Video Endoscopy Conference 1/15/21 Play Pause Volume Quality 1080P 720P 640P Fullscreen Captions Transcript Chapters Slides Endoscopy Conference 1/15/21 Overview Three cases presented here: • 00:00 – Gastric Ulcers • 16:12 – Protein-losing Enteropathy • 34:53 – Intestinal Hookworm Disease So you're saying you're up? Yep. I will share my good one second. Yeah. Yeah. Choose. All right. Hopefully this work. Um, Hi, everyone. I'm Yu Yang, one of the first year fellows. Um, share a case I did with Dr Cohen a couple months ago. So we have a nine year old male. He has a history of dementia. He's an ex smoker. 75 pack years C a d diabetes Prior p on L. A quiz. Who presented with melanoma for two weeks. Um, at time of presentation, we look back at his trend of his hemoglobin. It was 13.62 months ago, and on arrival, it was 5.6 on with tachycardia. So we took him for a scope that day. Apologies. I did not have a video. Um, and these were the best pictures and early endoscopy for me. Um, but these were the best pictures I could take. This you can see on retro flexion that there was a large non bleeding gastric ulcer with a clean ulcer base found on the lesser curvature of the stomach. Some are worryingly, we saw these heaped up edges, and maybe it looked a little bit raised. Um, and it could have been, like on top of the mast. So we took biopsies from, um, the edges of the ulcer as well as the base, um, to allow for malignancy versus something like h. Pylori. The pathology came back with invasive, moderately differentiated admiral carcinoma, predominantly intestinal type involving the gastric funding and body type mucosa. It was negative for H pylori, um, in terms of its clinical course. During the hospitalization, he end up getting a C staging CT chess, Um, that also found 2.4. It's just a centimeter right upper lobe nodule, which was suspicious. Also for early stage admiral carcinoma reading the oncology notes, they seem to still be debating whether or not the concomitant gastric ulcer was thought to be a second sort of primary or if this was metastatic from the lung of the lungs, metastatic from the stomach. But the staining of the gastric, um, will even see was PD l one positive. So the latest update was that they were considering a single agent immunotherapy such as level A map. The family is currently pursuing a second opinion before proceeding. Um, so today I thought we would return to the basics a little bit and talk about gastric ulcers and specifically while our gentleman's, um, endoscopy demonstrated very concerning features of malignancy. One of the questions I was wondering was, We perform a lot of surveillance. Endoscopy is for gastric ulcers as well. Um, even on ulcers that may be benign upon first sort of passed in terms of biopsy and also by appearance. So gastric ulcers, we all know, are associated with inset um, aspirin use H. Pylori infection and also malignancy and taking a look at the literature biopsy of all gastric ulcers are currently recommended both in the S G E and the nice skylines, which are from Orkney skylines from Europe. And this is actually based on older data from the seventies and eighties that suggested 5 to 11% of gastric cancers may represent malignancy, most commonly gastric adenocarcinoma, as in our gentleman, less commonly lymphoma and occasionally metastatic cancer. There are no recent data actually to guide recommendations about the need to biopsy all ulcers, but I think most endoscopy it's, um, feel the need to and, um, in terms of guidelines for for surveillance, there are no recent guidelines either. A lot of islands just say follow up gastric ulcers until healing is confirmed in order to exclude malignancy when the endoscopic appearance of a gastric ulcer is suggestive of malignancy because of specific feature, such as an associated mass lesion, as in our patient elevated irregular ulcer borders, which were also seen in our patient and abnormal adjacent folds and this topic biopsies are recommended to be performed from the base in the edges. Um, there was a 1982 seminal study that demonstrated that the correct diagnosis of gastric cancer increases from 70 to 95% if for biopsy, specimens are taken instead of one. So in terms of what I want to delve into a little bit more about the world, surveillance endoscopy, um, obviously should be considered in patients whose gastric ulcer appears endoscopic lee, suspicious for malignancy based on the features I just stated. Even if biopsy samples from the index endoscopy are benign, so false negative biopsy specimens in the literature occur in about 2 to 5% of malignant ulcers and any, um, healed ulcers and examination after 8 to 12 weeks should undergo repeat surveillance. Um, it's also recommended in patients who remain symptomatic despite a course of PP I, um, just to rule out refractory peptic ulceration and called Melich