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Introduction Infections are the most frequent and severe complications of acute necrotizing pancreatitis with a mortality rate of up to 80 percent. Although experimental and clinical studies suggest that the microbiologic source of pancreatic infection could be enteric, information in this regard is controversial. Case presentation We describe a Citrobacter freundii isolation by endoscopy ultrasound fine needle aspiration in a 80-year-old Caucasian man with pancreatic pseudocyst after acute necrotizing pancreatitis. Conclusion Our case report confirms that this organism can be recovered in patients with a pancreatic pseudocyst. On-site cytology feedback was crucial to the successful outcome of this case as immediate interpretation of the fine needle aspiration sample directed the appropriate cultures and, ultimately, the curative therapy. To the best of our knowledge, this is the first reported case of isolated pancreatic C. freundii diagnosed by endoscopy ultrasound fine needle aspiration.

Pancreatic cancer (PC) is considered as one of the malignant tumors with poorest survival rate (less than 5% 5-year survival). Despite new developments in imaging techniques, surgery and oncologic treatments, survival rate remains unchanged. In order to improve the outcome of this disease, it would be of interest the development of a screening program trying to detect small asymptomatic tumors or precursor lesions at the time when the disease is still at a curable stage. Although screening in general population is not feasible nowadays, screening programs in high risk individuals may be of help in this setting. A specific population has been defined to be screened, those with a10-fold increased risk for developing the disease (inherited PC syndromes due to inherited gene mutations and individuals with a strong family history of PC with at least 2 first-degree relatives affected, but without a known genetic defect). Regarding the methods for screening, endoscopic ultrasound (EUS) and magnetic resonance imaging (MRI) appears to be the most accurate, mainly based in their ability to detect those small pancreatic tumors and precursor lesions (like IPMN and PanIN lesions). In these patients screening should start at the age of 45, or 15 years earlier than the earliest occurrence of PC in the family, whichever is the earlier age. Explorations should be schedule every 1 to 3 years, depending on initial findings.

To evaluate the diagnostic accuracy of histological evaluation of pancreatic tissue samples obtained by a modified method for recovering and processing the endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA) material in the differential diagnosis of pancreatic solid masses.Sixty-two consecutive patients with pancreatic masses were prospectively studied. EUS was performed by the linear scanning Pentax FG-38UX echoendoscope. Three FNAs (22G needle) were carried out during each procedure. The materials obtained with first and second punctures were processed for cytological study. Materials of the third puncture were recovered into 10% formol solution by careful injection of saline solution through the needle, and processed for histological study.Length of the core specimen obtained for histological analysis was 6.5 +/- 5.3 mm (range 1-22 mm). Cytological and histological samples were considered as adequate in 51 (82.3%) and 52 cases (83.9%), respectively. Overall sensitivity of both pancreatic cytology and histology for diagnosis of malignancy was 68.4%. Contrary to cytology, histology was able to diagnose tumours other than adenocarcinomas, and all cases of inflammatory masses. Combination of cytology and histology allowed obtaining an adequate sample in 56 cases (90.3%), with a global sensitivity of 84.21%, specificity of 100% and an overall accuracy of 90.32%. The complication rate was 1.6%.Adequate pancreatic core specimens for histological examination can be obtained by EUS-guided FNA. This technique is mainly useful for the diagnosis of different types of pancreatic tumours and evaluation of benign diseases.

To the Editor: Darier's Disease (DD) is an uncommon, inherited, disorder characterized by abnormal keratinization in the epidermis, nails and mucosae [1]. Clinically, DD runs its course with hyperk...

