At the Focal Point
percutaneous transhepatic drain remained in situ and was fully functional (D). DISCLOSURE All authors disclosed no financial relationships relevant to this article. Premysl Falt, MD, PhD, Digestive Diseases Center, Vítkovice Hospital, Ostrava, Czech Republic, Faculty of Medicine,
University of Ostrava, Ostrava, Czech Republic, Petr Rohlík, MD, Surgical Department, Vsetín Hospital, Vsetín, Czech Republic, Petr Fojtík, MD, PhD, Ondrej Urban, MD, PhD, Digestive Diseases Center, Vítkovice Hospital, Ostrava, Czech Republic, Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic
http://dx.doi.org/10.1016/j.gie.2015.03.1896
Commentary Enteric feeding tubes are extensively used and generally safe, yet luminal obstruction, coiling, kinking, and malpositioning are often reported. Nasojejunal feeding tubes are often favored over nasogastric tubes because of their smaller caliber and postpyloric termination. They are preferred in impaired gastric motility, severe esophageal reflux, or other gastric dysfunction. However, their thin lumen and malleability can predispose them to knots. Excessive inserted tube length can predispose to adverse events, highlighting the recommendation of postplacement radiographic confirmation. Percutaneous transhepatic drains primarily have a short endoluminal segment, making primary looping, knotting, or kinking very rare. Only in cases with a secondary device (ie, an adjacent nasojejunal tube) would there be a risk of entanglement. The simultaneous use of multiple tubes crossing through the same enteric section should prompt consideration of risk and early recognition of adverse events. In retrospect, an alternate management option would have been to sever the nasojejunal feeding tube with endoscopic scissors and then remove the smaller pieces with a Roth net or rat-tooth graspers. This would reduce the need for manipulation of the percutaneous transhepatic drain, which comes with the inherent risk of dislodgment. In the spirit of not making a bad problem worse, only in cases in which the tubes can be easily untangled endoscopically would nasojejunal tube ligation not be preferred. William C. Palmer, MD Fellow in Gastroenterology, Mayo Clinic Florida Massimo Raimondo, MD Associate Editor for Focal Points
A rare cause of tarry stool and ileus A 51-year-old man visited the emergency department because of tarry stool, abdominal pain, and vomiting for 5 days. Physical examination showed diffuse abdominal tenderness without peritoneal sign and mildly increased bowel sound. Laboratory studies disclosed leukocytosis with immature white blood cells of peripheral blood (white blood cell: 16,160/mL, normal range 4000-10,000/ mL;band form 2%, normal range 0%-5%) and no anemia. An abdominal CT scan disclosed a tumor originating from the proximal jejunum, associated with a distended stomach and duodenum (A, left panel ). Several nodular lesions were noted in the lungs (A , right panel ), liver, left kidney, adrenal glands, and regional lymph nodes. Antegrade, single-balloon enteroscopy revealed a longitu-
dinal ulcerative tumor 20 cm in length, occupying approximately three fourths of the circumference, extending from the fourth portion of the duodenum to the proximal jejunum (B , left panel ). Multiple 0.3 to 0.8 cm, subepithelial tumors with central ulceration were found distal to the main lesion, located at the proximal to middle jejunum (B , right panel ). Histology of the main tumor revealed poorly to undifferentiated carcinoma with a predominantly solid pattern (C , left panel, H&E, orig. mag. x 200). Immunohistochemistry was positive for thyroid transcription factor-1 (C , right panel, TTF-1 staining, orig. mag. x 400) and cytokeratin (CK ) 7, and it was negative for CK 20, CDX2, and hepatocyte paraffin 1. The final diagnosis was pulmonary adenocarcinoma with multiple lymph
www.giejournal.org
Volume 82, No. 2 : 2015 GASTROINTESTINAL ENDOSCOPY 415
At the Focal Point
All authors disclosed no financial relationships relevant to this article.