cities. So I took a look at this article published in gastric cancer, um, which aimed to study if there was a diagnostic accuracy of endoscopic follow up in patients with a gastric ulcer with emphasis on endoscopic holler marks of malignancy and histology first endoscopy. Um, so this study, I thought was really interesting because it was done at a teaching hospital in the Netherlands over six years. Um, they reviewed both appearance as describing the report combined with histology at the first endoscopy at this hospital. The policy was to follow up every ulcer and misc optically until healing had occurred, regardless of it, whether it appeared benign or malignant. Um, and what was great was that if a patient left that hospital and got a surveillance endoscopy elsewhere, there was a national pathology database that they could follow up to actually determine if a gastric malignancy was diagnosed at a later time. So they were able to identify 321 cases of gastric ulcers, including 214 ultimately benign ulcers and 100 and seven malignant ulcers. So the malignancy rate was 33% of this population, which is high. The mean age of the population was 71 years old. Um, in 62% of ulcers were classified as benign at the first endoscopy. Five of those patients, however, at their follow up endoscopy, were eventually deemed militant based on histology. Um so the sensitivity of a benign appearance of the ulcer in combination with histology was 100% sensitive in this study to rule out malignancy. So even though they thought this was benign, they took their adequate for sample biopsies and found it was malignant. Now, in the 121 patients where the ulcers were explicitly deemed as potentially malignant, um, 84% of those patients were indeed confirmed to be have malignant ulcers as confirmed on histology. And 19 of those patients were benign actually at when they actually did the biopsies. So the sensitivity that they looked at in terms of the potential malignant characteristics and endoscopy was a dirty base which was 79% sensitive elevated order which our patient had was 94% sensitive for potential legacy in an irregular border at 91% Um, they also looked at location and size. Um, the takeaway, obviously is that nothing is 100%. It's more of a gestalt, but, um, ulcers in the entrance were predominantly benign. And then markedly 82% of ulcers in the cardia, um, and 45% of ulcers and the body were found to be malignant and of all gastric ulcers. They also found that, um, ulcers greater than three centimeters had a rate of lunacy of 86%. So basically, size and location can also tilt our clinical sort of needle in terms of going towards malignancy or, uh, the night. So just one more point in the study. What they found was that they use their sort of clinical crystal of both clinical appearance at first endoscopy that appeared benign, plus the histology at first endoscopy. And, you know, in this study, everyone did take the four biopsies from the the initial gastric ulcers. They found that they could have reduced 77% of follow up endoscopy. So my take home points are to sort of review at least for the first years. The characteristics of malignant gastric ulcers, which are associate mass lesion of elevated irregular ulcer borders of normal, adjacent folds and sort of the clinical, um, features such as like size and location can also tilt your clinical suspicion towards malignancy. Biopsy of all gastric ulcers was still recommended, even though the literature wavered in terms of saying, Oh, this is all based on order literature. I think we still obviously want to biopsy all gastric ulcers, provided they're not obviously active bleeding, Um, and then to take at least four samples from the edges and the base and to consider. And I'm curious to hear what everyone who's in practice they're, um they're feeling about this where if an ulcer appears benign and has been on histology, would you still consider doing surveillance to assess for healing? Um, thank you. Yeah. Christian Utopia speaking. Sorry about that. Um, that's a very interesting topic. Thank you for presenting that. It is a common scenario that comes up especially in the concert service. Because we see so many ulcers. I'd be interested to know if any of the guidelines stratify benefit of repeat endoscopy based on I want identifying an ideology or risk factor or two of the patient has, uh, if the patient has any risk factors for gastric cancer. So, for example, patient comes in with an ulcer bleed. They're not on n said's. And you know we don't know their H. Pylori status, obviously. But, um, you know, the rest of the stomach looks normal. Or they don't come from a part of the country or ethnic background where there's a high incidence of H. Pylori. Um, with that patient, would that patient benefit more from a follow up endoscopy being that new ulcer? No obvious ideology? Um, we