Endoscopic ultrasound (EUS) guided biopsy allows cytologic and/or histologic diagnosis of sub-mucosal lesions of the gastrointestinal tract (GIT). The diagnostic yield with fine needle aspiration (FNA), however, is often unsatisfactory (~30-40%). A newly developed Pro-Core needle (PCN) is able to obtain core tissue and may improve diagnostic yield. AIM: To compare the performance of two EUS guided biopsy needle systems, FNA versus PCN, in the evaluation of sub-mucosal lesions in the upper GIT. METHODS: Data related to patients referred for EUS and possible guided biopsy of sub-mucosal lesions in the upper GIT over 24 months were retrospectively reviewed. All specimens were prepared as cell-block for histo-cytological analysis. Measured outcomes were presence of diagnostic material, ability to perform immunohistochemistry (IHC), provision of a diagnosis, and complication. RESULTS: Of 84 patients who had EUS evaluation of an upper GIT sub-mucosal lesion, 30 patients did not have biopsy (lipoma=14, duplication cysts=6, vascular compression=1 and no abnormality=9). EUS-guided biopsy were performed in 54 patients, using 19-22G FNA (n=34) and 22G PCN (n=20) system, to clarify the tissue diagnosis of a hypo-echoic submucosal mass. There were no differences in age (61.1±2.6 vs. 59.2±5.3 yrs), gender (13M:17F vs. 3M:8F), site (22gastric : 8duodenal : 4esophageal vs. 17gastric : 1duodenal : 2esophageal) or size (2.1±0.1 vs. 2.1±0.3 cm) of biopsied lesion between the FNA and PCN groups, respectively. Biopsy with PCN obtained significantly more diagnostic material than FNA, leading to a substantially higher diagnostic yield (18/20 vs. 14/34; P ,0.001). Of the 17 suspected spindle cell tumours from the PCN group, IHC study (c-kit stain) were successful in all cases and provided tissue confirmation of 10 leiomyomas and 7 gastrointestinal stromal tumours (GIST). In contrast, only 7/14 patients with FNA needle had sufficient material for additional IHC study (P=0.008, vs. PCN), confirming GIST in only 3/12 of suspected spindle cell tumours. Neither group had abdominal pain or clinical significant bleeding after the biopsy. CONCLUSIONS: EUS guided biopsy with 22G PCN has substantially higher histocytological yield than that with FNA needles (90% vs. 41%) and without any complication. PCN, therefore, should be the needle of choice for tissue acquisition of sub-mucosal lesions in the GIT.

“cases” and healthy subjects as “controls” (who were selected from outside the hospital and had not chronic diseases; patients with most common functional gastrointestinal diseases were ruled out by a questionnaire considering Rome III criteria). Alexithymia was defined as a specific disturbance in psychic functioning characterized by difficulties in the capacity to verbalize affect. The level of alexithymia was determined using the Toronto Alexithymia Scale (TAS-20), adapted and validated in Spanish, through a self-administered questionnaire that assessed 3 concepts: (1) difficulty identifying feelings, (2) difficulty describing one’s feelings to others, and (3) externally oriented thinking. Alexithymia presence was defined by a score 61 on TAS-20. We calculated the risk (OR and CI95%) of having alexithymia in patients with IBD. Results: We analyzed 121 subjects:60 adult patients with IBD and 61 healthy adults from the general population. Among cases, 62% had ulcerative colitis and 38% Crohn’s disease; media age was 41 years (SD±13, range 17 85), 52% were male. Among the control group, mean age was 35 years (SD±13, range 19 81), 25% were male. The mean score of alexithymia was 46±14 in the cases and 39±11 in controls (p < 0.01). 23% (CI 13 36) of cases and 5% (CI 1 13) of controls had alexithymia (p < 0.01). Patients with IBD had higher risk of alexithymia compared to healthy controls: OR 5.88 (CI 1.45 27). After adjusting for gender, no significant differences in the level of alexithymia (p = 0.28) was observed. In the TAS-20, the main differences between the two groups were found in the items assessing “difficulty identifying feelings” (p < 0.01) and “difficulty describing feelings to others” (p = 0.04). Conclusions: Patients with IBD had almost 6 more chances to have alexithymia compared to healthy adults.

