Case Reports in Gastrointestinal Medicine The latest articles from Hindawi Publishing Corporation © 2014 , Hindawi Publishing Corporation . All rights reserved. Treatment of a Gastric Lactobezoar with N-Acetylcysteine Sun, 23 Nov 2014 00:00:00 +0000 Lactobezoars are a rare finding with potentially serious sequelae in pediatric patients with feeding intolerance. Aggressive treatment may be preferred to traditional treatments to avoid complications in medically complex patients. In our patient, N-acetylcysteine lavage was a safe and effective alternative that resulted in rapid resolution of his feeding intolerance. Brandon Sparks and Anil Kesavan Copyright © 2014 Brandon Sparks and Anil Kesavan. All rights reserved. Biliary Cystadenoma: An Unusual Cause of Acute Pancreatitis and Indication for Mesohepatectomy Tue, 18 Nov 2014 12:21:13 +0000 The classic presentation of cystic hepatobiliary lesions is usually nonspecific and often identified incidentally. Here we describe the case of a patient presenting with acute pancreatitis resulting from a large centrally located biliary cystadenoma compressing the pancreas. Determination of the origin of the cystic lesion was difficult on imaging studies. Due to the difficult location of the lesion, a complete surgical resection was achieved with mesohepatectomy and the suspected diagnosis confirmed by pathology. The patient continues to do well 2 years post-op with no signs of recurrence. Bilal Munir, Michael Meschino, Ashley Mercado, and Roberto Hernandez-Alejandro Copyright © 2014 Bilal Munir et al. All rights reserved. Leclercia adecarboxylata Bacteremia in a Patient with Ulcerative Colitis Tue, 28 Oct 2014 00:00:00 +0000 Patients with inflammatory bowel disease (IBD) are a high risk population for bacteremia. Derangement in the mucosal architecture of the gastrointestinal (GI) tract and frequent endoscopic interventions in immunocompromised individuals are considered primary causes. Isolation of opportunistic microorganisms from the bloodstream of IBD patients has been increasingly reported in recent years. Leclercia adecarboxylata is a ubiquitous, aerobic, motile, gram-negative bacillus. The human GI tract is known to harbor this rarely pathogenic microorganism. There are only a few case reports of bacteremia with this microorganism; the majority are either polymicrobial or associated with immunocompromised patients. We describe a case of monomicrobial L. adecarboxylata bacteremia in a 43-year-old female who presented with bloody diarrhea. Colonoscopy revealed diffuse colonic mucosal inflammation with numerous ulcers, and histopathology revealed crypt abscesses. Following an episode of rectal bleeding, two sets of blood cultures grew L. adecarboxylata, which was treated with intravenous ceftriaxone. After a complicated hospital course, she was eventually diagnosed with ulcerative colitis and enteropathic arthritis, treated with intravenous methylprednisolone, mesalamine, and infliximab which resulted in resolution of her symptoms. In our previously immunocompetent patient, derangement of the gut mucosal barrier was the likely cause of bacteremia, yet performing endoscopic intervention may have contributed to bacterial translocation. Amir Kashani, Morteza Chitsazan, Kendrick Che, and Roger C. Garrison Copyright © 2014 Amir Kashani et al. All rights reserved. Dieulafoy Lesion in the Ascending Colon Presenting with Gastrointestinal Bleeding and Severe Anemia Complicated by a Coexisting Severe Resistant Chronic Idiopathic Thrombocytopenic Purpura Thu, 23 Oct 2014 10:40:26 +0000 Background. GI (gastrointestinal) bleeding can be due to a variety of etiologies ranging from being common like bleeding peptic ulcer disease or esophageal varices. One of the rarely documented causes is the Dieulafoy lesion which is known as an abnormally large ectatic artery that penetrates the gut wall, occasionally eroding through the mucosa causing massive bleeding. In addition to that, we refer to the uncommon presentation of Dieulafoy lesion itself as it is well known to be found in the stomach, esophagus, duodenum, and jejunum but not the ascending colon as in our case. The patient had a coexisting ITP (idiopathic thrombocytopenic purpura) that was resistant to different therapies. Case Report. We report a case of a 48-year-old Egyptian female known for chronic ITP resistant to treatment. The patient presented