should rule out cancer or, um, in patients who haven't presumed and set ulcer. Do they need to follow up a bit of a convoluted question, I think. Yeah, no, I think you know, taking a look at the studies they do not stratify by risk factor. I think there are clinical risk factors, obviously play into one's decision to whether repeat or not, a lot of the studies I saw in the literature there's been a lot of cost effective in the studies as well focused on both both like in your population, who are, for example, young, obvious unsaid use. Is there a need to repeat, uh, sort of surveillance endoscopy in those circumstances and at least some of the costs affecting the studies, I've seen say like, no. And, um, usually only when your suspicion of, like, a preach like prevalence of gastric cancers at least like 6% in that patient, would it be cost effective to continue surveillance? Um, you know the best part of this what you're presenting is that it allows you some clinical judgment. So I mean, you know, I think like if you see a proximal gastric ALS But I think I did one of those with Stephanie Gold recently, you know, then I mean, it was it was sort of a deep, dark, hard ulcer, you know, And, you know, we made the decision of that person clearly needed to come back. On the other hand, the sort of garden variety gastric ulcer that's in the pre pill Oric region that clearly looks like it's acid peptic related. I don't think you need to go back and look at those at all. Dave, what are your thoughts on patients who present with complex ulcers such as a bleeding ulcer or one that you may have caused a gastric ballot obstruction. Would you routinely do a follow up to assure healing again? I think it's, you know, if you if it if I don't think you necessarily have to do that. I think that's kind of where all of the recent literature has gone. You know, if it appears to be acid peptic and said related, and patient has no other concerning, things haven't lost a ton of weight. They're not at somewhat increased risk for gastric cancer, and they do well over the next X period of time. I think you can, you know, just leave them big in terms of like biopsy at the time of the index procedure. I feel like sometimes one this it's a complicated bleeding. Also, we may not necessarily, um, biopsy They also, at that point in time, I don't know what people's thoughts on that, because I mean like they already bleeding, we should probably should be doing more biopsies. I was going to comment on that, too. I think you should biopsy. I don't know why there's this fear when somebody's bleeding I FC somehow going to hurt them when the rest of the time we biopsy people with impunity, right? I mean, they already bleeding anyway. I mean, but, I mean, you haven't seen anybody exsanguination from a biopsy. So I mean, if you need, if you get a patient and they need a biopsy in this case, they probably should have a biopsy. Do the biopsy. My feeling? I don't know what other people think, Chris. I agree. I don't think you can increase the risk of bleeding. Obviously. Don't biopsy a vessel. Correct? Which I have seen people do, and that's a bad idea. So Alright. Alright. Well, great. Thank you so much. That that very common very, very, uh, common scenario and very practical discussion. So thank you very much. I believe that June is up next. Hi. Apologies. My video isn't working this morning, but I think I will be able to share it. Mhm. Okay, You can do. Sure. Thank you. Mm. Mhm. Yeah. Is that working? Yes. Okay. Um, it's a good morning. I m g and one of the PGA four fellows, um, I'm going to present a more medicine case today. I was at a bit of a loss for interesting endoscopic images. Um, so here we have, um this patient is actually still in, um, admitted to the hospital. She's been there for about 25 days, and it seems like the medicine team or start a bit of a loss as to what's going on. So I thought I would pick your brains. So this is a lady 47 year old lady with a long history of Lupus. Been on Southampton Prednisone. Um, history of good. Um, some massive pe diagnosed at the beginning of December. Um, with right heart strain has been on Lovenox. She presents she Mount Sinai with increased lower extremity swelling and abdominal bloating. Abdominal pain. That's been going on for about two weeks. She, um we were consulted for severe Hypo Albany mia. They thought that it was not explained by any renal pathology. Um, and concerned for protein losing entire apathy, which is something I was very unfamiliar with before I came across this case. She endorsed sharp lower quadrant pain which improved during her Eddie stay. Um, she had a facial rash, Arthur algebra, no diarrhea or other G I symptoms before presenting to the emergency room. No history of travel no stick contact? No. N said use and no family history of IBD. Her exam was very significant