Hepatitis B virus (HBV) is a common viral pathogen that causes a substantial health burden worldwide. Significant progress has been made in the past few decades in understanding the natural history ...of HBV infection. A dynamic balance between viral replication and host immune response is pivotal to the pathogenesis of liver disease. In immunocompetent adults, most HBV infections spontaneously resolve, whereas in most neonates and infants they become chronic. Those with chronic HBV may present in 1 of 4 phases of infection: (1) in a state of immune tolerance, (2) with hepatitis B e antigen (HBeAg)-positive chronic hepatitis, (3) as an inactive hepatitis B surface antigen carrier, or (4) with HBeAg-negative chronic hepatitis. Of these, HBeAg-positive and HBeAg-negative chronic hepatitis may progress to cirrhosis and its long-term sequelae including hepatic decompensation and hepatocellular carcinoma. Several prognostic factors, such as serum HBV DNA concentrations, HBeAg status, serum aminotransferases, and certain HBV genotypes, have been identified to predict long-term outcome. These data emphasize the importance of monitoring all patients with chronic HBV infection to identify candidates for and select optimal timing of antiviral treatment, to recognize those at risk of complications, and to implement surveillance for early detection of hepatocellular carcinoma.
Background Cystic neoplastic lesions of the pancreas (CNLP) are increasingly detected and are associated with a potential for malignant transformation. Diagnostic assessment of these lesions is often ...limited by the cystic nature and focality of neoplastic progression of these lesions. EUS-guided FNA (EUS-FNA) of cyst fluid and exfoliated cells is one of the most accurate methods of diagnosis but still has limited sensitivity. A new, through-the-needle cytologic brush system has recently been approved for use during EUS evaluation of cystic lesions of the pancreas. Objective To evaluate the cytologic yield and safety profile of the new cytobrush compared with conventional FNA in evaluating CNLP. Design Ten consecutive patients with CNLP were included. All cysts were sampled by standard EUS-FNA (0.5 of cyst volume) followed by brush cytology, then by aspiration of the remaining fluid. Fluid samples were separately submitted (standard FNA and cytobrushings FNA) but were read by the same pathologist. Complications were assessed during the immediate postprocedure period (2-3 hours) and by a telephone call conducted approximately 30 days after the procedure to inquire about any new symptoms, including abdominal pain, melena, hematochezia, hematemesis, fever, nausea, and vomiting. Setting High-volume EUS referral center. Patients Ten consecutive patients with CNLP that measured at least 20 mm in maximal dimension were included. Main Outcome Measurements Cellularity and presence of diagnostic cells on the FNA. Results In 7 of 10 cases, the EchoBrush specimen was superior to FNA in terms of cellularity and detection of diagnostic cells. Two cases had complications: 1 major and 1 minor intracystic bleed. No infection or pancreatitis was observed. Limitations The interpreting pathologist for the case was not blinded to the results of either of the samples. In addition, this pilot study represents only a single-center experience. Conclusions This study suggests that brush cytology specimens obtained at the time of EUS are superior to conventional FNA because of the higher yield of epithelial cells. It is unclear whether bleeding is more common after EchoBrush sampling; however, caution should be taken in patients who require anticoagulation until further data are available.
Background On-site determination of cytologic adequacy increases the accuracy of EUS-guided FNA (EUS-FNA); however, on-site cytotechnologists are not available to all endosonographers. We hypothesize ...that experienced endosonographers can accurately assess whether an on-site FNA specimen is adequate. Objective To determine the accuracy of on-site cytopathology interpretation of EUS-FNA specimens by comparing endosonographers with a cytotechnologist. Design Prospective double-blind controlled trial. Setting Academic medical center with a high-volume EUS practice. Patients Consecutive patients undergoing EUS-FNA of lymph nodes or pancreas tumors. Main Outcome Measurements Accuracy, sensitivity, and specificity of 3 endosonographers and 1 cytotechnologist for interpretation of cytologic specimen adequacy and diagnosis compared with a criterion standard of a board-certified cytopathologist. Results There were 59 lymph node, 49 pancreas, and 9 liver specimens (117 total). For determination of adequacy, none of the endosonographers were statistically equivalent to the cytotechnologist ( P = .004). For determination of suspicious/malignant versus benign specimens, all 3 endosonographers were inferior ( P < .001) to the cytotechnologist. Limitations This study represents a small group of trained endosonographers in a high-volume practice and may not be applicable to other settings. The sample size does not allow an accurate evaluation of different biopsy sites (eg, pancreas vs lymph node). Conclusions Even trained endosonographers have variable and, in some cases, inferior abilities to interpret on-site cytologic adequacy compared with cytotechnologists.
Background Although total obstruction or secondary atresia of the esophagus is extremely rare, high-grade strictures are not uncommon. The retrograde approach was previously described to achieve ...dilation when the conventional antegrade method fails. Setting Gastroenterology laboratory in a tertiary referral center. Patient A 30-year-old man with congenital T-cell immunodeficiency had complete esophageal obstruction after a severe episode of cryptococcal meningitis that required prolonged nasogastric intubation. For the next 3 years, he had daily episodes of regurgitations and several hospitalizations for aspiration pneumonia. A barium study revealed a dilated megaesophagus, with no contrast reaching to the stomach. Intervention Initially, a new track was created by using access from above and below the obstruction. This was followed by placement of a self-expandable silicone stent after allowing sufficient time for the new track to mature. Main Outcome Measurements Restoration of esophageal continuity, which allowed resolution of the patient's aspiration pneumonia and resumption of oral feeding. Conclusions Complete esophageal obstruction after prolonged nasogastric intubation is a rare but serious complication. A novel endoscopic approach can be used to restore esophageal continuity, minimize complications, and avoid major reconstructive surgeries.
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