Case Reports in Gastrointestinal Medicine The latest articles from Hindawi Publishing Corporation © 2015 , Hindawi Publishing Corporation . All rights reserved. Cannabinoid Hyperemesis Syndrome: A Paradoxical Cannabis Effect Wed, 22 Jul 2015 10:05:38 +0000 Despite well-established antiemetic properties of marijuana, there has been increasing evidence of a paradoxical effect in the gastrointestinal tract and central nervous system, given rise to a new and underrecognized clinical entity called the Cannabinoid Hyperemesis Syndrome. Reported cases in the medical literature have established a series of patients exhibiting a classical triad of symptoms: cyclic vomiting, chronic marijuana use, and compulsive bathing. We present a case of a 29-year-old man whose clinical presentation strongly correlates with cannabinoid hyperemesis syndrome. Despite a diagnosis of exclusion, this syndrome should be considered plausible in the setting of a patient with recurrent intractable vomiting and a strong history of cannabis use as presented in this case. Ivonne Marie Figueroa-Rivera, Rodolfo Estremera-Marcial, Marielly Sierra-Mercado, José Gutiérrez-Núñez, and Doris H. Toro Copyright © 2015 Ivonne Marie Figueroa-Rivera et al. All rights reserved. A Rare Cause of Acute Abdomen: Perforation of Double Meckel’s Diverticulum Wed, 22 Jul 2015 08:19:02 +0000 Meckel’s diverticulum is the most common congenital anomaly of the gastrointestinal tract. In this report, we aimed to represent a case of intestinal perforation, caused by double Meckel’s diverticulum, which is a very rare entity in surgical practice. The patient was a 20-year-old Caucasian man, admitted to hospital with complaints of abdominal pain, nausea, and vomitting during the last 3 days. Physical examination indicated tenderness, rebound, and guarding in the right lower quadrant of abdomen. Abdominal X-ray revealed a few air-liquid levels in the left upper quadrant. In the operation, 2 Meckel’s diverticula were observed, one at the antimesenteric side, at 70 cm distance to the ileocecal valve, approximately in 3 cm size, and the other between the mesenteric and antimesenteric sides, approximately in 5 cm size. The first one had been perforated at the tip and wrapped with omentum. A 30 cm ileal resection, including both diverticula with end-to-end anastomosis, was performed. The diagnosis of symptomatic Meckel’s diverticulum is considerably hard, especially when it is complicated. Diverticulectomy or segmentary resections are therapeutic options. In patients with acute abdomen clinic, Meckel’s diverticulum and its complications should be kept in mind, and the intestines should be observed for an extra diverticulum for caution although it is a very rare condition. İlhan Tas, Serdar Culcu, Yigit Duzkoylu, Sadik Eryilmaz, Mehmet Mehdi Deniz, and Deniz Yilmaz Copyright © 2015 İlhan Tas et al. All rights reserved. A Novel Endoscopic Method to Relieve Food Impaction Using an Inflatable Balloon Tue, 21 Jul 2015 14:15:38 +0000 Food impaction in the esophagus is a relatively common medical emergency. Most of these food impactions are relieved spontaneously. But for complete esophageal food impactions or impactions not relieved spontaneously, traditional endoscopic methods like using a Roth net, polypectomy snare, or rat or alligator tooth forceps are used to gently manipulate the food material into the stomach. However, these methods may not work in certain circumstances. We present a case of proximal esophageal food impaction that was relieved using an inflatable balloon after the conventional methods proved unsuccessful. Rohit Anand, Shashank Garg, Ethan Dubin, and Sudhir Dutta Copyright © 2015 Rohit Anand et al. All rights reserved. Coccidioidomycosis Masquerading as Eosinophilic Ascites Tue, 21 Jul 2015 13:04:35 +0000 Endemic to the southwestern parts of the United States, coccidioidomycosis, also known as “Valley Fever,” is a common fungal infection that primarily affects the lungs in both acute and chronic forms. Disseminated coccidioidomycosis is the most severe but very uncommon and usually occurs in immunocompromised individuals. It can affect the central nervous system, bones, joints, skin, and, very rarely, the abdomen. This is the first case report of a patient with coccidioidal dissemination to the peritoneum presenting as eosinophilic ascites (EA). A 27-year-old male presented with acute abdominal pain and distention from ascites. He had