Clinical Medicine, National Yang-Ming University, Cheng-Yu Lo, MD, Department of Anatomical Pathology, Far Eastern Memorial Hospital, New Taipei City, Chen-Shuan Chung, MD, Department of Internal Medicine, Far Eastern Memorial Hospital, College of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan Association for the Study of Small Intestinal Diseases, Taiwan
Wei-Fan Hsu, MD, Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei City, Institute of
http://dx.doi.org/10.1016/j.gie.2015.02.008
nodes and organ involvement, including small-intestine metastasis. DISCLOSURE
416 GASTROINTESTINAL ENDOSCOPY Volume 82, No. 2 : 2015
www.giejournal.org
At the Focal Point
Commentary Familiarity with both primary and metastatic small-bowel tumors is paramount to the gastroenterologist. However, given their rarity compared with tumors of the large bowel as well as the nonspecific and variable signs and symptoms with which they present, they can pose a diagnostic challenge to clinicians, resulting in delay from symptom onset to diagnosis. Despite the small bowel making up approximately 75% of the length of the GI tract, small-bowel malignancies account for only 3% of all GI tract neoplasms in the United States. This case is therefore unique and relevant not only in the location of metastatic involvement and its endoscopic appearance but also in the nature of the primary malignancy, one not uncommonly found to be the cause of small-bowel metastasis. Primary malignant small-bowel tumors can include carcinoid tumors, adenocarcinomas, lymphomas, and sarcomas, with carcinoid tumors now surpassing all others as the most common small-bowel malignancy. Some tend to have a liking for a portion of the small bowel, with adenocarcinomas having a predilection for the duodenum and carcinoid tumors for the ileum. In contrast to primary malignant tumors of the small intestine, hematogenous spread of metastatic disease to the small bowel is uncommon. When this is seen, the most common metastases to the upper GI tract (including the small intestine) are from melanoma, breast, and lung malignancies. In fact, the small intestine is the most common GI site for metastatic melanoma. Upper GI bleeding and anemia are common presenting features. Treatment of small-bowel metastatic disease is focused on palliation. This can include resection of the lesion, intestinal bypass, or endoscopic stenting (the latter used mostly for gastroduodenal obstruction). A recent review of 57 case reports and 3 retrospective studies suggests a prevalence of small-bowel metastasis from primary lung cancer as high as 10.7%. Poor tumor differentiation and advanced T and N stages of the primary lung cancer are associated with intestinal metastasis. Patients experience 3 frequent clinical presentations, which include intestinal perforation, obstruction, and bleeding. Gastroenterologists must be cognizant of the various primary tumors affecting the small bowel but also those representing metastatic disease. Although once felt to be an uncommon presentation, it appears that primary lung cancer not uncommonly metastasizes to the small intestine. Given the frequency with which we encounter patients afflicted with lung cancer, we should keep small-bowel metastatic disease in the differential diagnosis for lung cancer patients presenting with melena or other small bowel–related symptoms. Raul Badillo, MD Fellow in Gastroenterology and Hepatology Mayo Clinic Florida Massimo Raimondo, MD Associate Editor for Focal Points
Anorectal malignant melanoma in a patient presenting with prolapsing hemorrhoids A 67-year-old, previously healthy woman presented with scanty rectal bleeding and protruding reducible anal masses. She was told previously that she had internal hemorrhoids. There was no family history of malignancy, including melanoma. Previous screening colonoscopies 9 and 3 years prior reportedly had normal results. Physical examination results were normal, apart from palpable mobile anal masses. A colonoscopy demonstrated 2 tancolored, pedunculated masses at the dentate line (A), which were removed by snare diathermy. Pathology showed a polypoid structure lined by squamocolumnar mucosa, with an underlying malignant population of spindle and epithelioid cells (B, H&E, orig. mag. x 400). Immunohistochemical staining showed that the tumor cells were positive for melan-A (C, Melan-A, orig. mag. x 600) and negative for pan-keratin (D, Pan-keratin, orig.
mag. x 600), consistent with melanoma. Abdominal perineal resection was performed, yielding residual invasive and in situ melanoma, with in situ disease extending to the distal resection margin. There was no initial metastatic disease; however, hepatic and pulmonary metastasis evolved, and the patient died 19 months after diagnosis despite aggressive surgery and chemotherapy.