with bright red bleeding per rectum and severe life threatening anemia. Endoscopic study showed a Dieulafoy lesion. Endoscopic clipping was successful in controlling the bleeding. Conclusion. Dieulafoy lesion is a rare reason for GI bleeding and can present in common or unexpected places. Also extreme caution should be used in patients with bleeding tendency due to different reasons, like ITP in our case. Sherif Ali Eltawansy, Brag Thyagarajan, and Nadeem Baig Copyright © 2014 Sherif Ali Eltawansy et al. All rights reserved. Colonic Dieulafoy’s Lesion: A Rare Cause of Lower Gastrointestinal Hemorrhage and Review of Endoscopic Management Sun, 19 Oct 2014 09:46:24 +0000 Dieulafoy’s lesions are a rare cause of gastrointestinal hemorrhage. Extragastric Dieulafoy’s lesions are even more uncommon. We report the case of a 75-year-old woman who presented with gastrointestinal bleeding from a transverse colonic Dieulafoy’s lesion. She presented with two episodes of melena followed by one episode of fresh blood per rectum. In addition, there was associated presyncope and anemia (hemoglobin 69 g/L) in the setting of supratherapeutic warfarin anticoagulation (INR 6.2) for nonvalvular atrial fibrillation. Esophagogastroduodenoscopy was negative for an upper GI source of bleeding but on colonoscopy an actively oozing Dieulafoy’s lesion was identified in the transverse colon. Bipolar cautery and hemostatic endoclips were applied to achieve hemostasis. Clinicians should consider this rare entity as a potential cause of potentially life-threatening lower gastrointestinal bleeding and we review the endoscopic modalities effective for managing colonic Dieulafoy’s lesions. Christopher Ma, Rajveer Hundal, and Edwin J. Cheng Copyright © 2014 Christopher Ma et al. All rights reserved. Self-Expandable Metal Stent Placement for Closure of a Leak after Total Gastrectomy for Gastric Cancer: Report on Three Cases and Review of the Literature Thu, 09 Oct 2014 08:10:24 +0000 In the setting of the curative oncological surgery, the gastric surgery is exposed to complicated upper gastrointestinal leaks, and consequently the management of this problem has become more critically focused than was previously possible. We report here three cases of placement of a partially silicone-coated SEMS (Evolution Controlled Release Esophageal Stent System, Cook Medical, Winston-Salem, NC, USA) in patients who underwent total gastrectomy with Roux-en-Y end-to-side esophagojejunostomy for a gastric adenocarcinoma. The promising results of our report, despite the small number of patients, suggest that early stenting (through a partially silicone-coated SEMS) is a feasible alternative to surgical treatment in this subset of patients. In fact, in the treatment of leakage after total gastrectomy, plastic stents and totally covered metallic stents may not adhere sufficiently to the esophagojejunal walls and, as a result, migrate beyond the anastomosis. However, prospective studies with a larger number of patients might assess the real effectiveness and safety of this procedure. Dario Raimondo, Emanuele Sinagra, Tiziana Facella, Francesca Rossi, Marco Messina, Massimiliano Spada, Guido Martorana, Pier Enrico Marchesa, Rosario Squatrito, Giovanni Tomasello, Attilio Ignazio Lo Monte, Giancarlo Pompei, and Ennio La Rocca Copyright © 2014 Dario Raimondo et al. All rights reserved. Immediate Free Jejunum Transfer for Salvage Surgery of Gastric Tube Necrosis Wed, 01 Oct 2014 10:01:14 +0000 Gastric tube necrosis after esophagus cancer surgery is a rare but critical situation. Salvage reconstruction of the esophagus remains a challenging procedure for head and neck surgeons. Historically, surgeons have employed a two-stage salvage surgery consisting of debridement followed by reconstruction. While this procedure generates good results, the time to restart oral alimentation is long. The present report describes the case of a 62-year-old male who developed gastric tube necrosis 3 days after undergoing surgery for thoracic-cervical esophageal cancer and immediate reconstruction with the retrosternal gastric pullup technique. He was treated with debridement and simultaneous free jejunum transfer 4 days after the primary surgery. He was able to restart oral alimentation 10 days after the salvage surgery. This rapid return to oral alimentation is a major advantage of the one-stage immediate esophagus