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Don't Blame It on the Scar Tissue
Clinical Challenges and Images in GI, continued Don’t Blame It on the Scar Tissue Javier F. Rosales,1 Xochiquetzal J. Geiger,2 and Victoria Gómez1 1
Division of Gastroenterology, and 2Department of Pathology, Mayo Clinic, Jacksonville, Florida
Question: A 61-year-old white woman was evaluated for complaints of intermittent attacks of a sharp, severe, periumbilical abdominal pain for 15 years with recent worsening in severity and nocturnal episodes. Her symptoms were partially alleviated by bowel movements and no worsening factors were identified. Her past medical history was significant for a total hysterectomy and adhesiolysis. Physical examination revealed prior surgical incisions over the abdominal wall and otherwise benign on examination. She denied fever, nausea, vomiting, painful adenopathy, weight loss, night sweats, recent infectious exposures, or foreign travels. Laboratory studies, including a complete blood cell count with white blood cell differential, renal profile, hepatic transaminases, erythrocyte sedimentation rate, serum electrophoresis, and 5-hydroxyindoleacetic acid levels, were negative or within normal values. Esophagogastroduodenoscopy and colonoscopy were unremarkable. A tuberculin purified protein derivative test was negative as was computed tomography (CT) of the chest. CT enterography (Figure A) showed enlarged mesenteric lymph nodes in the right mid abdomen (arrows). Capsule endoscopy and upper and lower double balloon enteroscopy with complete visualization of the entire small bowel lumen were unremarkable. Because of persistent symptoms, follow-up CT enterography was performed 8 weeks later and showed interval increase in the size of the conglomerate lymph nodes masses in the right side of the mesenteric fat, as well as cicatricial changes involving loops of bowel adjacent to the mesenteric masses. CT-guided fine-needle aspiration biopsy was performed. What is the diagnosis? Look on page 914 for the answer and see the GASTROENTEROLOGY web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. Conflicts of interest: The authors disclose no conflicts. © 2013 by the AGA Institute 0016-5085/$36.00 http://dx.doi.org/10.1053/j.gastro.2013.07.008
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been pressed between the endoscope shaft and hard palate (or against the posterior pharynx), causing pressure necrosis, an injury described in earlier reports.2,3 Oropharyngeal suction may also have played a role.2 Suction devices have sufficient negative pressure to result in the tip of the uvula being pulled into the suction tip. Necrosis of the uvula usually causes sore throat and odynophagia; management is supportive. For our patient, we used benzocaine for pain and sucralfate solution (1 g/10 mL) to promote healing. The larynx was found normal by an otolaryngologist who agreed with conservative management. A literature review of 11 patients with iatrogenic uvular injury (7 from upper endoscopies, 4 from endotracheal intubation) indicates that treatment with a topical anesthetic is sufficient and antimicrobials are usually unnecessary.2,3 Uvular necrosis has a good clinical outcome when inflammation subsides and the necrotic uvular tip sloughs off. Recovery is usually complete in 5–14 days.2 Our patient had complete resolution of pain and dysphagia at day 12, when the uvula again looked normal (Figure C). References 1. Bonder A, Sullivan MF, Gonzalez A, et al. Obliteration of symptomatic Schatzki’s ring with jumbo biopsy forceps. American College of Gastroenterology Abstract; 2011. 2. Tang SJ, Kanwal F, Gralnek IM. Uvular necrosis after endoscopy: a case report and review of the literature. Endoscopy 2002; 34:585–587. 3. Shores NJ, Bloomfeld RS. Images in clinical medicine: uvular necrosis after upper endoscopy. N Engl J Med 2009;361:e20. For submission instructions, please see the GASTROENTEROLOGY web site (www.gastrojournal.org).
