Pancreatic Cancer: The Use of Endosonography

Endoscopy in Crohn’s Disease
By:Peter Darwin, MD
Director of Gastrointestinal Endoscopy
University of Maryland Hospital
Division of Gastroenterology

Outline
* Case histories
* Diagnosis
* Assessment of response
* Dysplasia and surveillance
* Bleeding
* Stricture management
* Emerging technology

Case 1
Case 2

Diagnosis

* Asymmetric patchy inflammation
* Skip lesions
* Rectal sparring
* Ulcerations
* Biopsy
o Erosions and normal mucosa
o Granulomas in 15 to 35% of specimens

Assessment of Response
* Endoscopic monitoring may have a role with biologic agents
* Subgroup of the ACCENT-1 trial
o Mucosal healing with infliximab, time to relapse is significantly prolonged
+ 9 with endoscopic healing remained in remission for a median of 20 weeks
+ 4 clinical remission only, relapse after a median of 4 weeks


Dysplasia and Surveillance
* Extensive colitis > 8 years
* Accuracy in predicting dysplasia correlates with # of biopsies
* Annual colonoscopy with multiple biopsy specimens
o 4 circumferential each 10 cm


Approach to Polypoid Lesions
Adenoma like DALM
Outside colitis
Within colitis
Polypectomy/biopsy
Non-IBD
adenoma
Polypectomy
Regular surveillance
No dysplasia
No carcinoma
Indeterminate
Flat dysplasia
carcinoma
Polypectomy
Increased surveillance
Colectomy

Chawla A, Lichtenstein G. Gastrointest Endoscopy Clin N Am 12 (2002) 525-534

Hemorrhage in Crohn’s

* Acute major hemorrhage is uncommon
* Bleeding can occur in any segment
* Massive hemorrhage is usually from an ulcer eroding into a vessel
* Resuscitation
* Endoscopy vs tagged RBC scan to localize a bleeding segment
* Avoid embolization if possible

Hemorrhage in Crohn’s
* No data to support cautery or injection therapy
* Surgical intervention
* Consider tattooing of the site


* Database review from 1989 to 1996
o 1739 patients / 31 (1.8%) due to IBD
o 3 with UC and 28 with CD / 1 UGI source
o None hematemesis
o GI hemorrhage in 0.1% UC and 1.2% CD
* Diagnostic evaluation
o Source found by colonoscopy in 25 patients (25%) and EGD in 2 patients


Pardi D, Loftus E, et al. Gastrointest Endosc 1999;49:153-7.

Acute Major GI hemorrhage in IBD

Endoscopic Therapy for Patients with CD and Focal Sites of hemorrhage
Patient Site Stigmata Endoscopic Rx Medical Rx

1 Duodenum clot Injection Corticosteroids ranitidine

2 Jejunum oozing ulcer Injection Corticosteroids ranitidine

3 Colon clot Injection with Corticosteroids

coagulation metronidazole


Clinical Course
Balloon Dilation of Strictures


Descending Colon Stricture

Colonic Strictures
* No randomized clinical trials
* Consider nonsurgical management if:
o Endoscopically accessible
o Multiple prior resections
o Shorter strictures (less than 5 cm)
o Steroid injection if significant inflammation

Malignant Potential
* Increased incidence of colonic and small bowel carcinoma
* Higher risk with longer duration of disease
* Stricture biopsy required
* Utilize thin caliper scopes to evaluate proximal to the stenosis


Balloon Dilation of Strictures
* High success rate for anastamotic strictures
* Used for colonic and duodenal stenosis
* TTS balloons 15 to 18 mm for 1 minute
* Fluoroscopy only if needed
* Successful if scope passed post
* Medical treatment
* Complications

Injection of Corticosteroids
* Post dilation
* Sclerotherapy needle
* Triamcinolone 40 mg/ml – 1 cc in 4 quadrants at site of maximal inflammation/stenosis

Intestinal Stents
* Limited data
* Migration is common
* Coated metal enteral stents / plastic stents may be of benefit

Endoscopic Balloon Dilation of Ileal Pouch Strictures

* Aim: evaluate outpatient ileal pouch stricture dilation
* Methods: Nonfluroscopy, nonsedated dilation with 11-18 mm TTS balloons in 19 consecutive patients

Shen B, Fazio V, Remzi F, et al. Am J Gastro 2004;99:2340-47.