salvage reconstruction. Another advantage is the ease of the reconstructive procedure: the absence of scarring and prolonged inflammation, which are disadvantages of the two-stage procedure, meant that recipient vessel selection and anastomosis were uncomplicated. The one-step procedure may be particularly useful in cases where the inflammation is discovered early. Hiroki Umezawa, Takeshi Matsutani, Rei Ogawa, and Hiko Hyakusoku Copyright © 2014 Hiroki Umezawa et al. All rights reserved. Gallstone Ileus following Endoscopic Stone Extraction Sun, 28 Sep 2014 13:08:40 +0000 An 85-year-old woman was an outpatient treated at Tokyo Rosai Hospital for cirrhosis caused by hepatitis B. She had previously been diagnosed as having common bile duct stones, for which she underwent endoscopic retrograde cholangiopancreatography (ERCP). However, as stone removal was unsuccessful, a plastic stent was placed after endoscopic sphincterotomy. In October 2012, the stent was replaced endoscopically because she developed cholangitis due to stent occlusion. Seven days later, we performed ERCP to treat recurring cholangitis. During the procedure, the stone was successfully removed by a balloon catheter when cleaning the common bile duct. The next day, the patient developed abdominal pain, abdominal distension, and nausea and was diagnosed as having gallstone ileus based on abdominal computed tomography (CT) and abdominal ultrasonography findings of an incarcerated stone in the terminal ileum. Although colonoscopy was performed after inserting an ileus tube, no stone was visible. Subsequent CT imaging verified the disappearance of the incarcerated stone from the ileum, suggesting that the stone had been evacuated naturally via the transanal route. Although it is extremely rare for gallstone ileus to develop as a complication of ERCP, physicians should be aware of gallstone ileus and follow patients carefully, especially after removing huge stones. Yoshiya Yamauchi, Noritaka Wakui, Yasutsugu Asai, Nobuhiro Dan, Yuki Takeda, Nobuo Ueki, Takahumi Otsuka, Nobuyuki Oba, Shuta Nisinakagawa, and Tatsuya Kojima Copyright © 2014 Yoshiya Yamauchi et al. All rights reserved. Combined Use of Clips and Nylon Snare (“Tulip-Bundle”) as a Rescue Endoscopic Bleeding Control in a Mallory-Weiss Syndrome Thu, 25 Sep 2014 09:03:07 +0000 Mallory-Weiss syndrome (MWS) accounts for 6–14% of all cases of upper gastrointestinal bleeding. Prognosis of patients with MWS is generally good, with a benign course and rare recurrence of bleeding. However, no strict recommendations exist in regard to the mode of action after a failure of primary endoscopic hemostasis. We report a case of an 83-year-old male with MWS and rebleeding after the initial endoscopic treatment with epinephrine and clips. The final endoscopic control of bleeding was achieved by a combined application of clips and a nylon snare in a “tulip-bundle” fashion. The patient had an uneventful postprocedural clinical course and was discharged from the hospital five days later. To the best of our knowledge, this is the first case report showing the “tulip-bundle” technique as a rescue endoscopic bleeding control in the esophagus. Hrvoje Ivekovic, Bojana Radulovic, Suzana Jankovic, Pave Markos, and Nadan Rustemovic Copyright © 2014 Hrvoje Ivekovic et al. All rights reserved. Acute Abdomen Resulting from Concurrent Thrombosis of Celiac Trunk and Superior Mesenteric Artery Tue, 23 Sep 2014 00:00:00 +0000 Mesenteric ischemia is one of the most mortal diseases of the gastrointestinal system causing acute abdomen. In most of the patients, the etiological factor is the obstructive embolism or thrombosis of superior mesenteric artery. In the literature, there have been reports regarding also celiac trunk occlusion in rare situations. The gold standard treatment relies on early diagnosis. The originality of our report relies on the concurrent obstruction of both vascular structures. Savaş Bayrak, Hasan Bektas, Yigit Duzkoylu, Ayhan Guneyi, and Ekrem Cakar Copyright © 2014 Savaş Bayrak et al. All rights reserved. Stomach Carcinoma Presenting with a Synchronous Liver Cancer: A Case Report and Literature Review Mon, 22 Sep 2014 08:52:41 +0000 Multiple primary malignant neoplasms are two or more malignancies in an individual without any relationship between the tumors. Multiple primary malignancies are relatively rare but have