www.giejournal.org
Volume 82, No. 2 : 2015 GASTROINTESTINAL ENDOSCOPY 417
DISCLOSURE All authors disclosed no financial relationships relevant to this article. Zachary Bordman, BSc, Elliott Cohen, BSc, Division of Gastroenterology, Eugene Hsieh, MD, Department of Anatomic Pathology, Lawrence B. Cohen, MD, Division
percutaneous transhepatic drain remained in situ and was fully functional (D). DISCLOSURE All authors disclosed no financial relationships relevant to this article. Premysl Falt, MD, PhD, Digestive Diseases Center, Vítkovice Hospital, Ostrava, Czech Republic, Faculty of Medicine,
University of Ostrava, Ostrava, Czech Republic, Petr Rohlík, MD, Surgical Department, Vsetín Hospital, Vsetín, Czech Republic, Petr Fojtík, MD, PhD, Ondrej Urban, MD, PhD, Digestive Diseases Center, Vítkovice Hospital, Ostrava, Czech Republic, Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic
http://dx.doi.org/10.1016/j.gie.2015.03.1896
Commentary Enteric feeding tubes are extensively used and generally safe, yet luminal obstruction, coiling, kinking, and malpositioning are often reported. Nasojejunal feeding tubes are often favored over nasogastric tubes because of their smaller caliber and postpyloric termination. They are preferred in impaired gastric motility, severe esophageal reflux, or other gastric dysfunction. However, their thin lumen and malleability can predispose them to knots. Excessive inserted tube length can predispose to adverse events, highlighting the recommendation of postplacement radiographic confirmation. Percutaneous transhepatic drains primarily have a short endoluminal segment, making primary looping, knotting, or kinking very rare. Only in cases with a secondary device (ie, an adjacent nasojejunal tube) would there be a risk of entanglement. The simultaneous use of multiple tubes crossing through the same enteric section should prompt consideration of risk and early recognition of adverse events. In retrospect, an alternate management option would have been to sever the nasojejunal feeding tube with endoscopic scissors and then remove the smaller pieces with a Roth net or rat-tooth graspers. This would reduce the need for manipulation of the percutaneous transhepatic drain, which comes with the inherent risk of dislodgment. In the spirit of not making a bad problem worse, only in cases in which the tubes can be easily untangled endoscopically would nasojejunal tube ligation not be preferred. William C. Palmer, MD Fellow in Gastroenterology, Mayo Clinic Florida Massimo Raimondo, MD Associate Editor for Focal Points
A rare cause of tarry stool and ileus A 51-year-old man visited the emergency department because of tarry stool, abdominal pain, and vomiting for 5 days. Physical examination showed diffuse abdominal tenderness without peritoneal sign and mildly increased bowel sound. Laboratory studies disclosed leukocytosis with immature white blood cells of peripheral blood (white blood cell: 16,160/mL, normal range 4000-10,000/ mL;band form 2%, normal range 0%-5%) and no anemia. An abdominal CT scan disclosed a tumor originating from the proximal jejunum, associated with a distended stomach and duodenum (A, left panel ). Several nodular lesions were noted in the lungs (A , right panel ), liver, left kidney, adrenal glands, and regional lymph nodes. Antegrade, single-balloon enteroscopy revealed a longitu-
dinal ulcerative tumor 20 cm in length, occupying approximately three fourths of the circumference, extending from the fourth portion of the duodenum to the proximal jejunum (B , left panel ). Multiple 0.3 to 0.8 cm, subepithelial tumors with central ulceration were found distal to the main lesion, located at the proximal to middle jejunum (B , right panel ). Histology of the main tumor revealed poorly to undifferentiated carcinoma with a predominantly solid pattern (C , left panel, H&E, orig. mag. x 200). Immunohistochemistry was positive for thyroid transcription factor-1 (C , right panel, TTF-1 staining, orig. mag. x 400) and cytokeratin (CK ) 7, and it was negative for CK 20, CDX2, and hepatocyte paraffin 1. The final diagnosis was pulmonary adenocarcinoma with multiple lymph
www.giejournal.org
Volume 82, No. 2 : 2015 GASTROINTESTINAL ENDOSCOPY 415
At the Focal Point
All authors disclosed no financial relationships relevant to this article.