for a distended abdomen, which was non tender. No guarding dull to percussion. Although we didn't appreciate any shifting dullness. Um, no, not just fundamentally that we could appreciate. She had severe and a sarka, um, and had a malar rash. She was complaining, Arthur Roger. But she didn't have any appreciable sign of itis. Mhm. So, um, what I want to discuss today is protein losing antipathy, and I'll take you through the case, Um, whilst doing so, um, so the path of physiology of protein losing antipathy is, um uh, so I'm going to talk about the path physiology. So the daily interest loss of Syrian proteins is about 1 to 2% of the Syrian protein pool. So really not a significant loss. Um, through the gut, most proteins found in the feces or secretions are sloped on parasites. The path of physiology of protein using anthropology is thought to be an inflammatory accident or significant mucosal injury resulting in increased because of permeability or lymphatic obstruction, resulting in direct leakage of protein rich lymph. Um, this results in hyper album anemia resulting in an Osaka cities can result in hyper chemical anemia, resulting in frequent infections and severe nutritional deficiency. Um, there are many etiologies, um, causing protein losing Antara apathy, and it's a little overwhelming, but we can It can be divided into cirrhosis of non erosive G I disease and then, um causes, um of increased interstitial pressure. So eroded GI disease include inflammatory bowel disease malignancies and set on trump with these G p h d student member nous colitis and sarcoidosis. Non erosive GI disease can include um, celiac disease. Hypertrophic osteopathy is including many trees disease, Ciba amyloidosis um, infections, including tropical spree whipple and then connective tissue disorders. Um, increased interstitial pressure. Um, etiologies can include, um, intestinal live inject. Asia, I think, is more common in Children, but in adults can be heart failure. Pericarditis. Um also portal hypertension portal, hypertensive gas drop with the, um medicine Terek Venus thrombosis. Anything obstructing the lymphatic flow out of the gut, including military TB or sarcoidosis. Neo pleasure, including, um, involving the medicine technical, infinite or lymphatic and retro peritoneal fibrosis. These are all, um, uh, contributors to protein losing antipathy. So how do we diagnose? Um, protein losing an Tripathi. We first have to quantify g i protein loss. And that is mainly done by our for one anti trips and clearance. Um, it's a glycoprotein that is synthesized by the liver, which is a higher molecular weight than abdomen. And it's resistant to protease. Allah says in degradation than this intestinal Lumen. So it's representative of how much protein is lost through the gut. Um, okay, Usually the rate of excretion is, um, less than 2.6 mg program of store per day. And, um, you need both the stool, um, excretion of a 1 80. And you need a concurrent serum sample. You also need the stool volume or mass its 24 hour stool collection. You need the total volume of stool in order to calculate this, um, also and attitudes and clearance of greater than 27 mills in 24 hours is considered, um, suggested of protein. Losing entire empathy and diarrhea can actually increase the clearance so greater than 56 is considered significant. Okay, um, so in our patient General labs, her CBC was unremarkable. Admission. She was hyper album anemic, but she was extremely, um, uh, teletext It Probably hyperbole, Mick. Her creating a BU, and we're not suggestive of any, Um, a k I, um She also didn't have any other electrolyte abnormalities outside of those mentioned her, um, LFTs were normal, but I always wanted a 0.6. And it had been, um, in the twos or threes about 23 weeks before admission, when she was at a different hospital for the PE. Her Alpha one on trips and stool was elevated to 10.3, which is about 10 times the upper limit of normal. Um, for this study, um, and then Alpha one and two trips in serum level was low. Um, 87 but unfortunately, no stool volume was recorded. I actually called LabCorp and our lab client services to see whether there was anything they had recorded, but nothing. Nothing in the nursing notes. Sure. So we cannot calculate the clearance. Unfortunately, um, so, um, the remainder of her studies are to evaluate for other causes the ideologies of protein losing antipathy so her protein create. Actually, firstly, we wanted to rule out any necrotic syndrome. Protein creatinine ratio is 0.42 which is non neurotic range because she has Lupus. She does have a year in microscopy. No evidence of active sediment. Um, she had a BMP, which was 13. We recommended a diagnostic tab, but unfortunately, there was no safe pocket. Um, and then, um, rheumatology was consulted. Compliments were low, but are double stranded DNA was not