentiated carcinoma of the pancreas that usually coexists with garden-variety ductal cancer or mucinous cystic neoplasia. Fewer than 100 cases have been reported in the world’s literature since the first description of this lesion in 1968; perhaps it is more common in other galaxies. Its pleomorphic cellular hallmarks include discohesive, osteoclastlike multinucleated giant cells, mononuclear histiocytes, and a chondroid stroma. This is a high-grade neoplasm that at autopsy can reveal prominent cystic elements (radiographically mimicking a pancreatic pseudocyst), focal necrosis, calcifications, and even elements of bone formation. My neck was never thick enough to match in orthopedics, and this bizarre Focal Point is about as close as I’m likely to get. OGTPs typically present as large (5-10 cm), unresectable, and highly vascular tumors that are locally invasive and often have nodal metastases. One might rightly imagine the prognosis of a patient with OGTP is dismal. David Robbins, MD, MSc Assistant Editor for Focal Points
Acute pancreatitis caused by Anisakis A 63-year-old man presented with upper abdominal pain 36 hours after ingesting sliced raw fish (Sebastes schlegeli Hilgendorf). Laboratory analyses revealed the following: serum amylase, 3619 IU/L (normal 43-127 IU/L) and total bilirubin 6.0 mg/dL (0.2-1.2 mg/dL). Abdominal CT revealed a high-density lesion involving the extrahepatic bile duct and gallbladder, swelling of the pancreas, and peripancreatic fluid (A). Acute biliary pancreatitis was suspected, and duodenoscopy revealed GI bleeding (B, left) and a swollen ampulla of Vater with migration of a nematode into the ampulla (B, middle and right). The nematode was removed by biopsy forceps and identified as an Anisakis larva. ERCP revealed obstruction of the extrahepatic bile duct because of a blood clot (C, left and right, arrows). A nasobiliary drainage tube was placed endoscopically to ensure continued drainage of hemobilia. The diagnosis was acute pancreatitis and hemobilia caused by migration of Anisakis into the ampulla of Vater. Three days after worm extraction, serum amylase and bilirubin levels had decreased to the normal range. At 16 days after extraction, nasobiliary tube cholangiography revealed disappearance of the blood clot, and the following day,
the patient’s abdominal pain resolved, and oral food intake was resumed without ill effect. DISCLOSURE All authors disclosed no financial relationships relevant to this publication. Hiroaki Yamato, MD, PhD, Department of Gastroenterology, Hakodate Municipal Hospital, Hakodate, Japan, Hiroshi Kawakami, MD, PhD, Kikuko Takagi, MD, Department of Gastroenterology and Hepatology, Hokkaido University Graduate School of Medicine, Koji Ogawa, MD, PhD, Kazuteru Hatanaka, MD, PhD, Yoshiya Yamamoto, MD, PhD, Hirohito Naruse, MD, PhD, Department of Gastroenterology, Hakodate Municipal Hospital, Hakodate, Kazumichi Kawakubo, MD, PhD, Naoya Sakamoto, MD, PhD, Department of Gastroenterology and Hepatology, Hokkaido University Graduate School of Medicine, Sapporo Japan http://dx.doi.org/10.1016/j.gie.2013.11.026
Commentary
Sebastes is a genus of fish, most of which commonly are called rockfish, and the one that this patient ate is known as the Korean rockfish. Rockfish usually live benthically at the depths of the sea (Gr. Benthos, depth [of sea]) often, as the name 676 GASTROINTESTINAL ENDOSCOPY Volume 79, No. 4 : 2014
www.giejournal.org
At the Focal Point
suggests, around rocky outcrops. Two species of Anisakis account for most anisakid infections in humans and are caused by consumption of raw or undercooked seafood: Anisakis simplex (herring worm), and Phocanema (Pseudoterranova) decipiens (cod or seal worm). Anisakidosis occurs worldwide, with a higher incidence in regions where raw fish is commonly eaten. To understand how we get this infection, one must understand the life cycle of this nematode. The adult worm is found in the stomachs of marine mammals (eg, whales and dolphins). Fertilized eggs from the female worm are passed with the mammal’s feces. The eggs become embryonated in water, and first-stage larvae are formed. The larvae molt into second-stage larvae, become free-swimming, and are ingested by crustaceans, after which they develop into third-stage larvae that are infective to fish, squid, marine mammals, and humans. Humans become infected by eating raw or undercooked infected marine fish, usually pacific salmon, red snapper, cod, haddock, fluke, herring, flounder, monkfish and, in the patient presented here, the Korean rockfish. Four clinical forms of anisakidosis are known: gastric, intestinal, ectopic, and allergic; the latter two are less known to gastroenterologists. A simplex allergic manifestations, including urticaria and anaphylaxis, may occur after exposure to very small quantities of allergens from dead worms by food-borne, airborne, or skin-contact routes. If you develop upper abdominal pain, nausea, vomiting, diarrhea, or allergic symptoms within 48 hours after an evening of www.giejournal.org
Volume 79, No. 4 : 2014 GASTROINTESTINAL ENDOSCOPY 677
At the Focal Point