Clinical Medicine, National Yang-Ming University, Cheng-Yu Lo, MD, Department of Anatomical Pathology, Far Eastern Memorial Hospital, New Taipei City, Chen-Shuan Chung, MD, Department of Internal Medicine, Far Eastern Memorial Hospital, College of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan Association for the Study of Small Intestinal Diseases, Taiwan
Wei-Fan Hsu, MD, Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei City, Institute of
http://dx.doi.org/10.1016/j.gie.2015.02.008
nodes and organ involvement, including small-intestine metastasis. DISCLOSURE
416 GASTROINTESTINAL ENDOSCOPY Volume 82, No. 2 : 2015
www.giejournal.org
At the Focal Point
Commentary Familiarity with both primary and metastatic small-bowel tumors is paramount to the gastroenterologist. However, given their rarity compared with tumors of the large bowel as well as the nonspecific and variable signs and symptoms with which they present, they can pose a diagnostic challenge to clinicians, resulting in delay from symptom onset to diagnosis. Despite the small bowel making up approximately 75% of the length of the GI tract, small-bowel malignancies account for only 3% of all GI tract neoplasms in the United States. This case is therefore unique and relevant not only in the location of metastatic involvement and its endoscopic appearance but also in the nature of the primary malignancy, one not uncommonly found to be the cause of small-bowel metastasis. Primary malignant small-bowel tumors can include carcinoid tumors, adenocarcinomas, lymphomas, and sarcomas, with carcinoid tumors now surpassing all others as the most common small-bowel malignancy. Some tend to have a liking for a portion of the small bowel, with adenocarcinomas having a predilection for the duodenum and carcinoid tumors for the ileum. In contrast to primary malignant tumors of the small intestine, hematogenous spread of metastatic disease to the small bowel is uncommon. When this is seen, the most common metastases to the upper GI tract (including the small intestine) are from melanoma, breast, and lung malignancies. In fact, the small intestine is the most common GI site for metastatic melanoma. Upper GI bleeding and anemia are common presenting features. Treatment of small-bowel metastatic disease is focused on palliation. This can include resection of the lesion, intestinal bypass, or endoscopic stenting (the latter used mostly for gastroduodenal obstruction). A recent review of 57 case reports and 3 retrospective studies suggests a prevalence of small-bowel metastasis from primary lung cancer as high as 10.7%. Poor tumor differentiation and advanced T and N stages of the primary lung cancer are associated with intestinal metastasis. Patients experience 3 frequent clinical presentations, which include intestinal perforation, obstruction, and bleeding. Gastroenterologists must be cognizant of the various primary tumors affecting the small bowel but also those representing metastatic disease. Although once felt to be an uncommon presentation, it appears that primary lung cancer not uncommonly metastasizes to the small intestine. Given the frequency with which we encounter patients afflicted with lung cancer, we should keep small-bowel metastatic disease in the differential diagnosis for lung cancer patients presenting with melena or other small bowel–related symptoms. Raul Badillo, MD Fellow in Gastroenterology and Hepatology Mayo Clinic Florida Massimo Raimondo, MD Associate Editor for Focal Points
Anorectal malignant melanoma in a patient presenting with prolapsing hemorrhoids A 67-year-old, previously healthy woman presented with scanty rectal bleeding and protruding reducible anal masses. She was told previously that she had internal hemorrhoids. There was no family history of malignancy, including melanoma. Previous screening colonoscopies 9 and 3 years prior reportedly had normal results. Physical examination results were normal, apart from palpable mobile anal masses. A colonoscopy demonstrated 2 tancolored, pedunculated masses at the dentate line (A), which were removed by snare diathermy. Pathology showed a polypoid structure lined by squamocolumnar mucosa, with an underlying malignant population of spindle and epithelioid cells (B, H&E, orig. mag. x 400). Immunohistochemical staining showed that the tumor cells were positive for melan-A (C, Melan-A, orig. mag. x 600) and negative for pan-keratin (D, Pan-keratin, orig.
mag. x 600), consistent with melanoma. Abdominal perineal resection was performed, yielding residual invasive and in situ melanoma, with in situ disease extending to the distal resection margin. There was no initial metastatic disease; however, hepatic and pulmonary metastasis evolved, and the patient died 19 months after diagnosis despite aggressive surgery and chemotherapy.
www.giejournal.org
Volume 82, No. 2 : 2015 GASTROINTESTINAL ENDOSCOPY 417
DISCLOSURE All authors disclosed no financial relationships relevant to this article. Zachary Bordman, BSc, Elliott Cohen, BSc, Division of Gastroenterology, Eugene Hsieh, MD, Department of Anatomic Pathology, Lawrence B. Cohen, MD, Division
![[Colonic gallstone ileus: a rare cause of colonic obstruction].](/assets/img/hold.png)