Answer to the Clinical Challenges and Images in GI Question: Image 3 (page 728): Sclerosing Mesenteritis Fine-needle aspiration showed fat necrosis (arrow) with surrounding fibroblastic proliferation, dense fibrosis and admixed inflammatory infiltrate (Figure B, medium power). A high power image (Figure C) demonstrated inflammatory cells consisting of mononuclear leukocytes, histiocytes, and scattered plasma cells with background of bland fibroblasts and fibrosis. There was no evidence of malignant cells, lymphoma, or carcinoma. These findings were most consistent with a diagnosis of sclerosing mesenteritis (SM). First described in the 1920s, SM is a rare, idiopathic, nonmalignant inflammatory disease that generally affects the small bowel mesentery.1 The etiology is unknown and has been linked with a medical history of abdominal surgeries, trauma, paraneoplastic syndrome, and autoimmunity.2 SM is part of a spectrum of an inflammatory process of the mesentery that may manifest at different stages, including fat necrosis (lipodystrophy), chronic tissue inflammation (mesenteric panniculitis), and fibrosis (SM).2 Affecting men more than women (2:1) in the fifth to seventh decades of life, its nonspecific presenting symptoms represent a diagnostic challenge for physicians.3 Diagnosing SM includes the use of laboratory and imaging tests, with CT of the abdomen and pelvis being the most sensitive and useful, showing a soft tissue mass in the small bowel mesentery. However, the gold standard is biopsy.2 When concerning signs are present (eg, weight loss, anemia or night sweats), further workup is recommended to rule out a lymphoproliferative disorder.1 Thirty percent of patients may present with intra-abdominal malignancies, the majority being lymphoma.1
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Treatment is offered to symptomatic patients. A regimen of tamoxifen and glucocorticoids has been described, as well as use of other anti-inflammatory, immunomodulatory, and antifibrotic agents; bowel obstruction is treated with surgery.1 The patient was placed on a prednisone taper and started on tamoxifen 10 mg twice daily. Within 3 weeks, the intermittent abdominal pain attacks resolved completely and she continues to remain asymptomatic. References 1. Akram S, Pardi DS, Schaffner JA, et al. Sclerosing mesenteritis: clinical features, treatment, and outcome in ninety-two patients. Clin Gastroenterol Hepatol 2007;5:589–596. 2. Emory TS, Monihan JM, Carr NJ, et al. Sclerosing mesenteritis, mesenteric panniculitis and mesenteric lipodystrophy: a single entity? Am J Surg Pathol 1997;21:392–398. 3. Avelino-Silva VI, Leal FE, Coelho-Netto C, et al. Sclerosing mesenteritis as an unusual cause of fever of unknown origin: a case report and review. Clinics (Sao Paulo) 2012;67:293–295. For submission instructions, please see the GASTROENTEROLOGY web site (www.gastrojournal.org).
Answer to the Clinical Challenges and Images in GI Question: Image 4 (page 729): Inverted Meckel’s Diverticulum The images reveal the presence of an inverted Meckel’s diverticulum, although this diagnosis was not recognized preoperatively in this case. Although rare, inverted Meckel’s diverticulum has been reported in the literature.1 It can present as bleeding because of the presence of either ectopic gastric mucosa, trauma, or inversion-induced ischaemia.1 Abdominal radiographic imaging including computed tomography is usually nonspecific unless the patient has intestinal obstruction or intussusception; however, 1 case reported a positive preoperative diagnosis using MRI.2 It can appear as a smooth intraluminal mass or a pedunculated polyp.3 Treatment is surgical excision and is curative. It was initially felt that the findings at MRI (Figure B, arrow) and SBCE (Figure A) were consistent with a small bowel tumor and he underwent a laparoscopic small bowel resection of the lesion (midileum). The histology, however, confirmed the presence of an inverted Meckel’s diverticulum. Figure C shows a transverse cross-section through the Meckel’s diverticulum demonstrating periintestinal fat and covering inverted bowel wall.
Supplementary Material Note: To access the supplementary material accompanying this article, visit the online version of Gastroenterology at www. gastrojournal.org, and at http://dx.doi.org/10.1053/j.gastro.2013.07.005. References 1. Rashid OM, Ku JK, Nagahashi M, et al. Inverted Meckel’s diverticulum as a cause of occult lower gastrointestinal haemorrhage. World J Gastroenterol 2012;18:6155–6159. 2. Dujardin M, Op de Beek B, Osteaux M. Inverted Meckel’s diverticulum as a leading point ileoileal intussusception in an adult: case report. Abdominal Imaging 2002;27:563–565. 3. Levy AD, Hobbs CM. Meckel diverticulum: radiologic features with pathologic correlation. Radiographs 2004;24:565–587. For submission instructions, please see the GASTROENTEROLOGY web site (www.gastrojournal.org).
