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Al Saleh HA, Malikowski T, Patel DA, Ali IA, Mahmood S. Empirical Dilation of Non-obstructive Dysphagia: Current Understanding and Future Directions. Dig Dis Sci 2022; 67:5416-5424. [PMID: 35397698 DOI: 10.1007/s10620-022-07451-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 02/15/2022] [Indexed: 01/05/2023]
Abstract
Non-obstructive dysphagia (NOD) is defined as symptomatic dysphagia in patients with negative endoscopic and radiographic workup. The management of NOD remains controversial as there is a discrepancy between different guidelines and clinical practice. Despite the lack of high-quality studies, empiric dilation for NOD is a common clinical practice among endoscopists and the approach varies between different clinical centers. In this review, we summarize the published literature on empiric dilation for NOD and propose a management algorithm for offering empiric dilation to patients presenting with dysphagia.
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Affiliation(s)
- Hassan Ali Al Saleh
- Division of Gastroenterology, Department of Medicine, University at Buffalo, Buffalo, NY, USA. .,Department of Medicine, University at Buffalo, Buffalo, NY, USA.
| | - Thomas Malikowski
- Division of Gastroenterology, Department of Medicine, University at Buffalo, Buffalo, NY, USA.,Department of Medicine, University at Buffalo, Buffalo, NY, USA
| | - Dhyanesh Arvind Patel
- Center for Esophageal Disorders, Division of Gastroenterology, Hepatology, & Nutrition, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Ijlal Akbar Ali
- Digestive Diseases and Nutrition Section, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Sultan Mahmood
- Division of Gastroenterology, Department of Medicine, University at Buffalo, Buffalo, NY, USA.,Department of Medicine, University at Buffalo, Buffalo, NY, USA
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Malikowski T, Levy MJ, Gleeson FC, Storm AC, Vargas EJ, Topazian MD, Abu Dayyeh BK, Iyer PG, Rajan E, Gores GJ, Roberts LR, Chandrasekhara V. Endoscopic Ultrasound/Fine Needle Aspiration Is Effective for Lymph Node Staging in Patients With Cholangiocarcinoma. Hepatology 2020; 72:940-948. [PMID: 31860935 DOI: 10.1002/hep.31077] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 12/09/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND AIMS Presence of malignant regional lymph nodes (MRLNs) precludes curative oncological resection or liver transplantation for cholangiocarcinoma (CCA). Limited data support the utility of endoscopic ultrasound (EUS)/fine needle aspiration (FNA) for detection of MRLNs in extrahepatic CCA, but there are no data for its role in intrahepatic CCA (iCCA). The aim of this study is to evaluate the staging impact of EUS for CCA, including analysis by subtype. APPROACH AND RESULTS We identified consecutive patients with CCA who underwent EUS staging at a single tertiary care center from October 2014 to April 2018. Among this cohort, we abstracted clinical demographic, radiographical, procedural, cytopathological, and surgical data. STATA 15 software was used for comparative analysis calculations (StataCorp LP, College Station, TX). The study cohort included 157 patients; 24 (15%), 124 (79%), and 9 (6%) with intrahepatic, perihilar, and distal CCA, respectively. EUS was able to identify regional lymph nodes (RLNs) in a higher percentage of patients compared to cross-sectional imaging (86% vs. 47%; P < 0.001). FNA was performed in 133 (98.5%) patients with RLNs, with a median of three passes per node. EUS-FNA identified MRLN in 27 of 31 (87.1%) patients ultimately found to have MRLNs. For iCCA, EUS detected a higher percentage of RLN compared to cross-sectional imaging (83% vs. 50%; P = 0.048), with MRLNs identified in 4 (17%) patients. Among the entire cohort, identification of at least one MRLN by EUS was associated with lower median survival (353 vs. 1,050 days; P < 0.001) and increased risk of death (hazard ratio = 4.1; P < 0.001). CONCLUSIONS EUS-FNA is effective for identifying MRLN in patients with CCA, and should be routinely incorporated into staging of all CCA subtypes given the impact of MRLN on prognosis and management decisions.