sushi, get to the gastroenterologist promptly where, upon EGD, a nematode larva will be seen burrowing into the gastric wall and can be extracted with a biopsy forceps; end of story.usually. If the worm traverses the pylorus, its next home may be in the ileum, where it can cause an acute eosinophilic granulomatous process that may resemble Crohn’s disease. The omentum, mesentery, pancreas, and liver also may be the site of disease, as illustrated by the case described here. Patients may exhibit a slight elevation of temperature, moderate leukocytosis, and eosinophilia. Two morsels of advice: (1) Make sure your fish are gutted promptly, because with the death of the fish, infective larvae in the GI tract of the fish migrate to its muscle tissues; (2) Seek prompt EGD should GI or allergic symptoms occur soon after a sushi delight. The word sushi in its original meaning denoted “vinegar-cured rice,” and the raw fish was just a bonus. It’s not such a bonus, however, if you get anisakidosis. Lawrence J. Brandt, MD Associate Editor for Focal Points
Chronic iron deficiency anemia caused by small-bowel lipoma
A 64-year-old man presented with fatigue and unexplained chronic iron deficiency anemia for more than a year despite iron supplementation. The initial hemoglobin value was 11.2 g/dL, with a mean corpuscular volume (MCV) of 70.9 fL, ferritin level of 9.7 ng/mL, and iron saturation of 5%. Fecal occult blood test results were positive. After a normal upper and lower endoscopy, capsule endoscopy revealed an ulcerated submucosal lesion in the mid-ileum (A). Further workup with abdominal CT demonstrated a round, 1.9-cm, fat-containing mass within
the small intestine (B). Neither retrograde nor antegrade double-balloon enteroscopy could reach the area of the mass. Because of his continued anemia, it was decided to remove the mass laparoscopically. The gross specimen showed that the mucosa overlying the lesion had ulcerated (C). Pathology showed mature fat cells and confirmed the diagnosis of a small-bowel lipoma (D). Three months later, while the patient was still on iron supplementation, his laboratory values had normalized, with a hemoglobin value of 15.9 g/dL and an MCV of 84.4 fL.
678 GASTROINTESTINAL ENDOSCOPY Volume 79, No. 4 : 2014
www.giejournal.org
DISCLOSURE All authors disclosed no financial relationships relevant to this publication. Maryconi M. Jaurigue, MD,* Palaniappan Manickam, MD, MPH, Division of Gastroenterology and Hepatology, Department of Medicine, Mitual Amin, MD,y Department of
Pathology, Mitchell S. Cappell, MD, PhD,* Division of Gastroenterology and Hepatology, Department of Medicine, William Beaumont Hospital, Royal Oak, Michigan, USA *Drs Jaurigue and Cappell contributed equally to this article. yDr Amin is the author for pathology. http://dx.doi.org/10.1016/j.gie.2013.10.047
Commentary As if one needed one more reason not to smoke! Osteoclast-like giant cell tumor of the pancreas (OGTP) is an extremely rare, undifferentiated carcinoma of the pancreas that usually coexists with garden-variety ductal cancer or mucinous cystic neoplasia. Fewer than 100 cases have been reported in the world’s literature since the first description of this lesion in 1968; perhaps it is more common in other galaxies. Its pleomorphic cellular hallmarks include discohesive, osteoclastlike multinucleated giant cells, mononuclear histiocytes, and a chondroid stroma. This is a high-grade neoplasm that at autopsy can reveal prominent cystic elements (radiographically mimicking a pancreatic pseudocyst), focal necrosis, calcifications, and even elements of bone formation. My neck was never thick enough to match in orthopedics, and this bizarre Focal Point is about as close as I’m likely to get. OGTPs typically present as large (5-10 cm), unresectable, and highly vascular tumors that are locally invasive and often have nodal metastases. One might rightly imagine the prognosis of a patient with OGTP is dismal. David Robbins, MD, MSc Assistant Editor for Focal Points
Acute pancreatitis caused by Anisakis A 63-year-old man presented with upper abdominal pain 36 hours after ingesting sliced raw fish (Sebastes schlegeli Hilgendorf). Laboratory analyses revealed the following: serum amylase, 3619 IU/L (normal 43-127 IU/L) and total bilirubin 6.0 mg/dL (0.2-1.2 mg/dL). Abdominal CT revealed a high-density lesion involving the extrahepatic bile duct and gallbladder, swelling of the pancreas, and peripancreatic fluid (A). Acute biliary pancreatitis was suspected, and duodenoscopy revealed GI bleeding (B, left) and a swollen ampulla of Vater with migration of a nematode into the ampulla (B, middle and right). The nematode was removed by biopsy forceps and identified as an Anisakis larva. ERCP revealed obstruction of the extrahepatic bile duct because of a blood clot (C, left and right, arrows). A nasobiliary drainage tube was placed endoscopically to ensure continued drainage of hemobilia. The diagnosis was acute pancreatitis and hemobilia caused by migration of Anisakis into the ampulla of Vater. Three days after worm extraction, serum amylase and bilirubin levels had decreased to the normal range. At 16 days after extraction, nasobiliary tube cholangiography revealed disappearance of the blood clot, and the following day,