Division of Gastroenterology, and 2Department of Pathology, Mayo Clinic, Jacksonville, Florida
Question: A 61-year-old white woman was evaluated for complaints of intermittent attacks of a sharp, severe, periumbilical abdominal pain for 15 years with recent worsening in severity and nocturnal episodes. Her symptoms were partially alleviated by bowel movements and no worsening factors were identified. Her past medical history was significant for a total hysterectomy and adhesiolysis. Physical examination revealed prior surgical incisions over the abdominal wall and otherwise benign on examination. She denied fever, nausea, vomiting, painful adenopathy, weight loss, night sweats, recent infectious exposures, or foreign travels. Laboratory studies, including a complete blood cell count with white blood cell differential, renal profile, hepatic transaminases, erythrocyte sedimentation rate, serum electrophoresis, and 5-hydroxyindoleacetic acid levels, were negative or within normal values. Esophagogastroduodenoscopy and colonoscopy were unremarkable. A tuberculin purified protein derivative test was negative as was computed tomography (CT) of the chest. CT enterography (Figure A) showed enlarged mesenteric lymph nodes in the right mid abdomen (arrows). Capsule endoscopy and upper and lower double balloon enteroscopy with complete visualization of the entire small bowel lumen were unremarkable. Because of persistent symptoms, follow-up CT enterography was performed 8 weeks later and showed interval increase in the size of the conglomerate lymph nodes masses in the right side of the mesenteric fat, as well as cicatricial changes involving loops of bowel adjacent to the mesenteric masses. CT-guided fine-needle aspiration biopsy was performed. What is the diagnosis? Look on page 914 for the answer and see the GASTROENTEROLOGY web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. Conflicts of interest: The authors disclose no conflicts. © 2013 by the AGA Institute 0016-5085/$36.00 http://dx.doi.org/10.1053/j.gastro.2013.07.008
728
October 2013
CLINICAL CHALLENGES AND IMAGES IN GI 914
been pressed between the endoscope shaft and hard palate (or against the posterior pharynx), causing pressure necrosis, an injury described in earlier reports.2,3 Oropharyngeal suction may also have played a role.2 Suction devices have sufficient negative pressure to result in the tip of the uvula being pulled into the suction tip. Necrosis of the uvula usually causes sore throat and odynophagia; management is supportive. For our patient, we used benzocaine for pain and sucralfate solution (1 g/10 mL) to promote healing. The larynx was found normal by an otolaryngologist who agreed with conservative management. A literature review of 11 patients with iatrogenic uvular injury (7 from upper endoscopies, 4 from endotracheal intubation) indicates that treatment with a topical anesthetic is sufficient and antimicrobials are usually unnecessary.2,3 Uvular necrosis has a good clinical outcome when inflammation subsides and the necrotic uvular tip sloughs off. Recovery is usually complete in 5–14 days.2 Our patient had complete resolution of pain and dysphagia at day 12, when the uvula again looked normal (Figure C). References 1. Bonder A, Sullivan MF, Gonzalez A, et al. Obliteration of symptomatic Schatzki’s ring with jumbo biopsy forceps. American College of Gastroenterology Abstract; 2011. 2. Tang SJ, Kanwal F, Gralnek IM. Uvular necrosis after endoscopy: a case report and review of the literature. Endoscopy 2002; 34:585–587. 3. Shores NJ, Bloomfeld RS. Images in clinical medicine: uvular necrosis after upper endoscopy. N Engl J Med 2009;361:e20. For submission instructions, please see the GASTROENTEROLOGY web site (www.gastrojournal.org).