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Affiliation(s)
- Thomas Malikowski
- Department of Hospital Internal Medicine, Mayo Clinic, Rochester, MN
| | - Michael J Levy
- Division of Gastroenterology, Mayo Clinic, Rochester, MN
| | | | - Andrew C Storm
- Division of Gastroenterology, Mayo Clinic, Rochester, MN
| | - Eric J Vargas
- Division of Gastroenterology, Mayo Clinic, Rochester, MN
| | | | | | - Prasad G Iyer
- Division of Gastroenterology, Mayo Clinic, Rochester, MN
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Malikowski T, Lehrke HD, Henry MR, Gleeson FC, Alberts SR, Kendrick ML, Lennon RJ, McWilliams RR, Takahashi N, Topazian MD, Gara N, Abu Dayyeh BK, Chandrasekhara V, Chari ST, Iyer PG, Rajan E, Storm AC, Wang KK, Levy MJ. Clinical impact of celiac ganglia metastasis upon pancreatic ductal adenocarcinoma. Pancreatology 2020; 20:110-115. [PMID: 31759906 DOI: 10.1016/j.pan.2019.11.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 10/24/2019] [Accepted: 11/12/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Pre-operative staging of pancreatic adenocarcinoma guides clinical decision making. Limited data indicate that metastasis to celiac ganglia (CG) correlates with poor prognosis. We investigated feasibility and safety of endoscopic ultrasound fine needle aspiration (EUS-FNA) detection of CG metastasis and its impact upon tumor stage, resectability, and survival in pancreatic ductal adenocarcinoma (PDAC). PATIENTS We reviewed our prospectively maintained EUS and cytopathology databases to identify patients with FNA proven CG metastasis in patients with PDAC from 2004 to 2017. Clinical demographics, EUS, CT, MRI, cytopathology, cancer stage, and resectability data were analyzed. Survival of PDAC patients with CG metastasis was compared to the expected survival of PDAC patients of similar stage as reported by the United States National Cancer Database. RESULTS Twenty-one patients with PDAC [median age 73 (IQR63-78); 14 (67%) female)], had CG metastasis confirmed by cytopathologic assessment. CG metastasis resulted in tumor upstaging relative to other EUS findings and cross sectional imaging findings in 12 (57%) and 15 (71%) patients, and converted cancers from resectable to unresectable relative to EUS and cross sectional imaging in 7 (37%) and 7 (37%) patients, respectively. In patients with PDAC, the survival of patients with CG metastasis was not significantly different from the overall survival (hazard ratio 0.71; 95% confidence interval 0.44, 1.13; p = 0.15). CONCLUSIONS EUS-FNA may safely identify CG metastases. While CG metastasis upstaged and altered the resectability status among this cohort of patients with PDAC, the survival data with regard to PDAC suggest that this may be misguided.
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Affiliation(s)
- Thomas Malikowski
- Department of Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Heidi D Lehrke
- Division of Anatomic Pathology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Michael R Henry
- Division of Anatomic Pathology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Ferga C Gleeson
- Division of Gastroenterology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Steven R Alberts
- Division of Medical Oncology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Michael L Kendrick
- Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Ryan J Lennon
- Division of Biomedical Statistics and Informatics, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Robert R McWilliams
- Division of Medical Oncology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Naoki Takahashi
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Mark D Topazian
- Division of Gastroenterology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Naveen Gara
- Division of Gastroenterology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Barham K Abu Dayyeh
- Division of Gastroenterology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Vinay Chandrasekhara
- Division of Gastroenterology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Suresh T Chari
- Division of Gastroenterology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Prasad G Iyer
- Division of Gastroenterology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Elizabeth Rajan
- Division of Gastroenterology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Andrew C Storm
- Division of Gastroenterology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Kenneth K Wang
- Division of Gastroenterology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Michael J Levy
- Division of Gastroenterology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
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Malikowski T, Lehrke HD, Henry MR, Gleeson FC, Topazian MD, Harmsen WS, Takahashi N, Inoue D, Gara N, Abu Dayyeh BK, Chari ST, Iyer PG, Rajan E, Wang KK, Levy MJ. Accuracy of Endoscopic Ultrasound Imaging in Distinguishing Celiac Ganglia From Celiac Lymph Nodes. Clin Gastroenterol Hepatol 2019; 17:148-155.e3. [PMID: 29857152 DOI: 10.1016/j.cgh.2018.05.025] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Revised: 05/01/2018] [Accepted: 05/13/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Endoscopic ultrasound (EUS) allows visualization of celiac lymph nodes (CLNs) and celiac ganglia (CG). Reliably distinguishing these structures is important for tumor staging and CG ablative therapies. We aimed to evaluate the accuracy of EUS in distinguishing CLNs from CG using a strict cytopathology reference standard. We also determined the rate of detection of CLN and CG by conventional cross-sectional imaging. METHODS From EUS and cytopathology databases, we identified all patients who underwent EUS-FNA of a presumed CLN or CG from October 1, 2004, through March 1, 2017, and compared the findings with those from cytology (reference standard). Indeterminate cytology results were re-reviewed. EUS imaging (ie, index test) results were compared with those from the reference standard. An expert radiologist re-reviewed computed tomography and magnetic resonance images from 100 lesions, from 94 randomly selected patients with a reference standard, to determine the rates of CLN and CG detection. RESULTS A total of 504 patients (mean age, 63.4 ± 13.2 years; 292 men) underwent a median of 7 EUS-FNA passes (range, 1-13) for a total of 566 lesions perceived to be either a CLN or CG; the cytology reference standard was available for 521 lesions (92.1%). When we excluded indeterminate cytology results, the EUS accurately identified 281/286 CLNs (98.3%) and 166/186 CGs (89.2%), for an overall accuracy of 447/472 (94.7%). EUS-FNA distinguished CG from CLNs with a 93.3% sensitivity, 93.7% specificity, a positive predictive value of 96.2%, and a negative predictive value of 89.2%. Of 100 lesions in 94 patients randomly selected for a second expert radiology review, computed tomography and magnetic resonance imaging detected 59/67 CLNs (88.1%) and 13/33 CG (39.4%). CONCLUSION EUS accurately distinguishes CLNs from CG. EUS might therefore be used to increase the accuracy of tumor staging, to select tumor stage-appropriate therapy, and to guide CG-ablative therapies.