increased in recent decades. Two cancers are commonly observed among those with multiple primary malignancies, but two malignancies of stomach and liver are relatively rare to be reported. Mechanisms of the tumors were unclear; we described a patient who had stomach carcinoma presenting with a synchronous liver cancer and investigated his family history; we suggest that family history may be a key risk factor and early detection for additional primary malignancies should be needed for patients who had specific cancer history in their pedigree. Early diagnosis may be the key risk factor affecting prognosis. Yong Wang and Xiao-ting Wu Copyright © 2014 Yong Wang and Xiao-ting Wu. All rights reserved. Psoas Muscle Infiltration Masquerading Distant Adenocarcinoma Mon, 22 Sep 2014 00:00:00 +0000 Malignant metastasis to the psoas muscle is rare. We report a case that clinically mimicked psoas abscess that was subsequently proven to be from metastatic disease secondary to adenocarcinoma of the duodenum. A 62-year-old male presented with a seven-month history of right lower quadrant abdominal pain and progressive dysphagia. CT scan of abdomen-pelvis revealed a right psoas infiltration not amenable to surgical drainage. Patient was treated with two courses of oral antibiotics without improvement. Repeated CT scan showed ill-defined low-density area with inflammatory changes involving the right psoas muscle. Using CT guidance, a fine needle aspiration biopsy of the right psoas was performed that reported metastatic undifferentiated adenocarcinoma. Patient underwent upper endoscopy, which showed a duodenal mass that was biopsied which also reported poorly differentiated adenocarcinoma. In this case, unresponsiveness to medical therapy or lack of improvement in imaging studies warrants consideration of differential diagnosis such as malignancy. Iliopsoas metastases have shown to mimic psoas abscess on their clinical presentation and in imaging studies. To facilitate early diagnosis and improve prognosis, patients who embody strong risk factors and symptoms compatible with underlying malignancies who present with psoas imaging concerning for abscess should have further investigations. Kamel A. Gharaibeh, Arnaldo Lopez-Ruiz, and Tauqeer Yousuf Copyright © 2014 Kamel A. Gharaibeh et al. All rights reserved. A Rare Presentation of Hepatitis A Infection with Extrahepatic Manifestations Sun, 14 Sep 2014 00:00:00 +0000 Hepatitis A has a variety of associated extrahepatic manifestations that clinicians should be aware of for early diagnosis and treatment. We report a unique case of hepatitis A presenting with multiple extrahepatic manifestations not previously described in a single patient. A 34-year-old male presented with sudden onset of left sided facial pain, swelling, and skin rash, with diffuse body pains and muscle weakness, and was found to be positive for hepatitis A immunoglobulin M (IgM). He was initially started on antibiotics for concerns of bacterial parotitis but did not show any improvement. A punch biopsy of his mandibular rash and swelling was done which showed lymphohistiocytic infiltration with a few eosinophils. A trial of prednisone resulted in improvement of his symptoms. Clinicians should be aware to look for hepatitis A infection in a patient with atypical clinical picture causing a widespread systemic inflammatory response. Treatment with prednisone may result in resolution. Geetika Bhatt, Varrinder S. Sandhu, and Charlene K. Mitchell Copyright © 2014 Geetika Bhatt et al. All rights reserved. Lupus Enteritis as an Initial Presentation of Systemic Lupus Erythematosus Thu, 11 Sep 2014 09:34:35 +0000 Systemic lupus erythematosus (SLE) is an autoimmune disorder which can affect multiple organs and clinical presentation is often a myriad of symptoms; therefore, the index of suspicion should rise when evaluating patients with multiorgan symptomatology. Lupus enteritis is a distinct subset of SLE, defined as either vasculitis or inflammation of the small bowel, with supportive image and/or biopsy findings. The clinical picture of lupus enteritis is often nonspecific, with mild to severe abdominal pain, diarrhea, and vomiting being the cardinal manifestations. Although considered a form of visceral or serosal vasculitis, lupus enteritis is seldom confirmed on histology, making computerized tomography (CT) the gold standard for diagnosis. Lupus