Answer to the Clinical Challenges and Images in GI Question: Image 3 (page 728): Sclerosing Mesenteritis Fine-needle aspiration showed fat necrosis (arrow) with surrounding fibroblastic proliferation, dense fibrosis and admixed inflammatory infiltrate (Figure B, medium power). A high power image (Figure C) demonstrated inflammatory cells consisting of mononuclear leukocytes, histiocytes, and scattered plasma cells with background of bland fibroblasts and fibrosis. There was no evidence of malignant cells, lymphoma, or carcinoma. These findings were most consistent with a diagnosis of sclerosing mesenteritis (SM). First described in the 1920s, SM is a rare, idiopathic, nonmalignant inflammatory disease that generally affects the small bowel mesentery.1 The etiology is unknown and has been linked with a medical history of abdominal surgeries, trauma, paraneoplastic syndrome, and autoimmunity.2 SM is part of a spectrum of an inflammatory process of the mesentery that may manifest at different stages, including fat necrosis (lipodystrophy), chronic tissue inflammation (mesenteric panniculitis), and fibrosis (SM).2 Affecting men more than women (2:1) in the fifth to seventh decades of life, its nonspecific presenting symptoms represent a diagnostic challenge for physicians.3 Diagnosing SM includes the use of laboratory and imaging tests, with CT of the abdomen and pelvis being the most sensitive and useful, showing a soft tissue mass in the small bowel mesentery. However, the gold standard is biopsy.2 When concerning signs are present (eg, weight loss, anemia or night sweats), further workup is recommended to rule out a lymphoproliferative disorder.1 Thirty percent of patients may present with intra-abdominal malignancies, the majority being lymphoma.1
915
CLINICAL CHALLENGES AND IMAGES IN GI
GASTROENTEROLOGY Vol. 145, No. 4
Treatment is offered to symptomatic patients. A regimen of tamoxifen and glucocorticoids has been described, as well as use of other anti-inflammatory, immunomodulatory, and antifibrotic agents; bowel obstruction is treated with surgery.1 The patient was placed on a prednisone taper and started on tamoxifen 10 mg twice daily. Within 3 weeks, the intermittent abdominal pain attacks resolved completely and she continues to remain asymptomatic. References 1. Akram S, Pardi DS, Schaffner JA, et al. Sclerosing mesenteritis: clinical features, treatment, and outcome in ninety-two patients. Clin Gastroenterol Hepatol 2007;5:589–596. 2. Emory TS, Monihan JM, Carr NJ, et al. Sclerosing mesenteritis, mesenteric panniculitis and mesenteric lipodystrophy: a single entity? Am J Surg Pathol 1997;21:392–398. 3. Avelino-Silva VI, Leal FE, Coelho-Netto C, et al. Sclerosing mesenteritis as an unusual cause of fever of unknown origin: a case report and review. Clinics (Sao Paulo) 2012;67:293–295. For submission instructions, please see the GASTROENTEROLOGY web site (www.gastrojournal.org).
Answer to the Clinical Challenges and Images in GI Question: Image 4 (page 729): Inverted Meckel’s Diverticulum The images reveal the presence of an inverted Meckel’s diverticulum, although this diagnosis was not recognized preoperatively in this case. Although rare, inverted Meckel’s diverticulum has been reported in the literature.1 It can present as bleeding because of the presence of either ectopic gastric mucosa, trauma, or inversion-induced ischaemia.1 Abdominal radiographic imaging including computed tomography is usually nonspecific unless the patient has intestinal obstruction or intussusception; however, 1 case reported a positive preoperative diagnosis using MRI.2 It can appear as a smooth intraluminal mass or a pedunculated polyp.3 Treatment is surgical excision and is curative. It was initially felt that the findings at MRI (Figure B, arrow) and SBCE (Figure A) were consistent with a small bowel tumor and he underwent a laparoscopic small bowel resection of the lesion (midileum). The histology, however, confirmed the presence of an inverted Meckel’s diverticulum. Figure C shows a transverse cross-section through the Meckel’s diverticulum demonstrating periintestinal fat and covering inverted bowel wall.
Supplementary Material Note: To access the supplementary material accompanying this article, visit the online version of Gastroenterology at www. gastrojournal.org, and at http://dx.doi.org/10.1053/j.gastro.2013.07.005. References 1. Rashid OM, Ku JK, Nagahashi M, et al. Inverted Meckel’s diverticulum as a cause of occult lower gastrointestinal haemorrhage. World J Gastroenterol 2012;18:6155–6159. 2. Dujardin M, Op de Beek B, Osteaux M. Inverted Meckel’s diverticulum as a leading point ileoileal intussusception in an adult: case report. Abdominal Imaging 2002;27:563–565. 3. Levy AD, Hobbs CM. Meckel diverticulum: radiologic features with pathologic correlation. Radiographs 2004;24:565–587. For submission instructions, please see the GASTROENTEROLOGY web site (www.gastrojournal.org).