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Late Metastatic Renal Cell Carcinoma Diagnosed by Abdominal Pain and Endoscopy: A Case Report [Meeting Abstract]

Udaikumar, J; Krishnaiah, M; Serouya, S
Introduction: Metastases to the stomach from various primary malignancies is rare. Renal cell carcinoma (RCC) metastasis to the stomach is even more uncommon and should be suspected in patients complaining of the slightest of gastrointestinal symptoms. Here, we explore a rare case of gastric metastases from RCC, eleven years after radical nephrectomy diagnosed by endoscopy. Case Description/Methods: We report the case of a 71-year-old Hispanic female, medical history pertinent for RCC and left nephrectomy, who presented with persistent left lower quadrant abdominal pain and normal bloodwork. Repeat imaging reveals a gastric mass, unseen on CT scans 3 weeks prior (Figure a). Endoscopy (Figure b), histopathological findings, and immunohistochemical staining (Figure c) were consistent with metastatic RCC. Given the poor prognosis, patient chose to undergo targeted systemic chemotherapy.
Discussion(s): In the past two decades, there have been a limited number of case reports in the literature of RCC metastatic to the stomach (Table) Although gastric metastasis is a late finding in the course of renal malignancy, detection can come from a thorough evaluation of presenting symptoms followed by appropriate diagnostic imaging. Additionally, this case also emphasizes the need for targeted treatment modalities for patients with poor prognoses
EMBASE:641284147
ISSN: 1572-0241
CID: 5515372

An unusual cause of abdominal pain: Lupus enteritis as the sole presenting feature of systemic lupus erythematosus [Meeting Abstract]

Talati, R; Pineles, D; Krishnaiah, M; Goodman, A
LEARNING OBJECTIVE #1: Recognize the nonspecific clinical features of lupus enteritis as a rare but serious manifestation of SLE CASE: A 32 year old Asian female presented to clinic complaining of three days of abdominal pain and nausea. Her past medical history was notable for arthritis, H. pylori gastritis, chronic GERD, nephrolithiasis and migraine headaches. She was instructed to continue Nexium for presumptive dyspepsia management. She presented eight days later to the Emergency Room complaining of intractable epigastric abdominal pain. Vital signs were unremarkable. Exam was remarkable for significant lower abdominal tenderness without guarding or rigidity. CT abdomen/pelvis revealed mild right hydronephrosis and hydroureter with surrounding inflammatory changes. A pain regimen was initiated and patient was discharged with a presumptive diagnosis of passed ureteral stone. In the following three weeks she received multiple courses of amoxicillin for positive urine cultures thought to be contributing to abdominal pain without significant response. One month later she began experiencing daily, loose, non-bloody bowel movements. Outpatient EGD was notable only for gastritis. Symptomology persisted and a unifying diagnosis was not retained. Patient re-presented with similar pain three months later and was again admitted. Repeat CT imaging revealed a long segment of small bowel wall thickening not previously present. Infectious work up was unrevealing, however patient improved on a prolonged course of empiric ciprofloxacin/metronidazole. Patient was re-admitted two months later with recurrence of abdominal pain. CT imaging re-demonstrated proximal small bowel wall thickening. Push enteroscopy with biopsy was performed and unremarkable. Index of suspicion at that point prompted rheumatology work up. ANA was positive (>640, speckled). Serum C3 and C4 were low (48; 11 mg/dL), dsDNA and RNP were elevated (12 IU/mL; 1.8 AI). She was started on plaquenil and prednisone as an outpatient with improvement in her symptoms. IMPACT/DISCUSSION: Lupus enteritis is a rare manifestation of SLE. Few reports describe enteritis as the sole presentation in relapse or active disease, and rarely has it been reported as the initial presentation. This case highlights the challenge in a young, complex female with chronic, intermittent non-specific complaints 20 months after initial symptom onset. This case also highlights the importance of avoiding anchoring bias. The absence of pathognomonic imaging findings and unremarkable endoscopic biopsy findings led to multiple misdiagnoses and a delayed diagnosis. In this case, nonresolution of symptoms led to additional history and diagnostic evaluation that ultimately led to an accurate assessment.
CONCLUSION(S): Diagnosis of lupus enteritis requires a high index of suspicion given the low incidence and nonspecific clinical findings The treatment of lupus enteritis relies on complete bowel rest and steroid treatment, usually with complete remission
EMBASE:633957226
ISSN: 1525-1497
CID: 4803332

Plummer-Vinson Syndrome with Proximal Esophageal Web

Changela, Kinesh; Haeri, Nami Safai; Krishnaiah, Mahesh; Reddy, Madhavi
Plummer-Vinson Syndrome is a condition where iron deficiency is associated with difficulty swallowing due to the presence of an esophageal web. Deficiency of iron-dependent oxidative enzymes causes gradual degradation of the pharyngeal muscles which lead to mucosal atrophy and formation of webs. Although it is a very rare condition, an increased risk of esophageal squamous cell carcinoma makes its identification very important. Dilation of the esophageal web using a Savary dilator is a more effective and safer approach compared to conventional balloon dilation.
PMID: 26658794
ISSN: 1873-4626
CID: 1897072