elevated, given her active rash and sign of itis Thought could be consulted consistent with sle flair. Um, and then here's some imaging, right? Ultrasound with an ECA genic liver. No other significant findings. But it was not a duplex study. Um, m r E was unremarkable, except for a cities. Um, c t a, uh showed a known pe small left pleural effusion. And then she had an incidental finding of a right cf a complete occlusion. And then she ended up going for an endarterectomy. Um, her echo has not been repeated since the diagnosis. Herpes. So this is an outside study. She had a normal left ventricular function, but she has significant right? Ventricular dilation. Um, and hyper contract tile, apex and base. Um, and this was all suggestive of a P. These are her endoscopy finding. So since we were consulted for, um, protein losing antipathy. We wanted to rule out any intrinsic, um g I disease. And really, this is her stomach. And all we found was that she had congestive mucosa. Um, and we thought that maybe the findings looked a little bit like PhD with, like, the kind of chicken wire appearance of the mucosa. But there was no other real findings. Is a Judean Um um and this is her sick. I'm just congested mucosa. No, no. Luminal lesions. We took extensive biopsies, and this is the report. So non specific vaginitis, Um, she has some chronic, non specific gastritis with parietal cell hyperplasia. She is on a p p I, um And then she had a colonic mucosa with a single non necrotizing epithelial cell granuloma. And the significance is unclear, given that she really doesn't have any other symptoms of I'd, um, and this was actually reviewed with Dr Hart Pause. And he didn't really have anything else to add in terms of, um, other etiologies that could be considered so a non specific finding. Yeah, um, so we're at this point where she, you know, she's being She's being treated empirically, you know, she's the rheumatology. Recommended starting med rel her cells. That level was a little bit low, so they added pro graph. Um, they continue yourselves up, treating for possible SLE flair. Um, nephrology is on board and helping out with kind of, um, diaries is with abdomen, and she's also on TPN for a severe nutritional deficiency. Um, but she the things that we haven't really established at this point is does she really have significant GI protein loss? Um, I've kind of played around with the numbers a little bit, and it does seem that we just don't know how much stool was that? I think that's the issue. It certainly could be in the range of protein losing antipathy. We just don't don't know for sure at this point. So there was resending, um, that offer one anti trips and tests. Um, and hopefully this time they will have recorded the volume. Um, the repeat protein creatinine ratio was 1.9, which is still not in the necrotic range 13 area to account for her severely, though. Album, which is still 0.7. Um and then I just wanted to discuss possible next step with this lady. Um, I think the first step, obviously, is to wait for the Alpha one anti trips in and verify that she has significant GI protein loss. But if suggestive, if this is suggestive of protein losing enterococci, what should we do? Um, I think you know, we have a BNP, but she probably has. I'm not sure how significant that is in the right side of failure, first of all. And secondly, you know, we haven't had to repeat echo since her significant sub massive P, which could certainly cause right heart stand in terms of like her time. Course, it does seem that she had, um the onset was after her. P um, so I think we should probably repeat echo, but is a role for a liver vascular ultrasound. She has had multiple abdominal imaging with my view contrast and m r e. I'm not sure how much that would show. Um, And then does she merit, um, a liver biopsy? I think we should also try and do another diagnostic, Paris and thesis. Um, if we can. Mhm. So that's everything. So, Dave, um, there are any thoughts. I love cases like this. They are just fascinating. They make us think they're often multidisciplinary but equally there frustrating because there's often no easy answers and, you know, But it challenges us to remember all of our internal medicine, Uh, you know, skills. And like I said, it's often a multidisciplinary or multi organ issues, so definitely, definitely great presentation. And thank you for presenting this. Um, I have two quick questions before we open it up. Is there any role in similar to when you're, you know, when you're doing a fecal fat a quantitative fecal, fat patients get a high fat diet. Is there any role for, like, a protein challenge diet and then doing a dedicated 24 hour uh, still collection? Um, I didn't actually come across that in my reading. Um, I believe because what we're looking for is kind of, um, not actually. But like translocation from the inter