Managing end-stage carcinoid heart disease: A case report and literature review

BACKGROUND

Gastroenteropancreatic neuroendocrine neoplasms (GEP-NENs) are rare tumors, often diagnosed in an advanced stage when curative treatment is impossible and grueling symptoms related to vasoactive substance release by tumor cells affect patients' quality of life. Cardiovascular complications of GEP-NENs, primarily tricuspid and pulmonary valve disease, and right-sided heart failure, are the leading cause of death, even compared to metastatic disease.

CASE SUMMARY

We present a case of a 35-year-old patient with progressive dyspnea, back pain, polyneuropathic leg pain, and nocturnal diarrhea lasting for a decade before the diagnosis of neuroendocrine carcinoma of unknown primary with extensive liver metastases. During the initial presentation, serum biomarkers were not evaluated, and the patient received five cycles of doxorubicin, which he did not tolerate well, so he refused further therapy and was lost to follow-up. After 10 years, he presented to the emergency room with signs and symptoms of right-sided heart failure. Panneuroendocrine markers, serum chromogranin A, and urinary 5-hydroxyindoleacetic acid were extremely elevated (900 ng/mL and 2178 µmol/L), and transabdominal ultrasound confirmed hepatic metastases. Computed tomography (CT) showed liver metastases up to 6 cm in diameter and metastases in mesenteric lymph nodes and pelvis. Furthermore, an Octreoscan showed lesions in the heart, thoracic spine, duodenum, and ascendent colon. A standard transthoracic echocardiogram confirmed findings of carcinoid heart disease. The patient was not a candidate for valve replacement. He started octreotide acetate treatment, and the dose escalated to 80 mg IM monthly. Although biochemical response and symptomatic improvement were noted, the patient died.

CONCLUSION

Carcinoid heart disease occurs with carcinoid syndrome related to advanced neuroendocrine tumors, usually with liver metastases, which manifests as right-sided heart valve dysfunction leading to right-sided heart failure. Carcinoid heart disease and tumor burden are major prognostic factors of poor survival. Therefore, they must be actively sought by available biochemical markers and imaging techniques. Moreover, imaging techniques aiding tumor detection and staging, somatostatin receptor positron emission tomography/CT, and CT or magnetic resonance imaging, should be performed at the time of diagnosis and in 3- to 6-mo intervals to determine tumor growth rate and assess the possibility of locoregional therapy and/or palliative surgery. Valve replacement at the onset of symptoms or right ventricular dysfunction may be considered, while any delay can worsen right-sided ventricular failure.

IBD Patients' Perception of Severe Acute Respiratory Syndrome Coronavirus 2 Pandemic and Satisfaction with Provided Healthcare: A Cross-Sectional Study

BACKGROUND

Severe acute respiratory syndrome coronavirus 2 pandemic is affecting public health systems and mental health significantly. Patients with inflammatory bowel disease are witnessing vigorous organizational changes in inflammatory bowel disease centers and experiencing all psychosocial effects of the crisis. We conducted a single-center cross-sectional study in order to assess inflammatory bowel disease patients' concerns, behavior, and satisfaction with provided healthcare during severe acute respiratory syndrome coronavirus 2 pandemic.

METHODS

All inflammatory bowel disease patients treated in our center from April 1 to June 1, 2020, were invited to fulfill an anonymous online questionnaire.

RESULTS

A total of 132 participants have completed the questionnaire, 63.2% were female, 57.9% had Crohn's disease (CD) During the first wave of the pandemic, 74.2% of participants perceived themselves as a high-risk group for acquiring coronavirus disease 2019 only because they suffered from inflammatory bowel disease, and 66.2% thought inflammatory bowel disease medications make them more susceptible to coronavirus disease 2019. This especially concerned patients treated with biologics (B = 2.068, P < .01). Females were more stressed (B = -1.451, P < .01) and concerned (B = -1.488, P < .01) about the pandemic, and they also reported more potential benefits from professional psychological help (B = -2.664, P = .02). Six patients (5.3%) discontinued inflammatory bowel disease therapy on their own initiative. Seventy-eight (68.4%) patients were completely satisfied and 14 (12.3%) were partially satisfied with the quality of healthcare provided in our inflammatory bowel disease center.

CONCLUSION

Female inflammatory bowel disease patients tend to be more emotionally vulnerable during severe acute respiratory syndrome coronavirus 2 pandemic. Although psychological support should be continuously available to all inflammatory bowel disease patients, female gender may warrant special attention. Providing patients with adequate and early information during pandemic probably leads to better compliance and higher satisfaction.

Expression of adipokine ghrelin and ghrelin receptor in human colorectal adenoma and correlation with the grade of dysplasia

BACKGROUND

Ghrelin is an adipokine that plays an important role in energy balance. Expression of ghrelin and ghrelin receptor has been investigated in different tissues and tumors. Studies regarding expression of ghrelin and ghrelin receptor in colorectal tumors are scarce and no data on expression of ghrelin and its receptor in colorectal adenomas has been published. Ghrelin and ghrelin receptor were highly expressed in colon carcinoma cells while expression was decreased in less differentiated tumors, presuming that ghrelin might be important in early phases of tumorigenesis.

AIM

To investigate the expression of ghrelin and ghrelin receptor in human colorectal adenomas and adjacent colorectal tissue.