Differential Diagnosis of Solid Pancreatic Masses: Do Procore Histology Needles Improve the Diagnostic Yield of Standard Cytology Needles? Julio Iglesias-Garcia*, Ihab Abdulkader, Jose Larino-Noia, Enrique Dominguez-Munoz Gastroenterology, University Hospital of Santiago, Santiago de Compostela, Spain; Foundation for research in digestive diseases, Santiago de Compostela, Spain; Pathology, University Hospital of Santiago, Santiago de Compostela, Spain Endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA) is an accurate technique for sampling pancreatic solid lesions. However, cytology has a limited yield and accuracy, which may be overcome if histological specimens are provided to the pathologist. Aim of the study was to evaluate the accuracy of the newly developed 19-gauge and 22-gauge Procore needles, compared to the standard FNA needles. Methods: 203 consecutive patients (mean age 66.4 years, range 28-92, 123 male), who underwent EUS for the evaluation of solid pancreatic masses were prospectively included in the study. EUS was performed using a convex array echoendoscope, connected to an ultrasound equipment. Samples obtained with Procore needles (19 and 22 gauge, Cook Medical Inc, Limerick Ireland), were recovered into cytolit and processed for histological analysis, after just one needle pass. Samples obtained with standard cytology needles (22 and 25 gauge, Cook Medical Inc, Limerick Ireland), were recovered into slides and fixed for cytological evaluation, following the standard methodology after 2-4 needle passes. Results were compared to the gold standard of surgical histopathology, or global clinical and radiological assessment and follow-up in non-operated cases. Results are shown as mean or percentage (95%CI), and compared by chi-square test. Diagnostic accuracy was evaluated. Results: Mean size of solid pancreatic masses was 38.3 18.9 mm. 127 tumors were located in the head of the pancreas, 62 in the body, and 14 in the tail. 80 punctures (39.4%) were performed with Procore needles (35 with 19-gauge and 45 with 22-gauge), and 123 (60.6%) with standard cytology needles (72 with 25gauge and 59 with 22-gauge). Sensitivity, specificity, PPV and NPV for malignancy were 92.5%, 100%, 100% and 70.5% respectively with Procore needles, and 74.5%, 100%, 100% and 45% respectively with standard citology needles. Overall diagnostic accuracy of Procore needles (93.75%) was significantly higher than cytology needles (79.7%) (p 0.0039). Conclusion: EUSguided biopsy of solid pancreatic masses with the new Procore needle is significantly more accurate than with the standard cytology needle.

Background:Etiologies of recurrent pancreatitis include anatomical anomalies, hereditary, metabolic and autoimmune disorders. A significant number of patients remain with a diagnosis of idiopathic pancreatitis. The advent of genetic analysis and electrophysiologic testing may further assist in the diagnostic process. Evidence has shown that specific genetic mutations in the cationic trypsinogen gene PRSS1 and the SPINK1 gene for pancreatic secretory trypsin inhibitor cause pancreatitis; furthermore cystic fibrosis transmembrane conductance regulator (CFTR) gene mutations have been associated with pancreatitis. Aims :To present the work-up of patients with recurrent pancreatitis referred for genetic analysis and electrophysiological testing. Methods : Patients with recurrent, acute pancreatitis with no known etilology were referred to the Electrophysiology Laboratory, Division of Pediatric GI at Hadassah University Hospital for PRSS1 and SPINK1 gene mutations as well as evaluation of CFTR function by Nasal Potential Difference (NPD) testing. Results: A total of 42 patients with recurrent pancreatitis were evaluated; the mean age was 21 years ±14.9 years (range 2-54 yrs). A third (33%) of the patients was of Ashkenazi ancestry, 41% of mainly Sephardic ancestry, 24% of Arab ancestry and the remaining 2% of other ethnic background. There was a family history in 8 patients. The patients had a mean of 4 episodes (range 1-25). 6 (14%) patients showed PRSS1 genemutation (p.R112H and p.K23R) including 2 sets of siblings of Georgian Jewish ancestry with p.K23R. No SPINK1 mutation was found in the 26 patients submitted for testing. 3 patients out of 21 submitted for CFTR gene testing showed mutations (5T, F508del/p.L997F and D1152H/5T). 26 (61%) patients underwent sweat testing, with 13 patients with results >40 mmol/L. 35 (83%) patients had Nasal Potential Difference testing, 4 (11.5%) with abnormal results: 3 had sweat chloride>60mmol/L with no CFTR mutations found but one patient with D1152H/5T had a sweat test of 30 mmol/L. None of the 6 patients with PRSS1 gene mutation showed any concomitant CFTR dysfunction (by NPD or sweat testing) or gene mutation.Conclusion:This is the first study on recurrent pancreatitis in Israel examining both the presence of susceptibility gene mutations for pancreatitis and CFTR dysfunction. A prospective study with a larger number of patients may further clarify the impact of genetic mutations and CFTR dysfunction on the clinical presentation and outcome of recurrent pancreatitis.