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An interesting case of iron deficiency anemia
At the Focal Point
An interesting case of iron deficiency anemia
A 71-year-old man presented with new onset iron deficiency anemia and intermittent tarry stools. Routine upper endoscopy and colonoscopy were unremarkable. His medical history included Agent Orange exposure while serving in the armed forces in Vietnam and, subsequently, liposarcomas of the retroperitoneum and groin that had required multiple surgical resections. His second resection of a recurrent retroperitoneal liposarcoma was complicated by an abdominal abscess with a resultant small bowel resection and the need to allow the abdominal wound to close by secondary intent, leaving an abdominal wall defect. His medical history was further complicated by ischemic cardiomyopathy, with an ejection fraction of 15%, and recent placement of an automatic implantable cardioverter-defibrillator for which he was taking aspirin and clopidogrel. An upper GI and small bowel follow through was unremarkable, and he was admitted for video-capsule endoscopy. This study revealed a large subwww.giejournal.org
mucosal lesion with superficial ulceration in the distal small bowel (A). CT enteroclysis was performed to further localize the lesion and revealed a large filling defect in the distal jejunum (B). A 6-cm mass was resected (C), with pathology that showed a liposarcoma (D). DISCLOSURE All authors disclosed no financial relationships relevant to this publication. Jonathan M. Ricker, DO, Department of Gastroenterology and Hepatology, Derek A. Mathis, MD, Department of Pathology, Wilford Hall Medical Center, Lackland Air Force Base, Texas, Hays L. Arnold, MD, Brooke Army Medical Center, Department of Gastroenterology and Hepatology, Fort Sam Houston, Texas, USA doi:10.1016/j.gie.2010.01.038
Volume 72, No. 1 : 2010 GASTROINTESTINAL ENDOSCOPY
189
At the Focal Point
Commentary During the Vietnam war, the United States military used Agent Orange as a chemical defoliant. Agent Orange was given its name from the color of the 55-gallon orange-striped barrels it was shipped in. Agent orange is a mixture of two phenoxyl herbicides (2,4-dichlorophenoxyacetic acid [2,4-D] and 2,4,5 trichlorophenoxyacetic acid [2,4,5-T]). In addition, it contains a byproduct of 2,4,5-T which is a dioxin (2,3,7,8-tetrachlorobenzodioxin [TYCDD]) that is known to be a carcinogen. Diseases recognized by the U.S. Department of Veterans Affairs to be associated with Agent Orange, and thus rendering such affected individuals eligible for disability compensation and health care benefits, include soft tissue sarcoma, Hodgkin and nonHodgkin lymphoma, B-cell leukemia, chronic lymphocytic leukemia, multiple myeloma, and cancers of the lung, tracheobronchial tree, larynx, prostate, and amyloidosis, Parkinson disease, and diabetes mellitus. Fusion or chimeric proteins are key components of mesenchymal cancer development and the most common fusion gene associated with liposarcoma is FUSCHOP, which encodes a transcription factor necessary for adipocyte differentiation. Could this abnormality have been induced by Agent Orange? Regardless, liposarcoma is the most common soft tissue sarcoma in adults. First described by Virchow in the 1860s, it usually presents as a slowly enlarging abdomen without pain or bleeding in a middle-aged man and on evaluation may be seen to be a very large mass, sometimes weighing several pounds. Anatomic distribution, and to some extent prognosis, is related to histologic type of which there are five: well-differentiated, (adipocytic, sclerosing, and inflammatory subtypes), dedifferentiated, myxoid, round cell, and pleomorphic. It is the well-differentiated and dedifferentiated liposarcomas that tend to occur in the retroperitoneum. Although they rarely metastasize, repeated local recurrences may cause the tumor to evolve into a higher grade of sarcoma or to dedifferentiate, in which case metastasis may occur. Treatment was surgical now, but perhaps he would not have had this lesion were he not to have come in contact with Agent Orange. The writing of Rachel Carson in the classic, Silent Spring, seems appropriate: . . . These sprays, dusts, and aerosols are now applied almost universally to farms, gardens, forests, and homes—nonselective chemicals that have the power to kill every insect, the “good” and the “bad,” to still the song of birds and the leaping of fish in the streams, to coat the leaves with a deadly film, and to linger on in soil—all this though the intended target may be only a few weeds or insects. Can anyone believe it is possible to lay down such a barrage of poisons on the surface of the earth without making it unfit for all life? They should not be called “insecticides,” but “biocides.” Lawrence J. Brandt, MD Associate Editor for Focal Points