Endoscopic closure of colonic perforations using over-the-scope clip: a surgeon-sparing technique

Changela, Kinesh; Alhankawi, Dhuha; Anand, Sury; Krishnaiah, Mahesh
PMCID:4805747
PMID: 27065739
ISSN: 1108-7471
CID: 2162352

Endoscopic closure of persistent gastrocutaneous fistulae, after percutaneous endoscopic gastrostomy (PEG) tube placement, using the over-the-scope-clip system

Singhal, Shashideep; Changela, Kinesh; Culliford, Andrea; Duddempudi, Sushil; Krishnaiah, Mahesh; Anand, Sury
OBJECTIVES: The Over-The-Scope-Clip (OTSC) has had an evolving role in endoscopic closure of gastrointestinal wall defects, in hemostasis of primary or postinterventional bleeding, and approximation of postbariatric surgery defects. Rapid and effective closure of gastrocutaneous (GC) fistulae using this device has been recently described in the literature. The aim of this study was to evaluate the technical feasibility, efficacy and safety of OTSC as an effective tool in the management of persistent GC fistulae secondary to a complication of percutaneous endoscopic gastrostomy (PEG) tube placement. METHOD: In this multicenter prospective observational study, we describe our experience with OTSC in the closure of persistent GC fistulas secondary to PEG tube placement. Patients with GC fistulas were sequentially enrolled with a mean age of 84 years. Primary treatment outcome was the immediate successful closure of GC fistula and resolution of leak. Secondary outcome was no recurrence of the fistula and leaks on follow up. RESULTS: A total of 10 patients were enrolled over the study period. Mean age was 84.4 +/- 8.75 years. The primary treatment outcome was achieved in all the patients undergoing this intervention. Secondary outcome was observed in 9/10 (90%) subjects. No procedural complications were reported. Larger fistulae (>2.5 cm) and those with significant fibrosis were more difficult to close with the OTSC system. The mean follow-up time after OTSC application was 43.7 +/- 20.57 days. A limitation of this study was that there was no control group. CONCLUSIONS: OTSC application is a safe and effective endoscopic approach for the closure of persistent GC fistulae secondary to a complication of PEG tube placement.
PMCID:4480569
PMID: 26136836
ISSN: 1756-283x
CID: 1895662

Hemostatic powder spray: a new method for managing gastrointestinal bleeding

Changela, Kinesh; Papafragkakis, Haris; Ofori, Emmanuel; Ona, Mel A; Krishnaiah, Mahesh; Duddempudi, Sushil; Anand, Sury
Gastrointestinal bleeding is a leading cause of morbidity and mortality in the United States. The management of gastrointestinal bleeding is often challenging, depending on its location and severity. To date, widely accepted hemostatic treatment options include injection of epinephrine and tissue adhesives such as cyanoacrylate, ablative therapy with contact modalities such as thermal coagulation with heater probe and bipolar hemostatic forceps, noncontact modalities such as photodynamic therapy and argon plasma coagulation, and mechanical hemostasis with band ligation, endoscopic hemoclips, and over-the-scope clips. These approaches, albeit effective in achieving hemostasis, are associated with a 5-10% rebleeding risk. New simple, effective, universal, and safe methods are needed to address some of the challenges posed by the current endoscopic hemostatic techniques. The use of a novel hemostatic powder spray appears to be effective and safe in controlling upper and lower gastrointestinal bleeding. Although initial reports of hemostatic powder spray as an innovative approach to manage gastrointestinal bleeding are promising, further studies are needed to support and confirm its efficacy and safety. The aim of this study was to evaluate the technical feasibility, clinical efficacy, and safety of hemostatic powder spray (Hemospray, Cook Medical, Winston-Salem, North Carolina, USA) as a new method for managing gastrointestinal bleeding. In this review article, we performed an extensive literature search summarizing case reports and case series of Hemospray for the management of gastrointestinal bleeding. Indications, features, technique, deployment, success rate, complications, and limitations are discussed. The combined technical and clinical success rate of Hemospray was 88.5% (207/234) among the human subjects and 81.8% (9/11) among the porcine models studied. Rebleeding occurred within 72 hours post-treatment in 38 patients (38/234; 16.2%) and in three porcine models (3/11; 27.3%). No procedure-related adverse events were associated with the use of Hemospray. Hemospray appears to be a safe and effective approach in the management of gastrointestinal bleeding.
PMCID:4454021
PMID: 26082803
ISSN: 1756-283x
CID: 1895672

Importance of reporting segmental bowel preparation scores during colonoscopy in clinical practice