enteritis is generally steroid-responsive, and the route of administration is based on clinical status and organ involvement, with preference for intravenous (IV) route in flares with significant tissue edema. The following case describes a young woman presenting with lupus enteritis and lupus panniculitis as an initial manifestation of SLE, the utilization of abdominal CT in diagnosis, and current treatment protocols used for lupus enteritis. Sisira Sran, Manpreet Sran, Narmisha Patel, and Prachi Anand Copyright © 2014 Sisira Sran et al. All rights reserved. An Esophagogastroduodenal Crohn’s-Like Disease in a Long-Standing Pan-Ulcerative Colitis Patient Wed, 10 Sep 2014 07:16:26 +0000 Inflammatory bowel disease (IBD) comprises the principal subtypes Crohn’s disease (CD) and ulcerative colitis (UC), with a fraction remaining as IBD unclassified (IBDU). Given the complexity of IBD manifestations in a patient over time and our increasing understanding of IBD biology, a modification in subtype diagnosis can also occur. Herein is a case of a 27-year-old female with well-controlled and long-standing pan-UC, who developed Crohn’s-like esophagogastroduodenitis. The difficulty in classifying IBD into a single traditional subtype, and the debated presentation of a coexistent IBD will be discussed. Christopher Moore, Shriram Jakate, and Ali Keshavarzian Copyright © 2014 Christopher Moore et al. All rights reserved. Obstructive Pseudotumor of Tuberculosis in a Young Woman: A Rare Presentation Tue, 02 Sep 2014 12:18:28 +0000 Retroperitoneal pseudotumor is an extremely rare presentation of extrapulmonary tuberculosis. The diagnosis of this paucibacillary disease is difficult which is usually misdiagnosed as a malignant tumor. High index of suspicion is required for early diagnosis and treatment of retroperitoneal pseudotumor which can affect prognosis of this disease. Because of its rarity and difficult diagnosis, we report an 18-year-old immunocompetent girl who presented with abdominal pain and vomiting. Upper endoscopy showed an exudative mass between the second and third parts of duodenum. Abdominal computed tomography (CT) revealed a large retroperitoneal mass with extension into small bowel. Exploratory laparotomy and histopathological examination of tissue showed calcified granuloma. Ziehl-Neelsen staining and PCR confirmed the tuberculosis. The patient was successfully treated with standard antituberculosis therapy. Seyyed Reza Fatemi, M. Ghobakhlou, and L. Alizadeh Copyright © 2014 Seyyed Reza Fatemi et al. All rights reserved. Unawareness of a Prolonged Retained Capsule Endoscopy: The Importance of Careful Follow-Up and Cooperation between Medical Institutions Tue, 02 Sep 2014 00:00:00 +0000 A 50-year-old man with anemia was referred to our hospital to undergo capsule endoscopy (CE), which revealed small intestinal ulcers. After 5 months of CE, he returned because of recurrent anemia without abdominal symptoms. Abdominal X-ray and computed tomography showed capsule retention in the small intestine at the pelvic cavity. The capsule remained at the same place for 7 days. We performed capsule retrieval by laparoscopy-assisted surgery with resection of the involved small intestine, including an ileal stricture. Resected specimen showed double ulcers with different morphologies, an ulcer scar with stricture, and a wide ulcer at the proximal side of the others. Each ulcer had different histopathological findings such as the degree of fibrosis and monocyte infiltration. These differences led us to consider that the proximal ulcer may have been secondarily induced by capsule retention. Our experience indicated that careful follow-up and the cooperation between medical institutions after CE examination should be undertaken for patients with incomplete examination, unknown excretion of the capsule, and/or ulcerative lesions despite the lack of abdominal symptoms. Additionally, a retained CE remaining over long periods and at the same place in the small intestine may lead to secondary ulceration. Susumu Saigusa, Masaki Ohi, Hiroki Imaoka, Tadanobu Shimura, Ryo Uratani, Yasuhiro Inoue, and Masato Kusunoki Copyright © 2014 Susumu Saigusa et al. All rights reserved. Collagenous Colitis Associated with Protein Losing Enteropathy in a Toddler Wed, 20 Aug 2014 09:22:42 +0000 Collagenous mucosal inflammatory disease is a rare gastrointestinal