the patient’s abdominal pain resolved, and oral food intake was resumed without ill effect. DISCLOSURE All authors disclosed no financial relationships relevant to this publication. Hiroaki Yamato, MD, PhD, Department of Gastroenterology, Hakodate Municipal Hospital, Hakodate, Japan, Hiroshi Kawakami, MD, PhD, Kikuko Takagi, MD, Department of Gastroenterology and Hepatology, Hokkaido University Graduate School of Medicine, Koji Ogawa, MD, PhD, Kazuteru Hatanaka, MD, PhD, Yoshiya Yamamoto, MD, PhD, Hirohito Naruse, MD, PhD, Department of Gastroenterology, Hakodate Municipal Hospital, Hakodate, Kazumichi Kawakubo, MD, PhD, Naoya Sakamoto, MD, PhD, Department of Gastroenterology and Hepatology, Hokkaido University Graduate School of Medicine, Sapporo Japan http://dx.doi.org/10.1016/j.gie.2013.11.026
Commentary
Sebastes is a genus of fish, most of which commonly are called rockfish, and the one that this patient ate is known as the Korean rockfish. Rockfish usually live benthically at the depths of the sea (Gr. Benthos, depth [of sea]) often, as the name 676 GASTROINTESTINAL ENDOSCOPY Volume 79, No. 4 : 2014
www.giejournal.org
At the Focal Point
suggests, around rocky outcrops. Two species of Anisakis account for most anisakid infections in humans and are caused by consumption of raw or undercooked seafood: Anisakis simplex (herring worm), and Phocanema (Pseudoterranova) decipiens (cod or seal worm). Anisakidosis occurs worldwide, with a higher incidence in regions where raw fish is commonly eaten. To understand how we get this infection, one must understand the life cycle of this nematode. The adult worm is found in the stomachs of marine mammals (eg, whales and dolphins). Fertilized eggs from the female worm are passed with the mammal’s feces. The eggs become embryonated in water, and first-stage larvae are formed. The larvae molt into second-stage larvae, become free-swimming, and are ingested by crustaceans, after which they develop into third-stage larvae that are infective to fish, squid, marine mammals, and humans. Humans become infected by eating raw or undercooked infected marine fish, usually pacific salmon, red snapper, cod, haddock, fluke, herring, flounder, monkfish and, in the patient presented here, the Korean rockfish. Four clinical forms of anisakidosis are known: gastric, intestinal, ectopic, and allergic; the latter two are less known to gastroenterologists. A simplex allergic manifestations, including urticaria and anaphylaxis, may occur after exposure to very small quantities of allergens from dead worms by food-borne, airborne, or skin-contact routes. If you develop upper abdominal pain, nausea, vomiting, diarrhea, or allergic symptoms within 48 hours after an evening of www.giejournal.org
Volume 79, No. 4 : 2014 GASTROINTESTINAL ENDOSCOPY 677
At the Focal Point
sushi, get to the gastroenterologist promptly where, upon EGD, a nematode larva will be seen burrowing into the gastric wall and can be extracted with a biopsy forceps; end of story.usually. If the worm traverses the pylorus, its next home may be in the ileum, where it can cause an acute eosinophilic granulomatous process that may resemble Crohn’s disease. The omentum, mesentery, pancreas, and liver also may be the site of disease, as illustrated by the case described here. Patients may exhibit a slight elevation of temperature, moderate leukocytosis, and eosinophilia. Two morsels of advice: (1) Make sure your fish are gutted promptly, because with the death of the fish, infective larvae in the GI tract of the fish migrate to its muscle tissues; (2) Seek prompt EGD should GI or allergic symptoms occur soon after a sushi delight. The word sushi in its original meaning denoted “vinegar-cured rice,” and the raw fish was just a bonus. It’s not such a bonus, however, if you get anisakidosis. Lawrence J. Brandt, MD Associate Editor for Focal Points
Chronic iron deficiency anemia caused by small-bowel lipoma
A 64-year-old man presented with fatigue and unexplained chronic iron deficiency anemia for more than a year despite iron supplementation. The initial hemoglobin value was 11.2 g/dL, with a mean corpuscular volume (MCV) of 70.9 fL, ferritin level of 9.7 ng/mL, and iron saturation of 5%. Fecal occult blood test results were positive. After a normal upper and lower endoscopy, capsule endoscopy revealed an ulcerated submucosal lesion in the mid-ileum (A). Further workup with abdominal CT demonstrated a round, 1.9-cm, fat-containing mass within
the small intestine (B). Neither retrograde nor antegrade double-balloon enteroscopy could reach the area of the mass. Because of his continued anemia, it was decided to remove the mass laparoscopically. The gross specimen showed that the mucosa overlying the lesion had ulcerated (C). Pathology showed mature fat cells and confirmed the diagnosis of a small-bowel lipoma (D). Three months later, while the patient was still on iron supplementation, his laboratory values had normalized, with a hemoglobin value of 15.9 g/dL and an MCV of 84.4 fL.
678 GASTROINTESTINAL ENDOSCOPY Volume 79, No. 4 : 2014
www.giejournal.org