eosinophilia of 11.1% with negative testing for stool studies, HIV, and tuberculosis infection. Ascitic fluid exam was remarkable for low serum-ascites albumin gradient (SAAG), PMN count >250/mm3, and eosinophils of 62%. Abdominal imaging showed thickened small bowel and endoscopic testing negative for gastric and small bowel biopsies. He was treated empirically for spontaneous bacterial peritonitis, but no definitive diagnosis could be made until coccidioidal serology returned positive. We noted complete resolution of symptoms with oral fluconazole during outpatient follow-up. Disseminated coccidioidomycosis can present in an atypical fashion and may manifest as peritonitis with low SAAG EA. The finding of EA in an endemic area should raise the suspicion of coccidioidal dissemination. Kourosh Alavi, Pradeep R. Atla, Tahmina Haq, and Muhammad Y. Sheikh Copyright © 2015 Kourosh Alavi et al. All rights reserved. Characteristics of Small Bowel Polyps Detected in Cowden Syndrome by Capsule Endoscopy Wed, 24 Jun 2015 11:23:03 +0000 Cowden syndrome is an uncommon, autosomal dominant disease characterized by multiple hamartomas and hyperplastic lesions in the skin, mucous membrane, brain, breast, thyroid, and gastrointestinal tract. About 30% of Cowden syndrome cases are reportedly complicated by malignant diseases. Hamartomatous polyps occur throughout the gastrointestinal tract, the most common sites being the stomach, colon, esophagus, and duodenum. Small bowel polyps can occur in Cowden syndrome; however, they are difficult to detect by conventional examination, including double-contrast X-ray study. Here, we report three cases of Cowden syndrome with small bowel polyps, which were detected by capsule endoscopy. The small bowel polyps of Cowden syndrome frequently occur at the oral end of the small bowel, especially in the duodenum and jejunum, and their color is similar to that of the surrounding mucosa; additionally, the polyps are relatively small (2–5 mm). Capsule endoscopy is useful for detecting small bowel polyps in Cowden syndrome. Keita Saito, Eiki Nomura, Yu Sasaki, Yasuhiko Abe, Nana Kanno, Naoko Mizumoto, Rika Shibuya, Kazuhiro Sakuta, Makoto Yagi, Kazuya Yoshizawa, Daisuke Iwano, Takeshi Sato, Shoichi Nishise, and Yoshiyuki Ueno Copyright © 2015 Keita Saito et al. All rights reserved. Scrotal Swelling as a Complication of Hydrochlorothiazide Induced Acute Pancreatitis Wed, 24 Jun 2015 08:06:44 +0000 Background. Scrotal swelling is a rare complication of acute pancreatitis with few reported cases in the literature. In this case report, we present a 59-year-old male with hydrochlorothiazide induced pancreatitis who developed scrotal swelling. Case Presentation. A 59-year-old male presented to the emergency department with sharp epigastric abdominal pain that radiated to the back and chest. On physical examination, he had abdominal tenderness and distention with hypoactive bowel sounds. Computed tomography (CT) scan of the abdomen showed acute pancreatitis. The patient’s condition deteriorated and he was admitted to the intensive care unit (ICU). After he improved and was transferred out of the ICU, the patient developed swelling of the scrotum and penis. Ultrasound (US) of the scrotum showed large hydrocele bilaterally with no varicoceles or testicular masses. Good blood flow was observed for both testicles. The swelling diminished over the next eight days with the addition of Lasix and the patient was discharged home in stable condition. Conclusion. Scrotal swelling is a rare complication of acute pancreatitis. It usually resolves spontaneously with conservative medical management such as diuretics and elevation of the legs. Ivan Nikiforov, Qurat Mansoora, Hassan Al-Khalisy, Sarah Joseph, and Pramil Cheriyath Copyright © 2015 Ivan Nikiforov et al. All rights reserved. Obstructing Colonic Mass: A Case of Recurrent Endometrial Cancer Wed, 24 Jun 2015 06:59:41 +0000 A 71-year-old female with a history of endometrial cancer presented to our hospital with bilateral lower quadrant abdominal pain, which had been worsening over the past two months. The pain was associated with constipation, pencil-thin stools, and a 60 lb weight loss. On physical examination, the patient had suprapubic and left lower quadrant abdominal tenderness. Contrast-enhanced CT scan revealed a 6 cm pelvic mass in the left lower quadrant. It was unclear if this mass was arising from the sigmoid colon or abutting it. A