disorder that involves the columnar lining of gastric and intestinal mucosa and is characterized by a distinct subepithelial collagen deposition. Recent clinical and pathological evidence have indicated that collagenous mucosal inflammatory disease can be extensive disease that may concomitantly involve several gastrointestinal sites at the same time. This entity, however, occurs infrequently in children. It is even less common to find concomitant depositions of collagen in the mucosa of gastrointestinal sites other than the colon. Only two cases in pediatric literature reported concomitant involvement, one with gastric and colonic involvement and the other one with gastroduodenocolitis. We are reporting a 15-month-old boy who presented with severe diarrhea and diffuse edema secondary to hypoalbuminemia. Further testing documented protein losing enteropathy (PLE) associated with collagenous colitis. Osama F. Almadhoun, Philip J. Katzman, and Thomas Rossi Copyright © 2014 Osama F. Almadhoun et al. All rights reserved. Enteric Duplication Cyst Containing Squamous and Respiratory Epithelium: An Interesting Case of a Typically Pediatric Entity Presenting in an Adult Patient Wed, 20 Aug 2014 08:28:41 +0000 Enteric duplication cysts are rare congenital malformations that can occur at any point along the digestive tract, most commonly the small bowel. They are characterized by the presence of an outer layer of smooth muscle and an inner lining of mucosa that may resemble any portion of the digestive tract. Less commonly, cases have been reported that also contain mucosal components of nonintestinal origin. This entity is typically diagnosed in young children, but occasionally presents in adolescence and young adulthood. We present a rare case of a 21-year-old male who presented with nonspecific symptoms of abdominal discomfort and weight loss and was later found to have a 9 cm nonenhancing mass in the distal ileum on CT imaging. Laparoscopic dissection of the mass revealed a cystic lesion lined mainly by pseudostratified ciliated columnar respiratory-type epithelium, with patchy areas of squamous epithelium as well as villous columnar epithelium resembling small bowel. The unique histology and advanced patient age make this case a unique presentation of what is already a rare pathological entity. Jessica Leigh Baumann and Charmi Patel Copyright © 2014 Jessica Leigh Baumann and Charmi Patel. All rights reserved. Cutaneous Vasculitis, Interstitial Pneumonia with Crazy-Paving Appearance, and Positive pANCA in a Patient with Severe Crohn’s Disease Thu, 14 Aug 2014 12:29:07 +0000 Cutaneous vasculitis, interstitial pneumonia with crazy-paving appearance on high-resolution computed tomography, and repeated positive perinuclear anti-neutrophil cytoplasmic antibodies (pANCA) are rarely found together in patients with inflammatory bowel disease in the existing literature. We report the case of a Chinese patient previously diagnosed with cutaneous vasculitis and interstitial pneumonia, who presented with acute pain and mass in his right lower quadrant a couple of years later. The terminal ileum biopsy and postoperative pathology confirmed Crohn’s disease (CD). Guang-liang Chen, Juan Wang, Bao-zhen Li, Li-mei Li, Han-you Mo, and Shuang Ye Copyright © 2014 Guang-liang Chen et al. All rights reserved. Acute Pancreatitis as the Initial Presentation of Systematic Lupus Erythematosus Thu, 14 Aug 2014 07:22:04 +0000 Systematic lupus erythematosus (SLE) is a multisystem disease, including the gastrointestinal system in about half of SLE patients. As a rare complication of SLE, acute pancreatitis presents as generalized flare-ups in most cases of patients previously diagnosed with SLE. Here we report a rare case of acute pancreatitis as the initial presentation with later diagnosis of SLE. Yi Jia, Arleen Ortiz, Richard Mccallum, Hasan Salameh, and Pedro Serrato Copyright © 2014 Yi Jia et al. All rights reserved. Cephalexin Induced Cholestatic Jaundice Thu, 07 Aug 2014 10:33:28 +0000 Cephalexin is a very commonly prescribed orally administered antibiotic which has many potential side effects. Amongst these cholestatic jaundice has been infrequently reported as an adverse reaction. We present a case of a 57-year-old male who exhibited features of cholestatic jaundice including elevated liver function tests (LFTs) after taking cephalexin and showed improvement