station or the or the serum into the gut that I think a protein challenge of more tests for malabsorption rather than like true got loss of protein And then as far as management outside of obviously under finding the underlying ideology and treating that is there temporizing measures with either an elemental diet or TPN. What is the plan for her recommended is, um, you know, firstly, a high protein diet of at least two. I think it's two grounds per day. Um, but they do acknowledge that in a lot of the cases, the patients have G I pathology that limits the efficacy of that. This might not apply to my patient. And in those cases, um, you know, TPN, OPM is recommended. Um, there have been, um, some anecdotal, um, reports of Austria type being used to some success, but there isn't any large studies verifying it. I could see. So it's really treatment of underlying causes. And then, lastly, was there any I gave, like a retro flex view of the stomach? There was no thought that there were hypertrophic gastric folds or enlarged gastric folds suggestive of money tree air disease. Yeah. So when we went in, um, that we didn't really We insulated the stomach significantly, and I don't There was no, um, no, we didn't really notice any hypertrophic gastric holes at that point. And the pathology also from the stomach, I believe, was not suggestive. So usually the classic the classic diagnostic move for diagnosing. Monitoring air disease when it's suspected is something called a strip biopsy, which is essentially an m r of a gastric fold. Because the diagnosis is really made off of sub mucosal findings and deep epithelial or deep mucosal findings which are typically not seen on mucosal biopsies. So usually just you inject a little bit of saline and you take a snare and you snare off one of the big, big piece of a gastric fold as you would a colon polyps or something. Yeah, I'll take another look at the at the images. Um, it doesn't look like it. It's not suspicious, but probably the most one of the relevant things from my standpoint. Um, anyone have any thoughts or other comments? Yeah, actually, I was in service when this case was being discussed. Uh, right after the endoscopy, and we had similar thoughts like this does not look like military is just on the endoscopy. But it does have this appearance of court life intensive gas property, which is one of the reasons why we were pushing for getting a Paris and pieces all right from the get go. Of course I am. Amyloidosis was another one of the concerns could not be seen on the path Um, CellCept was one of the concerns causing that could cause information. But again, there was no apathetic bodies or anything else, which could suggest, uh, self that mediated colitis or such as mediated and writers. Um, I think one of the I think the two thoughts, which I'm still unfinished as far as, uh, exploring our one is doing the parts and pieces and other is one is the echo. And then probably doing the right heart cat and saying, because I have seen patients who had three bad right heart strain who can have issues with the lymphatic drainage and then lead to 14 losing interrupt with the And by that you can also looking at the lymphatic drainage with the lymph angiogram, or city will limp angiography something along those lines. So those are our main thoughts. It's great. It's great. Any other thoughts? I mean, she does have Lupus, which is on that long list, you know, of, um, potential causes of protein losing under apathy, and I bet if you get the stool collection, you can prove this. But you've got a lot of good evidence that he has that. So I mean, first, it's good to keep evaluating, but first crack is treating the underlying disease here. The Lupus as aggressively as you can. But it's really interesting case. I remember when I was a medicine resident and we had morning report and we went through our differential diagnosis. You can always put Lupus for any disease or any complaint, and you're you're not incorrect. So I think it holds true here too. Um, all right. Fantastic. Fantastic case. Thank you so much. Thanks for your comments. A beak? Um, all right. I think we have time for one more, and I'm going to turn it over to the pediatric GI team. I think they have an interesting case to present as well. Hi. Good morning, everyone. This is Hannibal person. I'm one of the third year P G. I fellows just going to share my screen here. Uh, so So this is a case of a two year old I saw for a second opinion. She was seen by an outside gastroenterologist. She came to me with diagnoses of functional constipation, GERD, and also had a history of a topic dermatitis. Really her chief complaint in the history was that she developed episodic, severe, generalized abdominal pain associated with non bloody, non bilious emphasis for the past year. And so she had returned from a trip to from Bangladesh