colonoscopy to further investigate the mass was pursued and this revealed a moderate 5 cm long stenosis in the sigmoid colon starting at 15 cm from the anal verge. The stenosis was not ulcerated but had a bluish/purplish hue to it circumferentially. Multiple biopsies were obtained from that area and these revealed architectural changes with mild fibrosis but no malignancy. The mass was further explored with CT-guided fine needle aspiration. The results obtained were positive for cytokeratin-7, CA-125, estrogen receptor protein, and PAX-8 confirming that the mass was endometrial in origin. Victor Chedid, Mona Arasoghli, and Jana G. Hashash Copyright © 2015 Victor Chedid et al. All rights reserved. Gallbladder Agenesis with Refractory Choledocholithiasis Mon, 22 Jun 2015 12:09:09 +0000 Congenital agenesis of the gallbladder is a rare anomaly which is usually asymptomatic and found incidentally. In some cases, however, patients are symptomatic. Common symptoms include right upper quadrant abdominal pain, nausea, and vomiting. Jaundice is present in some symptomatic cases and is due to associated choledocholithiasis (Fiaschetti et al. 2009). In this case, a 63-year-old female presents with jaundice and episodic right upper quadrant abdominal pain with nausea and vomiting. Bilirubin and alkaline phosphatase were found to be markedly elevated. Upper endoscopic ultrasound (EUS) revealed choledocholithiasis, and the patient required multiple endoscopic retrograde cholangiopancreatography (ERCP) sessions before successful extraction of all stones. Subsequent surgical exploration revealed congenital agenesis of the gallbladder. Although this is a rare finding, patients with agenesis of the gallbladder are at increased risk of developing de novo choledocholithiasis which may be challenging to extract. Jamie Tjaden, Kevin Patel, and Aziz Aadam Copyright © 2015 Jamie Tjaden et al. All rights reserved. Acute Cholangitis following Biliary Obstruction after Duodenal OTSC Placement in a Case of Large Chronic Duodenocutaneous Fistula Sun, 21 Jun 2015 12:08:27 +0000 Over-the-Scope Clip system, also called “Bear Claw,” is a novel endoscopic modality used for closure of gastrointestinal defect with high efficacy and safety. We present a patient with history of eosinophilic gastroenteritis and multiple abdominal surgeries including Billroth II gastrectomy complicated by a large chronic duodenocutaneous fistula from a Billroth II afferent limb to the abdominal wall. Bear Claw clip was used for closure of this fistula. The patient developed acute cholangitis one day after placement of the Bear Claw clip. Acute cholangitis due to papillary obstruction is a potential complication of Bear Claw placement at the dome of the duodenal stump (afferent limb) in patient with Billroth II surgery due to its close proximity to the major papilla. Yaseen Alastal, Tariq A. Hammad, Mohamad Nawras, Basmah W. Khalil, Osama Alaradi, and Ali Nawras Copyright © 2015 Yaseen Alastal et al. All rights reserved. Treatment of Hepatic Epithelioid Hemangioendothelioma: Finding Uses for Thalidomide in a New Era of Medicine Wed, 17 Jun 2015 12:50:41 +0000 Hepatic epithelioid hemangioendothelioma (HEH) is extremely rare, occurring in 1 to 2 per 100,000, with chemotherapy options not well defined. Our case involved a 49-year-old female who had hepatic masses and metastasis to the lungs with a liver biopsy revealing HEH. After developing a rash from sorafenib, thalidomide was started with the progression of disease stabilized. Resection is only an option in 10% of the cases; therefore, chemotherapy is the only line of treatment. Newer chemotherapy alternatives are targeting angiogenesis via the vascular endothelial growth factor. Thalidomide was first used as an antiemetic, but, sadly, soon linked to phocomelia birth defects. Given the mechanism of action against angiogenesis, thalidomide has a valid role in vascular tumors. In conclusion, the use of thalidomide as chemotherapy is novel and promising, especially in the setting of a rare vascular liver tumor such as HEH. Matthew P. Soape, Rashmi Verma, J. Drew Payne, Mitchell Wachtel, Fred Hardwicke, and Everardo Cobos Copyright © 2015 Matthew P. Soape et al. All rights reserved. Familial Abdominal and Intestinal Lipomatosis Presenting with Upper GI Bleeding Thu, 04 Jun 2015 08:50:04 +0000 Although lipomas are encapsulated benign tumors, systemic lipomatosis defines infiltrative nonencapsulated