on removal of the offending agent. During this time he was symptomatically treated with cholestyramine. Complete resolution of LFTs was seen in four weeks. Cephalexin induced cholestasis is rare and hence requires a high degree of clinical suspicion for prompt diagnosis and treatment. Abhinav Agrawal, Mana Rao, Sarfaraz Jasdanwala, Ajay Mathur, and Margaret Eng Copyright © 2014 Abhinav Agrawal et al. All rights reserved. Small Bowel Pleomorphic Liposarcoma: A Rare Cause of Gastrointestinal Bleeding Mon, 04 Aug 2014 06:45:23 +0000 In this case report we present a 60-year-old male patient with overt midgastrointestinal bleeding of a primary ileal pleomorphic liposarcoma diagnosed by video capsule endoscopy (VCE). Clinical work-up for final diagnosis and the pathological background of this uncommon tumorous entity of the small bowel will be discussed in this paper. Simon Nennstiel, Martin Mollenhauer, Christoph Schlag, Valentin Becker, Bruno Neu, Norbert Hüser, Ralf Gertler, Roland M. Schmid, and Stefan von Delius Copyright © 2014 Simon Nennstiel et al. All rights reserved. Embedded Pork Bone Causing Esophageal Perforation and an Esophagus-Innominate Artery Fistula Sun, 03 Aug 2014 09:11:41 +0000 Chronically embedded foreign bodies can lead to perforations, mediastinitis, and abscess, amongst a host of other complications. A 20-year-old mentally challenged female presented with “something stuck in her throat,” severe dysphagia, and recurrent vomiting. Initial imaging was unremarkable; however, subsequent imaging and esophagogastroduodenoscopy two weeks later revealed an embedded pork bone. Surgery was performed to remove the bone and fix the subsequent esophageal perforation and esophagus-innominate artery fistula. This case helps reinforce the urgency in removing an ingested foreign body and the ramifications that may arise with chronically embedded foreign bodies. Andrew C. Berry, Peter V. Draganov, Brijesh B. Patel, Danny Avalos, Warren L. Reuther III, Avinash Ravilla, Bruce B. Berry, and Michael J. Monzel Copyright © 2014 Andrew C. Berry et al. All rights reserved. Gastric Emphysema a Spectrum of Pneumatosis Intestinalis: A Case Report and Literature Review Tue, 01 Jul 2014 08:35:11 +0000 The finding of gas within the gastric wall is not a disease by itself, rather than a sign of an underlying condition which could be systemic or gastric. We present the case of a woman identified with gastric emphysema secondary to the administration of high doses of steroids, with the purpose of differentiating emphysematous gastritis versus gastric emphysema due to the divergent prognostic implications. Gastric emphysema entails a more benign course, opposed to emphysematous gastritis which often presents as an acute abdomen and carries a worse prognosis. Owing to the lack of established diagnostic criteria, computed tomography is the assessment method of choice. Currently no guidelines are available for the management of this entity, since the evidence is limited to a few case series and a considerable number of single case reports. Guillermo López-Medina, Roxana Castillo Díaz de León, Alberto Carlos Heredia-Salazar, and Daniel Ramón Hernández-Salcedo Copyright © 2014 Guillermo López-Medina et al. All rights reserved. Severe Hypercholesterolemia: A Unique Presentation of Non-Hodgkin’s Lymphoma in a Patient with Neurofibromatosis Type 1 Tue, 01 Jul 2014 00:00:00 +0000 We report a case of non-Hodgkin’s lymphoma (NHL) with an unusual initial manifestation as severe hypercholesterolemia and obstructive jaundice in a patient with neurofibromatosis type 1 (NF 1). NHL should be considered in the evaluation of obstructive jaundice alone or in combination with severe hypercholesterolemia. Relief of biliary obstruction led to the resolution of hypercholesterolemia in our 59-year-old male patient, followed by doxorubicin-based chemotherapy for the underlying lymphoma. NF 1 is a genetic condition that results from a defect in a tumor-suppressor gene and it is likely that this led to the development of NHL in our patient. It is important that clinicians are familiar with the gastrointestinal manifestations of NF 1, especially its association with intra-abdominal malignancies, when treating patients with a personal or family history. To the best of our knowledge, this is the first case of NHL presenting initially as severe hypercholesterolemia and it is