Gastric heterotopia in the rectum A 36-year-old woman was referred to the gastroenterology service for evaluation of a 5-year history of dull, aching, lower abdominal discomfort unaccompanied by diarrhea or constipation and without aggravating or relieving factors. Review of systems and medical history were otherwise unremarkable with the exception of a caesarean section performed 10 years previously. Six years later, she had a diagnostic laparoscopy to investigate lower abdominal pain; no abnormalities were found. She subsequently had an intrauterine coil inserted. Physical examination, complete blood count, and biochemical profile were normal. An abdominal ultrasound scan and CT with enteroclysis were noncontributory. Upon retroflexion in the rectum during colonoscopy, a 1-cm raised lesion (Paris classification 2a) was noted approximately 1 cm from the dentate line (from which tissue was taken for a biopsy) (A, B). Histology from the rectal lesion showed a fragment of colonic mucosa with gastric specialized mucosa consistent with gastric heterotopia in the rectum (C). A Meckel’s 190 GASTROINTESTINAL ENDOSCOPY
Volume 72, No. 1 : 2010
nuclear scan showed uptake in the rectum that persisted at 65 minutes, but no evidence of Meckel’s diverticulum (D). Endoscopic mucosal resection of this lesion was performed and the resection margins were treated by argon plasma coagulation.
DISCLOSURE All authors disclosed no financial relationships relevant to this publication. Jimmy K. Limdi, MBBS, MRCP (London), FRCP (Edinborough), Consultant Gastroenterologist, Milan Sapundzieski, MD, FRCR, Consultant Radiologist, Ranjani Chakravarthy, MD, MRCPath, Consultant Pathologist, Regi George, MD, FRCP, Consultant Gastroenterologist, The Pennine Acute Hospital NHS Trust, BL9 7TD Manchester, UK doi:10.1016/j.gie.2010.01.045
www.giejournal.org
An interesting case of iron deficiency anemia
A 71-year-old man presented with new onset iron deficiency anemia and intermittent tarry stools. Routine upper endoscopy and colonoscopy were unremarkable. His medical history included Agent Orange exposure while serving in the armed forces in Vietnam and, subsequently, liposarcomas of the retroperitoneum and groin that had required multiple surgical resections. His second resection of a recurrent retroperitoneal liposarcoma was complicated by an abdominal abscess with a resultant small bowel resection and the need to allow the abdominal wound to close by secondary intent, leaving an abdominal wall defect. His medical history was further complicated by ischemic cardiomyopathy, with an ejection fraction of 15%, and recent placement of an automatic implantable cardioverter-defibrillator for which he was taking aspirin and clopidogrel. An upper GI and small bowel follow through was unremarkable, and he was admitted for video-capsule endoscopy. This study revealed a large subwww.giejournal.org
mucosal lesion with superficial ulceration in the distal small bowel (A). CT enteroclysis was performed to further localize the lesion and revealed a large filling defect in the distal jejunum (B). A 6-cm mass was resected (C), with pathology that showed a liposarcoma (D). DISCLOSURE All authors disclosed no financial relationships relevant to this publication. Jonathan M. Ricker, DO, Department of Gastroenterology and Hepatology, Derek A. Mathis, MD, Department of Pathology, Wilford Hall Medical Center, Lackland Air Force Base, Texas, Hays L. Arnold, MD, Brooke Army Medical Center, Department of Gastroenterology and Hepatology, Fort Sam Houston, Texas, USA doi:10.1016/j.gie.2010.01.038
Volume 72, No. 1 : 2010 GASTROINTESTINAL ENDOSCOPY
189
At the Focal Point