Jain, Deepanshu; Momeni, Mojdeh; Krishnaiah, Mahesh; Anand, Sury; Singhal, Shashideep
AIM: To evaluate the impact of reporting bowel preparation using Boston Bowel Preparation Scale (BBPS) in clinical practice. METHODS: The study was a prospective observational cohort study which enrolled subjects reporting for screening colonoscopy. All subjects received a gallon of polyethylene glycol as bowel preparation regimen. After colonoscopy the endoscopists determined quality of bowel preparation using BBPS. Segmental scores were combined to calculate composite BBPS. Site and size of the polyps detected was recorded. Pathology reports were reviewed to determine advanced adenoma detection rates (AADR). Segmental AADR's were calculated and categorized based on the segmental BBPS to determine the differential impact of bowel prep on AADR. RESULTS: Three hundred and sixty subjects were enrolled in the study with a mean age of 59.2 years, 36.3% males and 63.8% females. Four subjects with incomplete colonoscopy due BBPS of 0 in any segment were excluded. Based on composite BBPS subjects were divided into 3 groups; Group-0 (poor bowel prep, BBPS 0-3) n = 26 (7.3%), Group-1 (Suboptimal bowel prep, BBPS 4-6) n = 121 (34%) and Group-2 (Adequate bowel prep, BBPS 7-9) n = 209 (58.7%). AADR showed a linear trend through Group-1 to 3; with an AADR of 3.8%, 14.8% and 16.7% respectively. Also seen was a linear increasing trend in segmental AADR with improvement in segmental BBPS. There was statistical significant difference between AADR among Group 0 and 2 (3.8% vs 16.7%, P < 0.05), Group 1 and 2 (14.8% vs 16.7%, P < 0.05) and Group 0 and 1 (3.8% vs 14.8%, P < 0.05). chi(2) method was used to compute P value for determining statistical significance. CONCLUSION: Segmental AADRs correlate with segmental BBPS. It is thus valuable to report segmental BBPS in colonoscopy reports in clinical practice.
PMCID:4385548
PMID: 25852286
ISSN: 2219-2840
CID: 1897082

Correlation of Breast and Gynecologic Cancers With Colorectal Adenomas-Colorectal Cancer (CRC): A Multicenter Look at Minority Populations From Community Hospitals in Brooklyn, NY [Meeting Abstract]

Linn, Sandar; Lopez-Morra, Hernan; Singh, Amaninder Jeet Dhaliwal; Tejada, Juan; Blankenship, Zachary; Aziz, Ishtiaque; Baptiste, Nerissa; Amin, Hisham; Krishnaiah, Mahesh; Xiao, Philip Q; Reddy, Madhavi; Duddempudi, Sushi; Anand, Sury
ISI:000363715903052
ISSN: 1572-0241
CID: 1854342

A rare presentation of metastasis of prostate adenocarcinoma to the stomach and rectum

Soe, Aye Min; Bordia, Sonal; Xiao, Philip Q; Lopez-Morra, Hernan; Tejada, Juan; Atluri, Sreedevi; Krishnaiah, Mahesh
Prostate cancer is the second most common cause of cancer death in men in the United States. The most common sites of metastasis include the bone, lymph nodes, lung, liver, pleura, and adrenal glands, whereas metastatic prostate cancer involving the gastrointestinal tract has been rarely reported. A 64-year-old African-American man with a history of prostate cancer presented with anemia. He reported the passing of dark colored stools but denied hematemesis or hematochezia. Colonoscopy revealed circumferential nodularity, and histology demonstrated metastatic carcinoma of the prostate. Esophagogastroduodenoscopy showed hypertrophic folds in the gastric fundus, and microscopic examination revealed tumor cells positive for prostate-specific antigen. Bone scanning and computed tomography of the abdomen and pelvis did not show metastasis. It is crucial to distinguish primary gastrointestinal cancer from metastatic lesions, especially in patients with a history of cancer at another site, for appropriate management.
PMCID:4286907
PMID: 25580360
ISSN: 2093-582x
CID: 1897092

Role of over the scope clips in the management of iatrogenic gastrointestinal perforations [Letter]

Changela, Kinesh; Virk, Muhhamad A; Patel, Niravkumar; Duddempudi, Sushil; Krishnaiah, Mahesh; Anand, Sury
Advances in endoscopic and surgical techniques have increased the frequency and complexity of these procedures and associated complications such as gastrointestinal perforation. With the advancements in the field of gastroenterology, the promising use of an over the scope clips (OTSC) has fulfilled the unmet need for a reliable endoscopic devise in approximation of gastrointestinal perforation. This novel approach has raised the level of confidence in endoscopist in dealing with this serious complication during endoscopy. Here we have shared our experience with OTSC to evaluate its efficacy and safety in managing iatrogenic gastrointestinal perforations during endoscopy.
PMCID:4145791
PMID: 25170237
ISSN: 2219-2840
CID: 1895702