also one of the few instances where NHL has been reported in association with NF 1. Kenechukwu Chudy-Onwugaje, Nnaemeka Anyadike, Yuriy Tsirlin, Ira Mayer, and Rabin Rahmani Copyright © 2014 Kenechukwu Chudy-Onwugaje et al. All rights reserved. A Rare Case of Metastatic Malignant Melanoma to the Colon from an Unknown Primary Mon, 30 Jun 2014 11:31:41 +0000 Metastatic melanoma from an unknown primary (MUP) is rare; its occurrence in the gastrointestinal tract is of exceedingly low prevalence. We report a case of a 73-year-old man with metastatic malignant melanoma to the colon from an unknown primary. The rarity of MUP and importance of screening for gastrointestinal metastasis in patients with malignant melanoma are discussed along with the role of surgical resection in improving prognosis and overall survival. Preethi Reddy, Courtney Walker, and Bianca Afonso Copyright © 2014 Preethi Reddy et al. All rights reserved. Black Cohosh and Liver Toxicity: Is There a Relationship? Mon, 30 Jun 2014 11:15:27 +0000 Herbal supplements are commonly used by patients for various problems. It is a well-known fact that most patients do not tell their physicians about the use of herbal supplements unless they are specifically asked. As a result, sometimes important information regarding drug side effects is missed in history taking. During our literature search, we found several retrospective studies and other meta-analyses that claim a lacking or weak link between black cohosh use and hepatotoxicity. We present a case of a 44-year-old female who developed subacute liver injury demonstrated on a CT scan and liver biopsy within a month of using the drug to resolve her hot flashes and discuss a possible temporal and causal association between black cohosh use and liver disease. Since the patient was not taking any other drugs, we concluded that the acute liver injury was caused by the use of black cohosh. We agree with the United States Pharmacopeia recommendations that a cautionary warning about hepatotoxicity should be labeled on the drug package. Mohammed Muqeet Adnan, Muhammad Khan, Syed Hashmi, Muhammad Hamza, Sufyan AbdulMujeeb, and Syed Amer Copyright © 2014 Mohammed Muqeet Adnan et al. All rights reserved. Concurrent Esophageal Dysplasia and Leiomyoma Sun, 29 Jun 2014 08:51:14 +0000 Esophageal leiomyomas (ELMs) are rare but described in the literature. They are usually benign and do not require resection unless they are large and symptomatic. Most of such masses arise from the muscularis mucosa. It is very uncommon to find epithelial dysplasia overlying a subepithelial leiomyoma. A review of the literature reveals only one prior case of ELM with an overlying epithelia dysplasia and here we report a second case. Asim Shuja and Khalid A. Alkimawi Copyright © 2014 Asim Shuja and Khalid A. Alkimawi. All rights reserved. Irinotecan Plus S-1 Followed by Hepatectomy for a Patient with Initially Unresectable Colorectal Liver Metastases, Who Showed Severe Drug Rash with Oxaliplatin Plus 5-FU and Leucovorin (FOLFOX) Tue, 17 Jun 2014 09:14:08 +0000 For unresectable colorectal liver metastases (CRLM), hepatic resection with or without chemotherapy is the only curative treatment that sufficiently achieves long-term survival. However, occasional severe allergic responses to anticancer drugs necessitate treatment discontinuation. A 45-year-old woman presented with metachronous unresectable colorectal liver metastases. Chemotherapy with oxaliplatin plus 5-FU and leucovorin (FOLFOX) was initiated, but severe allergic dermatitis developed after the second cycle. Although she reported no prior history of adverse reactions to tegafur-uracil, a drug lymphocyte stimulation test showed an allergic response to 5-FU. We subsequently replaced with Irinotecan plus S-1 (IRIS) chemotherapy which was well tolerated and resulted in a partial response after 3 cycles. As a result, right trisectionectomy was successfully performed and no recurrence was detected in the following 3 years. A severe allergic reaction to intravenous 5-FU-containing drug regimens can be successfully alleviated by switching to S-1-containing regimens such as IRIS or S-1 plus oxaliplatin (SOX). Hiroyuki Komori, Toru Beppu, Yasuo Sakamoto, Yuji Miyamoto, Hiromitsu Hayashi, Katsunori Imai, Hidetoshi Nitta, Masayuki Watanabe, and Hideo Baba Copyright © 2014 Hiroyuki Komori et al. All rights reserved.