Inlet and Outlet Strictures

Clinical Presentation
n (%)
Diarrhea
Abdominal pain
Perianal pain
Bloating
Nausea or vomiting
Bleeding
Daily use of antidiarrheal agents
Fistulas
Weight loss

Types of Strictures
Number Inlet Outlet of cases strictures strictures
Crohn’s disease of the pouch Cuffitis
Pouchitis

Total
Pouch Disease Activity Index

Strictures Scores
Cleveland Global Quality of Life Scores

Emerging Technology

* Double balloon enteroscopy
* Endoscopic ultrasound
* Optical coherence tomography
* Magnification chromoendoscopy


Takayuki Matsumoto, Tomohiko Moriyama, et. al.
Gastrointest Endosc 2005;62 :392-8


Optical Coherence Tomography
* Based on low-coherence

interferometry
* High resolution imaging
* Uses light (not sound)
* Resolution 10X greater than EUS
* No acoustic coupling

Magnification Chromoendoscopy
* Utilizes magnifying endoscopes with tissue stains to better characterize the mucosa
* May improve efficacy of surveillance colonoscopy
o 165 patients with UC randomized to conventional screening vs CE.
o Targeted biopsies
o Identified more areas of dysplasia

Kiesslich R, Fritch J, et. al. Gastro 2002;124:880-8.

Colonic Pit Pattern
Huang Q, Norio F, et. al. Gastrointest Endosc 2004; 60:520-6.

Case 1

* The patient is a 28 year old man with isolated iliocolonic Crohn’s disease resected 8 years prior.
* Was without symptoms but has developed intermittent abdominal distension, bloating and emesis requiring admission.
* SBFT shows a 1 cm tight anastamotic stenosis
* Is attempt at endoscopic management appropriate?

Case 2

* 19 year old student presents with several months of vague epigastic discomfort, night sweats and weight loss.
* Evaluation shows a microcytic anemia and thrombocytosis.
* Abdominal CT shows a thickened mid-ileum without lymphadenopathy. Attempts to intubate the TI during colonoscopy were unsuccessful.
* Is tissue needed prior to treatment ?

Pancreatic Cancer: The Use of Endosonography

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Myasthenia Gravis

Myasthenia Gravis
By:
* Cathie Rohleder
* Sydnee Jacobson
* Ashley Cox

Pathology
* A chronic Autoimmune Disease
* Affects the Neuromuscular junction
* Postsynaptic acetylcholine receptors on muscle cells plasma membrane are no longer recognized as ‘self’ and elicit the generation of auto antibodies.
* IgG antibody is produced against the acetylcholine receptors and fixes to receptor sites, blocking the binding of acetylcholine.
* Diminished transmission and lack of muscular depolarization results.
* Several Types of Myasthenia Gravis
o Neonatal Myasthenia Gravis: A transient condition in 10% to 15% of infants born to mothers with MG.
o Congenital Myasthenia
o Juvenile Myasthenia: Onset is around 10 years of age.
o Ocular Myasthenia
o Generalized Autoimmune Myasthenia