METHODS

In this prospective study (conducted from June 2015 until May 2019) we included 92 patients (64 male and 28 female) who underwent polypectomy for colorectal adenomas in the Department of Gastroenterology and Hepatology, “Sestre milosrdnice” Clinical Hospital Center in Zagreb, Croatia. After endoscopic removal of colorectal adenoma, an additional sample of colon mucosa in the proximity of the adenoma was collected for pathohistological analysis. Adenomas were graded according to the stage of dysplasia, and ghrelin and ghrelin receptor expression were determined immunohistochemically in both adenoma and adjacent colon tissue using the polyclonal antibody for ghrelin (ab150514, ABCAM Inc, Cambridge, United States) and ghrelin receptor (ab48285, ABCAM Inc, Cambridge, United States). Categorical and nominal variables were described through frequencies and proportions and the difference between specific groups were analyzed with Fisher’s and Fisher-Freeman-Halton’s method respectively. Spearman's rank correlation coefficient was determined for correlation of expression of ghrelin and ghrelin receptor in adenoma and adjacent colon tissue with the grade of adenoma dysplasia.

RESULTS

Among 92 patients with colorectal adenoma 43 had adenomas with high-grade dysplasia (46.7%). High expression of ghrelin was 7 times more common in high-grade adenoma compared to low-grade adenomas (13.95% to 2.04%, P = 0.048), while the expression of ghrelin in adjacent colon tissue was low. We found no correlation between ghrelin receptor expression in adenoma and adjacent colon tissue and the grade of colorectal adenoma dysplasia. The most significant correlation was found between ghrelin and ghrelin receptor expression in adenomas with high-grade dysplasia (rho = 0.519, P < 0.001).

CONCLUSION

Ghrelin and ghrelin receptor are expressed in colorectal adenoma and adjacent tissue with ghrelin expression being more pronounced in high grade dysplasia as a possible consequence of increased local synthesis.

Therapy of nonalcoholic fatty liver disease: current status

Nonalcoholic fatty liver disease (NAFLD), the hepatic manifestation of the metabolic syndrome, has become a common entity in clinical practice. In most of the patients it presents as simple steatosis with nonprogressive clinical course. However, some patients have progressive form of NAFLD, nonalcoholic steatohepatitis (NASH), and are at increased risk of developing cirrhosis and hepatocellular carcinoma. NAFLD treatment includes lifestyle modifications and pharmacotherapy aiming at increasing insulin sensitivity, and attenuating inflammation and hepatic fibrosis. Weight reduction has consistently been shown to reduce levels of liver enzymes and insulin resistance. Although dietary intervention and exercise remain the first-line therapy, due to low patients compliance to these measures pharmacotherapy or surgical approaches are often required. Metformin and thiazolidinediones may improve insulin sensitivity, serum aminotransferase level and liver histology. However, little evidence exists regarding their sustained effects after drug discontinuation which, together with their side effects, limits their widespread use in clinical practice. Statins appear to be safe agents for the treatment of hyperlipidemia, although trials documenting their efficacy in NAFLD are scarce. Based on the recent clinical trials, weight loss medication orlistat, ursodeoxycholic acid and antioxidant agents could potentially be used as adjunctive therapy. Considering still largely controversial clinical data regarding pharmacological agents, their high cost and known side-effects, lifestyle modifications at present remain the only essential considerations in the NAFLD treatment.

Pericarditis in exacerbation of ulcerative colitis

Acute pericarditis occurs very rarely in association with inflammatory bowel disease (IBD). It has been described both as an extraintestinal manifestation of IBD and as an adverse drug reaction in IBD treatment. We present a case of a 26-year-old female patient with a severe exacerbation of ulcerative colitis, who was previously under long-term treatment with mesalazine and low-dose prednisone. The literature on pericardial involvement in IBD is reviewed.

Physicochemical Properties of Dodecylammonium Picrate

A novel surfactant, dodecylammonium picrate (DDAP), was synthesized and its crystal structure was determined by X-ray diffraction analysis. DDAP's physicochemical properties were examined by spectral (infrared and nuclear magnetic resonance), thermal, microscopic, and conductometric studies. The results revealed the influence of counterion specificity on thermal solid-state transitions and solution properties: the Krafft point, the aqueous solubility, the critical micelle concentration, the degree of counterion binding, and thermodynamic parameters of micellization. Copyright 2000 Academic Press.

Solid State Transitions of Asymmetric Catanionic Surfactants

A series of asymmetric surfactants were prepared from cationic surfactant, hexadecyltrimethylammonium bromide, and anionic surfactant, sodium alkyl sulfate (the number of carbon atoms per chain being 10, 12, or 14). The influence of the alkyl chain asymmetry on the thermal properties of formed hexadecyltrimethylammonium alkyl sulfates was investigated by means of polarizing microscopy, differential scanning calorimetry, and X-ray diffraction. Asymmetric catanionic surfactants exhibited a complex polymorphism and thermotropic mesomorphism from the stable crystalline form to the isotropic phase. On heating, successive phase transitions (several solid crystalline-solid crystalline, solid crystalline-liquid crystalline, and liquid crystalline-isotropic liquid) were observed. The number of polymorphs, in all of the bilayered structure, depended on the asymmetry between the lengths of surfactant tails. The basic lamellar thickness varied linearly with the increase of alkyl sulfate chain length. An increase of the basic lamellar thickness with temperature was determined. Polarizing microscopy revealed a characteristic texture of the smectic phase. On cooling, all compounds underwent reversibly the isotropic liquid-liquid crystalline transitions, while crystallization from melted samples was kinetically controlled. Copyright 1999 Academic Press.