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Affiliation(s)
| | - Heidi D Lehrke
- Division of Anatomic Pathology, Mayo Clinic, Rochester, Minnesota
| | - Michael R Henry
- Division of Anatomic Pathology, Mayo Clinic, Rochester, Minnesota
| | - Ferga C Gleeson
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota
| | - Mark D Topazian
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota
| | - William S Harmsen
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | | | - Dai Inoue
- Department of Radiology, Kanazawa University, Kanazawa, Japan
| | - Naveen Gara
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota
| | | | - Suresh T Chari
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota
| | - Prasad G Iyer
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota
| | - Elizabeth Rajan
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota
| | - Kenneth K Wang
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota
| | - Michael J Levy
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota.
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Malikowski T, Mahmood M, Smyrk T, Raffals L, Nehra V. Tuberculosis of the gastrointestinal tract and associated viscera. J Clin Tuberc Other Mycobact Dis 2018; 12:1-8. [PMID: 31720391 PMCID: PMC6830173 DOI: 10.1016/j.jctube.2018.04.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Revised: 03/10/2018] [Accepted: 04/09/2018] [Indexed: 02/07/2023] Open
Abstract
Tuberculosis involvement of the gastrointestinal tract, peritoneum, and associated viscera is an uncommon but well described entity. While peritoneal tuberculosis and tuberculous enteritis are more common, involvement of the esophagus, stomach, colon, rectum, anus, liver, bile ducts, gallbladder, and pancreas can occur. Diagnosis is challenging as cases often mimic neoplasm or inflammatory bowel disease. In this review we outline the pathogenesis, clinical presentation, diagnostic testing, and treatment strategies pertaining to such cases.
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Affiliation(s)
- Thomas Malikowski
- Department of Internal Medicine, Mayo Clinic 200 First St. SW, Rochester, MN 55905 507-284-2511, United States
| | - Maryam Mahmood
- Division of Infectious Diseases, Mayo Clinic 200 First St. SW, Rochester, MN 55905 507-284-2511, United States
| | - Thomas Smyrk
- Department of Anatomic Pathology, Mayo Clinic 200 First St. SW, Rochester, MN 55905 507-284-2511, United States
| | - Laura Raffals
- Division of Gastroenterology and Hepatology, Mayo Clinic 200 First St. SW, Rochester, MN 55905 507-284-2511, United States
| | - Vandana Nehra
- Division of Gastroenterology and Hepatology, Mayo Clinic 200 First St. SW, Rochester, MN 55905 507-284-2511, United States
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Malikowski T, Yang AL, Beckman TJ. Altered Bowel Habits and Occult Gastrointestinal Bleeding in a 67-Year-Old Man. Gastroenterology 2017; 153:e12-e13. [PMID: 28781220 DOI: 10.1053/j.gastro.2017.01.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Accepted: 01/12/2017] [Indexed: 12/02/2022]
Affiliation(s)
- Thomas Malikowski
- Department of Internal Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Allison L Yang
- Department of Internal Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Thomas J Beckman
- Department of Internal Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota
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Malikowski T, Al-Bawardy B, Oxentenko AS. Abnormal Liver Tests and Persistent Lactic Acidosis in an 18-Year-Old Woman. Gastroenterology 2017; 152:947-949. [PMID: 28259720 DOI: 10.1053/j.gastro.2016.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Revised: 10/19/2016] [Accepted: 11/14/2016] [Indexed: 12/02/2022]
Affiliation(s)
- Thomas Malikowski
- Department of Internal Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Badr Al-Bawardy
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Amy S Oxentenko
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, Minnesota
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