Clinical Manifestations
* Insidious onset
o May first appear during pregnancy, during the postpartum period, or in combination with the administration of anesthetic agents.
* Complaints
o Most individuals complain of fatigue and progressive weakness.
o The person usually has a history of frequent respiratory tract infections.
* Muscles affected
o First muscles affected
+ Muscles of the eyes, mouth, face, throat and neck.
+ The most affected muscles are the extra ocular (eye) muscles and levator muscles.
o Second most affected muscles
+ Muscles of mastication, swallowing, facial expression, and speech.
o Less frequently affected muscles
+ Neck, shoulder girdle, and hip flexors
o All muscles are weak in the advanced stage of the disease.
* Other occurrences
o Myasthenic Crisis happens when extreme muscle weakness causes quadriparesis or quadriplegia, difficulty swallowing, and shortness of breath. A person in this state is in danger of respiratory arrest.
o Cholinergic Crisis occurs from anticholinesterase drug toxicity. This is similar to Myasthenic Crisis, but also includes increased intestinal motility with diarrhea and complaints of cramping, fasciculation, bradycardia, constriction of the pupils, increased salvation, and sweating. A person in this state may also be in danger of respiratory arrest.

Treatment
* Surgery
o Thymectomy: removal of the thymus gland
o A tumor is usually present in the thymus gland

* Medication
o Cholinesterase inhibitors
+ These include neostigmine and pyridostigmine
+ Helps improve neuromuscular transmission and increase muscle strength
o Immunosuppressive drugs
+ These include prednisone, cyclosporine, and azathioprine
+ Improves muscle strength by suppressing the production of abnormal antibodies
o Corticosteroids
+ Inhibits the immune system
+ Limits antibody production.
* Plasmapheresis
o remove abnormal antibodies from the blood
o Used for more serious conditions.
o Benefits last around a few weeks
* High-dose of Intravenous Immune Globulin (IVIG)
o Modifies immune system temporarily
o Provides the body with normal antibodies from donated blood
o Less risk of side effects
o Benefits last 1-2 months and takes a couple weeks to start working

Treatment
* One or more of the treatments may be used to alleviate symptoms caused by Myasthenia Gravis

Resources
Myasthenia Gravis.ppt

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MYASTHENIA GRAVIS

MYASTHENIA GRAVIS
By Terra Cunningham

DEFINITION
* “A disorder of neuromuscular function thought to be due to the presence of antibodies to acetylcholine receptors at the neuromuscular junction”3

DISCOVERED IN
* First described in 1672 by Thomas Willis and later described in 1890 by German physicians, Samuel Goldflam, Wilhelm Erb, and Friedrich Jolly.

SYMPTOMS
* Drooping of the eyelids
* Double vision
* Difficulty smiling, speaking, swallowing
* Difficulty raising the arms
* Difficulty walking
* Difficulty breathing if chest muscle are affected

CAUSE
* The cause is unknown
* “Antibodies act against the acetylcholine receptor making a nerve come in contact with the muscle. The nerve cell conveys its message to tell the muscle to contract. The antibodies interfere with the message and the muscle contracts less efficiently. Resulting in the weakness of the arms or legs or of the muscles of the head.”4

PREVALENCE
* Today there are an estimated 50,000 cases in the United States
* Myasthenia Gravis can be found in anyone, but it is “most common in females around the third decade of life”1

TREATMENT
* Symptomatic treatment: medications that enhance the function of the acetylcholine system at the neuromuscular junction.
* Medications include – Prostigmin, Mestinon, Mytelase, Tensilon
* Long range treatment is thymectomy.
* Thymectomy is the surgical removal of the thymus gland that lies behind the breastbone and overlies the heart.

Lifestyles
* A person with Myasthenia Gravis can lead a normal life if the medications are taken in the correct dosages and at the right time of the day.

References
* Collier’s Encyclopedia with Bibliography and Index, 1988, volume 17.,Macmillan
* Dictionary of Medical Syndromes, 3rd edition, Magalini
* Dorland's Illustrated Medical Dictionary, 26th edition, 1985, Saunders
* Encyclopedia Americana, 1993, volume 19., Grolier
* The Medical and Health Encyclopedia, volume 1., Southwestern Company

MYASTHENIA GRAVIS.ppt

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