had had began developing these very discreet episodes that last lasted days, somewhat characteristic in terms of how long they last. There'll be a period where she was completely okay and then her symptoms would resume with a kind of mild program of her seeming kind of more fussy, not wanting to eat, and then sort of going into a full blown sort of episode of abdominal pain in sort of recurrent MSs. Uh, as we sort of got to know each other, how the episodes became more severe and more frequent. Um, she had previously had several emergency room visits where multiple negative abdominal ultrasounds have been done. She had multiple K u B s that were all non focal, and the work up, as at that time, was the negative. H. Pylori, fetal androgen and kind of routine labs at the emergency room visits which were all normal, including electrolytes, CBC, etcetera, There was no family history. She was an only child living with her parents in Queens and the family spends about half the year in Bangladesh. Half the year in Queens, while she was tiny, she was continued to grow and gain weight and height. Um, and her physical exam was only significant for her. A topic dermatitis but really otherwise. The completely benign abdominal exam school biofire was negative in a review of her. Outside records from only emergency room settings showed pretty much essentially normal labs. Um, so the thought the initial thought was good. This be cyclic vomiting syndrome. She was started on separate routine prophylaxis. Uh, could this be more rotation? She had an upper GI that just showed, uh, just commented on some redundant duodenum, otherwise, within normal limits. Normal rotation. Um, and she proceeded to have numerous CD visits at our institution, including end to hospitalizations with a very broad work up that included a negative CT, abdomen, pelvis. There was some thought it could be source of parenthesis. This was more kind of emphasis, predominant in terms of her symptoms. Etiology early. Could this be central? She had memory. Brain, which was normal, was seen by a metabolic steam. There was no thought for a mitochondrial or other disorder as a cause. For her, vomiting had a normal e g colon, both macro and microscopically. At the end of July of last year, um was tried on numerous prophylactic, another abortive treatments with really very limited success, and her pain episodes became more and more frequent, more and more emergency room presentations. Over the course of her emergency room visits, her syrupy Nasr was noted to be persistently elevated. She did have periods where she was Hippo album, anemic, as low as 3.2. Playlets were normal, and occasionally she sort of had a mild anemia for her age with a low, normal M. C. V. So eventually, given the persistent elevation of her inflammatory markers, we really didn't feel comfortable with the diagnosis of cyclic vomiting syndrome or some other functional process. So we got a capsule endoscopy on the 18th of December of last year, and as you can see here on the first image duodenum, you begin to see these worms. Also, there were areas of erosion and even bleeding throughout, and these worms were most concentrated in the June, um, and so you can see here and Some are adherent of the lining of the mucosa that appears. And so we got our answer. And so we thought that this was helmet disease, and these really look like hookworms. Um and so she's been treated with tremendous All, uh, two weeks post treatment. She's doing very well. I'm seeing her in clinic in a week or two. Um, but this was sort of a very interesting presentation, particularly this pain pattern for hookworm disease. Um, so hookworm disease in humans can be caused by these organisms. Uh, they kind of appear like this, but they don't have a very heterogeneous appearance on endoscopy, which sometimes makes identifying them a little challenging. And, of course, we know they also have cutaneous manifestations solely sometimes. And they use this to enter the human body. Uh, this is their life cycle. And one thing that's really important to note is that for a duodenal, they can actually be uncontaminated food that's not well washed, particularly like fruits. So it doesn't just you don't just have to have a history of us. Someone who was in an endemic area walking around barefoot. It could be through an oral route, but they penetrate the skin. They start in the lungs there, coughed up into the pharynx, swallowed, uh, and then, uh, in the gut. Um, the females lay their eggs, which are excreted in the stool. Um, the ova live in soil, and this is why they're actually more, uh, they're really prevalent in more tropical regions because there's very specific needs of the over in terms of the soil, including, I think, like 40 or 50 inches of rain a year. But the ova matures there, develops into the chloroform larva, which can then