tumors resembling normal adipose tissue. Abdominal lipomatosis and intestinal lipomatosis are different clinicopathological entities with similar clinical symptoms. We describe here a case presenting with upper gastrointestinal bleeding from eroded submucosal lipoma at duodenum secondary to intestinal lipomatosis and abdominal lipomatosis. Yilmaz Bilgic, Hasan Baki Altinsoy, Nezahat Yildirim, Ozkan Alatas, Burhan Hakan Kanat, and Abdurrahman Sahin Copyright © 2015 Yilmaz Bilgic et al. All rights reserved. Large Bowel Obstruction Due to a Big Gallstone Successfully Treated with Endoscopic Mechanical Lithotripsy Tue, 02 Jun 2015 11:25:25 +0000 Colonic gallstone ileus in an uncommon mechanical bowel obstruction caused by intraluminal impaction of one or more gallstones. The surgical management of gallstone ileus is complex and is potentially of high risk. There have been reports of gallstone extractions using various endoscopic modalities to relieve the obstruction. In this report we present the technique employed to successfully perform a mechanical lithotripsy and extraction of a large gallstone embedded in a sigmoid colon affected by diverticular stenosis. We passed through the stenosis with a 11.3 mm videoscope with 3.7 mm channel. A large lithotripsy extraction basket was used to catch and break up the stone and fragments were removed using the same basket. The patient was discharged asymptomatic three days after the procedure. Using appropriate devices mechanical lithotripsy is a safe and effective method to treat colonic obstruction and avoid surgery in the setting of gallstone ileus even in case of big stones. Marco Balzarini, Laura Broglia, Giovanni Comi, and Calcedonio Calcara Copyright © 2015 Marco Balzarini et al. All rights reserved. Marked Direct Hyperbilirubinemia due to Ceftriaxone in an Adult with Sickle Cell Disease Mon, 25 May 2015 13:53:00 +0000 Drugs are a significant cause of liver injury. Drug-induced liver injury (DILI) can cause acute hepatitis, cholestasis, or a mixed pattern. Ceftriaxone is a commonly used antibiotic and has been associated with reversible biliary sludge, pseudolithiasis, and cholestasis. A 32-year-old male with sickle cell disease was admitted to the hospital for acute sickle cell crisis. On the second day of hospitalization, he developed cough and rhonchi with chest X-ray revealing right middle lobe infiltrates. Ceftriaxone and azithromycin were initiated. Subsequently, he developed conjugated hyperbilirubinemia and mild transaminitis. His total bilirubin trended upwards from 3.3 mg/dL on admission to 17 mg/dL. It was predominantly conjugated bilirubin, with preadmission bilirubin levels of 3-4 mg/dL. His transaminases were mildly elevated as well compared to previous levels. Extensive workup for bilirubin elevation was unremarkable. Ceftriaxone was switched to levofloxacin and the hyperbilirubinemia improved. On ambulatory follow-up, his bilirubin remained below 4 mg/dL. Ceftriaxone may be associated with marked direct hyperbilirubinemia particularly in sickle cell patients with chronic liver chemistry abnormalities. In the case of elevated bilirubin with concomitant ceftriaxone use, elimination of the offending agent should be considered. Daniyeh Khurram, Leonid Shamban, Robert Kornas, and Maryann Paul Copyright © 2015 Daniyeh Khurram et al. All rights reserved. Solitary Colonic Ganglioneuroma: A Rare Incidental Finding of Hematochezia Thu, 14 May 2015 11:18:12 +0000 Ganglioneuromas (GNs) are hamartomatous tumors derived from the autonomic nervous system. It is rare to encounter GN in the gastrointestinal tract. Patients with these tumors usually present with abdominal pain, constipation, ileus, weight loss, or even bleeding. GNs are categorized into three different morphological subtypes, namely, polypoid GN, ganglioneuromatous polyposis, and diffuse ganglioneuromatosis. We present a case of hematochezia from GN in a colon polyp discovered on diagnostic colonoscopy. Due to a lack of guidelines, we reviewed the literature to discuss treatment and other associated conditions for GN. George Abraham and Sateesh R. Prakash Copyright © 2015 George Abraham and Sateesh R. Prakash. All rights reserved. Visceral Kaposi’s Sarcoma Presenting as Upper Gastrointestinal Bleeding Wed, 06 May 2015 09:42:03 +0000 Since the advent of highly active antiretroviral therapy (HAART), the incidence of acquired immunodeficiency syndrome- (AIDS-) related Kaposi’s sarcoma (KS) has decreased dramatically. While cutaneous KS is the most common and well-known manifestation, knowledge of alternative sites such as the gastrointestinal (GI) tract is important. GI-KS is particularly dangerous because of its potential for serious complications including perforation, obstruction, or bleeding. We report a rare case of GI-KS presenting as upper GI bleeding in a human immunodeficiency virus- (HIV-) infected transgendered individual. Prompt diagnosis and early initiation of therapy are the cornerstones for management of this potentially severe disease. Naomi Hauser, Devon McKenzie, Xavier Fonseca, and Jose Orsini Copyright © 2015 Naomi Hauser et al. All rights reserved. Eosinophilic Gastroenteritis: Case Report and Review in Search for Diagnostic Key Points Tue, 05 May 2015 12:31:26 +0000 Eosinophilic gastroenteritis is considered an uncommon disease with a low incidence rate that remains as a diagnostic challenge for the clinician, in spite of the fact that seventy years have passed since its original description. Hereby we present the case of a 29-year-old male without history of allergies who was evaluated for unspecific gastrointestinal symptoms, without relevant findings on physical examination and presenting an initial complete blood count (CBC) with severe eosinophilia. The patient was evaluated and the diagnosis of eosinophilic gastroenteritis was confirmed by histopathological findings. The relevance of the case resides in highlighting the lack of guidelines or consensus for histological diagnosis being virtually the only one available. To a similar extent, treatment evidence is based on case series with a reasonable number of patients and case reports. Guillermo López-Medina, Manuel Gallo, Alejandro Prado, Iliana Vicuña-Honorato, and Roxana Castillo Díaz de León Copyright © 2015 Guillermo López-Medina et al. All rights reserved. Metastatic Periampullary Tumor from Hepatocellular Carcinoma Presenting as Gastrointestinal Bleeding Wed, 29 Apr 2015 07:34:10 +0000 Periampullary tumors constitute a number of diverse neoplastic lesions located within 2 cm of the major duodenal papilla; among these, metastatic lesions account for only a small proportion of the periampullary tumors. To our knowledge, a metastatic periampullary tumor from hepatocellular carcinoma has never been reported. A 62-year-old male reported to our institute for fatigue and low hemoglobin. His medical history was remarkable for multifocal hepatocellular carcinoma (HCC) treated with selective transcatheter arterial chemoembolization (TACE). An esophagogastroduodenoscopy (EGD) was performed which revealed a periampullary mass. Histopathology was consistent with metastatic moderately differentiated HCC. Two endoloops were deployed around the base of the mass one month apart. The mass eventually sloughed off and patient’s hemoglobin level stabilized. We postulated that periampullary metastasis in this patient was the result of tumor fragments migration through the biliary tracts and that TACE which increases tumor fragments burden might have played a contributory role. Metastasis of HCC to the gastrointestinal (GI) tract should be considered as a cause of GI bleeding. Amir Kashani, Nicholas N. Nissen, Maha Guindi, and Laith H. Jamil Copyright © 2015 Amir Kashani et al. All rights reserved. Recurrent C. difficile in a Patient with IgG Deficiency Sun, 05 Apr 2015 13:17:06 +0000 IgG deficiency can predispose to recurrent pyogenic infections. The association of IgG deficiency with Clostridium difficile infection has been infrequently reported in the literature. We present a case of a middle-age woman with multiple hospitalizations for recurrent C. difficile in a short span of time which prompted consideration of a possible fecal transplant. On evaluation, she was found to have low total IgG, with subclass analysis revealing low IgG1 and IgG3. She was started on monthly infusions of immunoglobulins and one year after her last episode of C. difficile she has not had any recurrence. The role of immunoglobulin infusion in the treatment of recurrent C. difficile is controversial, with some studies revealing no clear evidence of benefit. Our case report suggests that the patients who have underlying IgG deficiency may benefit from immunoglobulin, as this can significantly reduce the incidence of recurrent infections and hence save the healthcare costs. Asad Jehangir, Kyle Bennett, Shoaib Bilal Fareedy, Andrew