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Gast ric antral vascular ectasia (GAVE) is a rare cause of upper gastrointestinal (GI) bleeding, accounting for 4% of nonvariceal upper GI bleeding and associated with occult bleeding that manifests as iron deficiency anemia. 1 In recent years, it has emerged as a distinctive, well-defined entity within the spectrum of acquired vasculopathies of the stomach.We report two cases of GAVE presenting with two different endoscopy findings. We discuss the etiology, endoscopic features, histology, pathogenesis, and management options of this rare entity, and present a review of the pertinent literature. Case 1A man, age 57 years, presented with a one-week history of hematemesis. He described three episodes of coffee ground emesis, about a half-cupful on each occasion. The most recent episode occurred on the day of admission. His past medical history was significant for alcoholic cirrhosis with portal hypertension. He had an episode of hematochezia in the past that was diagnosed as a diverticular bleed on colonoscopy. His social history was significant for alcohol abuse, but he had quit drinking about 10 years prior.His vital signs showed a temperature of 98.9 o F, pulse 102 beats/minute, respiratory rate 16 breaths/minute, and blood pressure 120/79 mm Hg. Physical examination revealed a pale, jaundiced, malnourished male with ascites, pedal edema, and bilateral basal crackles. Initial laboratory studies were significant for hemoglobin of 8.8 gm/dL (reference range 12.9-17.3 g/dL). Serum liver tests Gastric antral vascular ectasia is the source of up to 4% of nonvariceal upper gastrointestinal bleeding. It can present with occult bleeding requiring transfusions or with acute gastrointestinal bleeding. It is associated with significant morbidity and mortality and has been associated with such underlying chronic diseases as scleroderma, diabetes mellitus, and hypertension. Approximately 30% of cases are associated with cirrhosis. We report two cases of gastric antral vascular ectasia with two strikingly different endoscopic appearances. We further describe the clinical, endoscopic, histologic, and therapeutic aspects of this entity.

Patients with end-stage renal disease (ESRD) and on dialysis are at increased risk of pneumococcal disease. We evaluated the immunogenicity of the 13-valent pneumococcal conjugate vaccine (PCV13) in this population. Eligible patients with ESRD and on dialysis were given a single dose of PCV13. The concentrations of serum antibodies against 13 pneumococcal capsular polysaccharides were measured at the baseline and at 2 and 12 months postvaccination. A response to the vaccine was defined as a >2-fold increase in antibody concentration from that at the baseline and an absolute postvaccination value of at least 1 g/ml. Seventeen patients completed the study. Increases in the concentrations of antibodies to the vaccine serotype were demonstrated 2 months after vaccination. The geometric mean antibody concentrations at 12 months postvaccination declined by 38% to 72% compared to those measured at 2 months postvaccination. A response to at least 1 serotype in the vaccine was seen in all patients at both 2 and 12 months postvaccination. The overall rate of the response to each individual vaccine serotype varied between 23.5% and 94.1% at 2 months postvaccination and 23.5% and 65% at 12 months postvaccination. Pain at the injection site was the most common local reaction. Vaccination with PCV13 induces antibody responses to vaccine serotypes in patients with ESRD and on dialysis at 2 months postvaccination. However, the decline in antibody concentrations at 12 months postvaccination with a conjugate pneumococcal vaccine requires further study. (This study has been registered at ClinicalTrials.gov under registration no. NCT01974817.) P atients with end-stage renal disease (ESRD) and on dialysis are predisposed to infections with Streptococcus pneumoniae (1). Mortality rates from pneumonia in dialysis patients are about 10 to 16 times higher than those in the general population (2, 3). Furthermore, the emergence of multiple-antibiotic-resistant pneumococcal strains has added to this therapeutic challenge. This has led to an increased focus on vaccination for the prevention of pneumococcal diseases in this subset of patients.End-stage renal disease is associated with disorders of the adaptive immune system, which result in decreases in antigenpresenting function, the T-cell-mediated immune response, and immunological memory (4, 5). These patients are thus at risk of vaccine hyporesponsiveness. There is evidence of a decreased immunologic response to the 23-valent pneumococcal polysaccharide vaccine (PPSV23) in patients undergoing dialysis compared to that in the general population (6, 7). Moreover, a rapid decline in anti-pneumococcal IgG levels is observed in patients with ESRD within 1 year after vaccination with PPSV23 (8).PPSV23 predominantly induces a T-cell-independent immune response, and hence, immunologic memory is not achieved (9, 10). Conjugate polysaccharide vaccines, which incorporate a protein carrier (diphtheria toxin cross-reactive material 197 [CRM 197 ]) to the purified capsular saccharides of S. pneumoni...