Commentary During the Vietnam war, the United States military used Agent Orange as a chemical defoliant. Agent Orange was given its name from the color of the 55-gallon orange-striped barrels it was shipped in. Agent orange is a mixture of two phenoxyl herbicides (2,4-dichlorophenoxyacetic acid [2,4-D] and 2,4,5 trichlorophenoxyacetic acid [2,4,5-T]). In addition, it contains a byproduct of 2,4,5-T which is a dioxin (2,3,7,8-tetrachlorobenzodioxin [TYCDD]) that is known to be a carcinogen. Diseases recognized by the U.S. Department of Veterans Affairs to be associated with Agent Orange, and thus rendering such affected individuals eligible for disability compensation and health care benefits, include soft tissue sarcoma, Hodgkin and nonHodgkin lymphoma, B-cell leukemia, chronic lymphocytic leukemia, multiple myeloma, and cancers of the lung, tracheobronchial tree, larynx, prostate, and amyloidosis, Parkinson disease, and diabetes mellitus. Fusion or chimeric proteins are key components of mesenchymal cancer development and the most common fusion gene associated with liposarcoma is FUSCHOP, which encodes a transcription factor necessary for adipocyte differentiation. Could this abnormality have been induced by Agent Orange? Regardless, liposarcoma is the most common soft tissue sarcoma in adults. First described by Virchow in the 1860s, it usually presents as a slowly enlarging abdomen without pain or bleeding in a middle-aged man and on evaluation may be seen to be a very large mass, sometimes weighing several pounds. Anatomic distribution, and to some extent prognosis, is related to histologic type of which there are five: well-differentiated, (adipocytic, sclerosing, and inflammatory subtypes), dedifferentiated, myxoid, round cell, and pleomorphic. It is the well-differentiated and dedifferentiated liposarcomas that tend to occur in the retroperitoneum. Although they rarely metastasize, repeated local recurrences may cause the tumor to evolve into a higher grade of sarcoma or to dedifferentiate, in which case metastasis may occur. Treatment was surgical now, but perhaps he would not have had this lesion were he not to have come in contact with Agent Orange. The writing of Rachel Carson in the classic, Silent Spring, seems appropriate: . . . These sprays, dusts, and aerosols are now applied almost universally to farms, gardens, forests, and homes—nonselective chemicals that have the power to kill every insect, the “good” and the “bad,” to still the song of birds and the leaping of fish in the streams, to coat the leaves with a deadly film, and to linger on in soil—all this though the intended target may be only a few weeds or insects. Can anyone believe it is possible to lay down such a barrage of poisons on the surface of the earth without making it unfit for all life? They should not be called “insecticides,” but “biocides.” Lawrence J. Brandt, MD Associate Editor for Focal Points
Gastric heterotopia in the rectum A 36-year-old woman was referred to the gastroenterology service for evaluation of a 5-year history of dull, aching, lower abdominal discomfort unaccompanied by diarrhea or constipation and without aggravating or relieving factors. Review of systems and medical history were otherwise unremarkable with the exception of a caesarean section performed 10 years previously. Six years later, she had a diagnostic laparoscopy to investigate lower abdominal pain; no abnormalities were found. She subsequently had an intrauterine coil inserted. Physical examination, complete blood count, and biochemical profile were normal. An abdominal ultrasound scan and CT with enteroclysis were noncontributory. Upon retroflexion in the rectum during colonoscopy, a 1-cm raised lesion (Paris classification 2a) was noted approximately 1 cm from the dentate line (from which tissue was taken for a biopsy) (A, B). Histology from the rectal lesion showed a fragment of colonic mucosa with gastric specialized mucosa consistent with gastric heterotopia in the rectum (C). A Meckel’s 190 GASTROINTESTINAL ENDOSCOPY
Volume 72, No. 1 : 2010
nuclear scan showed uptake in the rectum that persisted at 65 minutes, but no evidence of Meckel’s diverticulum (D). Endoscopic mucosal resection of this lesion was performed and the resection margins were treated by argon plasma coagulation.
DISCLOSURE All authors disclosed no financial relationships relevant to this publication. Jimmy K. Limdi, MBBS, MRCP (London), FRCP (Edinborough), Consultant Gastroenterologist, Milan Sapundzieski, MD, FRCR, Consultant Radiologist, Ranjani Chakravarthy, MD, MRCPath, Consultant Pathologist, Regi George, MD, FRCP, Consultant Gastroenterologist, The Pennine Acute Hospital NHS Trust, BL9 7TD Manchester, UK doi:10.1016/j.gie.2010.01.045
www.giejournal.org