re infect. Um and so my thought was especially cause Bangladesh does have, um, several areas where infection is very common. That she either eight, um, some food that was contaminated or was walking around barefoot of note. None of the other family members at all have any symptoms so that they have not been tested. Um, then so symptoms of this included the gastric, abdominal pain, nausea, vomiting, diarrhea, early satiety, fatigue, flatulence and GI bleeding. And there's case literature about people actually presenting with acute G I bleeding significant GI bleeding attributed to hookworm. Um, there can be pulmonary and cutaneous symptoms as well. Complications include anemia and malnutrition. Some studies suggest that an adult hookworm can consume from 0.32 point five liters of blood daily. Um, and these complications. Not only is this very widespread 600 million people affected in the world, including the United States, particularly in areas of the South, that have sort of the right environment for them. But this becomes more and more significant in areas where people already are at risk for malnutrition for pregnant women, for Children, because it really can cause complications with growth, with a healthy pregnancy, etcetera. And so diagnosis really relies on finding the ova and their various ways of analyzing the school. But it's important to note that doing a stool and P is not 100%. You can miss the eggs, especially for hookworm. The eggs are very fragile and can sort of disappear on you. And there are PCR tests being developed, but they're not widely commercially available, at least yet. Treatments include these anti Helmand therapies and really the emphasis in areas where it's endemic as prevention measures. There's an interesting kind of growing body of literature about using endoscopy in order to screen people, so you'll in reading about this? There's a ton of case literature about, just incidentally, finding hookworm on colonoscopy endoscopy, but also seeing them on capsule. But there's a lot of work done. UH, now being done now using AI to try to actually use this as a screening measure. Just cause stool testing is not always the easiest or the most reliable. So actually using computer programming to detect these, although that's somewhat limited by their heterogeneous appearance and sometimes the images you get on capsule, but a very interesting way to maybe go to some of these areas and screen people very quickly. Um, one thing I thought was kind of cool, um, is whenever I've seen these swarms of some sort a few times in endoscopy and the question is always like, should I try to catch them with my biopsy? Forceps. And the answer is yes. Um, so I found some literature to suggest that it's not just endoscopy to diagnosis, but it's actually therapeutic, because when you use your anti Helmand therapy, uh, it's not always 100% effective, and these things can be so adherent to the mucosa that they persist can still shed over, and so they actually physically removing them when you see them, it actually has a therapeutic benefit. Potentially, Um, and so that's my case. But I thought it was very interesting and very atypical presentation in terms of symptom apology for this type of infection. I don't have many comments to make. I think the pictures say them off. I don't know if anyone has any thoughts. I think I would like to share, um, as a child who grew up in India as well as after having done medical in India. We then we have such a highest suspicion for worm infestation that any child with any GI complaints, and especially if they have anemia, um, even before testing it's a you know, M. Pericles of Al Bundy is all that's given because it's a one dose, and then it has to be defeated 2 to 3 weeks later to make sure if any other eggs have hatched after that to address them, too. So this is pretty much just handed out to Children. And if one child is treated, usually their siblings get treated as well, because sometimes the argument is maybe the child is not able to complain if they have any mild symptoms. So they're honestly, you know, before diagnostics. It's the It's a treat and test strategy that's adopted. And I can attest that I was teaching, interested mhm. And, um, I just want to thank Hannibal for presenting that that I probably read thousands of capsule studies now, and I've been waiting to find a worm all these years, and the pediatrics folks are reading most of their own now. So they called me up and said, Take a look at this. Do you think it's a word? And I was like, Oh, wait, let me see And I was like, Absolutely definitely so Thanks for sharing that with us, Hannibal. Published January 25, 2021 Created by Featured Faculty Yuying Luo PGY4 Icahn School of Medicine at Mount Sinai Ji Yoon Yoon, MD PGY4 Mount Sinai Hospital Hannibal Person, MD PGY8 Icahn School of Medicine at Mount Sinai