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EDITORIAL COMMENT In this histological study of surgical specimens it has been shown that duodenal ulcer is associated with mild inflammation and gastric ulcer with marked changes and degeneration with metaplasia.Very few detailed descriptions of the antrum are available in the literature, yet the importance of this organ has been stressed by many writers in the past (Konjetzny, 1928;Faber, 1935;Hebbel, 1943; Magnus, 1954;Dean and Mason, 1964; and others). An attempt has been made in this laboratory to study the gastric antrum in normal stomachs and in duodenal and gastric ulcer in greater detail. METHODSOne hundred and thirty specimens were examined. Seventy-five of these were surgical specimens from cases of duodenal ulcer and 40 from cases of gastric ulcer. Sixteen were from post-mortem specimens removed within a few hours of death, in which as far as could be ascertained, there was no question of gastrointestinal disease. The surgical specimens were opened immediately after operation by cutting along the greater curvature and they were pinned out with care on cork mats. They were formalin fixed immediately. The specimens with duodenal ulcer had a cuff of duodenum some 5 cm. in width. The amount of duodenum in gastric ulcer specimens was much reduced, but all the specimens showed an intact sphincter. The proximal portion of the specimen consisted of gastric mucosa.After fixation, the specimens were photographed. The size of the photograph was exactly the same as the size of the stomach. A tracing was made from the photograph onto thin paper. The whole of the specimen was cut into longitudinal strips 1-Ij cm. broad. Transverse cuts were then made through the strips at three places, the result being 30-40 shorter pieces measuring approximately 6 cm. in length. A plan of these cut strips was made on the tracing from the stomach. The strips were numbered and these numbers entered on the plan. The strips were then processed, blocked in wax, and sectioned on a sledge microtome. The boundary between the antrum and the body mucosa was studied and mapped out and the surface area of the antrum measured with a planimeter. This procedure enabled us to study thoroughly all of the gastric mucosa and get acquainted with the whole of its cellular topography.The stains used in this study were haematoxylin and eosin and Zimmerman's stain using the method described by Marks and Drysdale (1957); also 30 specimens were stained with Van Gieson stain. The Zimmerman stain was used to show up well the parietal, peptic, and mucous cells. The Van Gieson stain was used to show the increase in fibrous tissue in the mucosa and submucosa. RESULTS CLASSIFICATION OF THE INFLAMMATORY CHANGES Theinflammatory changes in the antral mucosa were classified as follows: 1 Changes showing inflammatory reaction and no destruction of pyloric glands, and according to severity, divided into grades Al and A2 (Figs. 1 and 2); 2 changes resulting in damage and destruction of the pyloric glands with increasing amounts of intestinalization. The final stage s...

Ganglioneuromatous proliferation in the gastrointestinal tract is a rare occurrence and is usually associated with specific syndrome complexes such as multiple endocrine neoplasia Type 2B or von Recklinghausen's disease. We report here a case of diffuse intestinal ganglioneuromatosis, presenting as intestinal obstruction and chronic constipation in an 11-year-old boy. Sporadic cases of intestinal ganglioneuromatosis in the absence of any systemic manifestations are a very rare cause of enteric motility disorders in childhood, and we discuss the pathological and clinical significance of this finding. Histopathological identification of this uncommon cause of a common pediatric problem is important since the condition is amenable to surgical treatment.

DesCripTionA 56-year-old man with a known history of type 2 diabetes mellitus, hypertension, nephrolithiasis and gout presented with fatigue and flank pain for 3 days. The above symptoms were associated with fevers and chills. On admission, the patient's vitals were remarkable for fever with maximum temperature (T max) 39.1°C, hypotension requiring pressor support and tachycardia. On auscultation, he had reduced air entry at lung bases, distended abdomen, bipedal oedema and petechial rash over the upper extremities and the trunks. In addition, there was purplish discolouration over the left medial sacral area. Laboratory work-up was remarkable for elevated white cell count 21.4x10 9 /L (4.0-12.0x10 9 /L), creatinine 7.98 mg/dL (0.60-1.40 mg/dL), anion gap of 25, erythrocyte sedimentation rate of 70 mm/hour (0-20 mm/hour), total bilirubin of 4.9 mg/dL (0.2-1.2 mg/dL) and lipase 422 U/L (0-140 U/L). Platelet count was 31×10 3 /µL (150-400 10 3 /µL), aspartate aminotransferase of 71 U/L (10-40 U/L) and alanine aminotransferase of 37 U/L (3-45 U/L). Septic shock was suspected, and the patient was placed on empiric coverage with piperacillin-tazobactam and vancomycin. His CT scan of the abdomen (figures 1 and 2) showed left emphysematous pyelonephritis and a 4 mm obstructing proximal left ureteral stone (figure 3). Urology was consulted, and the patient underwent cystoscopy with left ureteral stent placement. Interval CT abdomen and pelvis on the fourth day of antibiotic treatment showed resolution of air from the left pelvicalyceal system; however, it showed air bubbles within L5/S1 vertebral bodies and L5-S1 disc which was suggestive of emphysematous osteomyelitis (EO) (figures 4 and 5). The patient developed acute kidney injury, so antibiotics were switched to intravenous meropenem and linezolid. Blood cultures grew Escherichia coli (E. coli), linezolid (5 days) was then discontinued and meropenem (7 days) was then switched to ceftriaxone. Soon, he developed hives, it was attributed to ceftriaxone and was shifted to aztreonam which was renally dosed. Transoesophageal echo was performed since he had prolonged E. coli bacteraemia and was negative for vegetations. The blood cultures also cleared up, and he showed clinical improvement. He was subsequently discharged on aztreonam. A follow-up MRI of the back was recommended in 8 weeks.

Multiple myeloma is a neoplastic disease of plasma cells accounting for 13 % of haematological malignancies and 2 % of all malignancies worldwide. Ascites may develop very rarely during the course of disease in multiple myeloma. We report the case of a 78 years old male with IgG lambda multiple myeloma who initially presented with plasmacytic ascites. An exhaustive review of world literature reveals 65 cases of ascites to have been reported in myeloma over a span of 62 years (1952 till date), usually developing in the course of treatment. This is the 7th case of plasmacytic ascites to have been diagnosed at initial presentation. We review the clinical features, diagnosis, prognostic significance and treatment of such cases.