Rettew, Bilal Shaikh, Anam Qureshi, Qasim Jehangir, and Richard Alweis Copyright © 2015 Asad Jehangir et al. All rights reserved. Loss of HER2 Positivity after Trastuzumab in HER2-Positive Gastric Cancer: Is Change in HER2 Status Significantly Frequent? Sun, 29 Mar 2015 11:15:16 +0000 Trastuzumab has recently been introduced as a treatment for HER2-positive metastatic and/or unresectable gastric cancer (MUGC); however, compared with breast cancer, some issues concerning HER2 and trastuzumab therapy for gastric cancer remain unclear. A 74-year-old woman received trastuzumab-containing chemotherapy for HER2-positive MUGC. She had a marked response to 8 months of chemotherapy, and gastrectomy and hepatic metastasectomy with curative intent were performed. The resected specimen showed complete loss of HER2 positivity in the residual tumor. For MUGC, a change in HER2 status during the course of the disease with or without chemotherapy has rarely been reported. However, in breast cancer, a significant frequency of change in HER2 status during the course of disease has been reported, and reevaluation of HER2 positivity in metastatic/recurrent sites is recommended. The choice of trastuzumab for MUGC is currently based on the HER2 status of the primary tumor at the time of initial diagnosis, without reassessment of HER2 status during the course of disease and/or in metastatic/recurrent sites, on the assumption that HER2 status is stable. However, our case casts doubt on the stability of HER2 in gastric cancer. Yu Ishimine, Akira Goto, Yoshito Watanabe, Hidetaka Yajima, Suguru Nakagaki, Takashi Yabana, Takeya Adachi, Yoshihiro Kondo, and Kiyoshi Kasai Copyright © 2015 Yu Ishimine et al. All rights reserved. Osteogenesis Imperfecta, Pseudoachalasia, and Gastric Cancer Sun, 22 Mar 2015 14:24:15 +0000 Osteogenesis imperfecta (OI) is a rare, inherited skeletal disorder characterized by abnormalities of type 1 collagen. Malignancy is rarely reported in patients with OI and it was suggested that this disease can protect against cancer. Here, we report a 41-year-old woman with symptoms of achalasia where repeated treatment of pneumatic dilation and stent replacement was unsuccessful; therefore, surgery was performed. Pathology showed gastric adenocarcinoma unexpectedly. Chemotherapy was given after assessing dihydropyrimidine dehydrogenase (DPD) enzyme activity, which can be deficient in OI patients. This is the first report of gastric cancer mimicking achalasia in a patient with OI. Dilsa Mizrak, Ali Alkan, Batuhan Erdogdu, and Gungor Utkan Copyright © 2015 Dilsa Mizrak et al. All rights reserved. Acute Cholangitis following Intraductal Migration of Surgical Clips 10 Years after Laparoscopic Cholecystectomy Sun, 22 Mar 2015 13:38:56 +0000 Background. Laparoscopic cholecystectomy represents the gold standard approach for treatment of symptomatic gallstones. Surgery-associated complications include bleeding, bile duct injury, and retained stones. Migration of surgical clips after cholecystectomy is a rare complication and may result in gallstone formation “clip cholelithiasis”. Case Report. We report a case of a 55-year-old female patient who presented with right upper quadrant pain and severe sepsis having undergone an uncomplicated laparoscopic cholecystectomy 10 years earlier. Computed tomography (CT) imaging revealed hyperdense material in the common bile duct (CBD) compatible with retained calculus. Endoscopic retrograde cholangiopancreatography (ERCP) revealed appearances in keeping with a migrated surgical clip within the CBD. Balloon trawl successfully extracted this, alleviating the patient’s jaundice and sepsis. Conclusion. Intraductal clip migration is a rarely encountered complication after laparoscopic cholecystectomy which may lead to choledocholithiasis. Appropriate management requires timely identification and ERCP. Natalie E. Cookson, Reza Mirnezami, and Paul Ziprin Copyright © 2015 Natalie E. Cookson et al. All rights reserved. Acute on Chronic Pancreatitis Causing a Highway to the Colon with Subsequent Road Closure: Pancreatic Colonic Fistula Presenting as a Large Bowel Obstruction Treated with Pancreatic Duct Stenting Tue, 17 Mar 2015 09:54:48 +0000 Context. Colonic complications associated with acute pancreatitis have a low incidence but carry an increased risk of mortality with delayed diagnosis and treatment. Pancreatic colonic fistula is most commonly associated with walled off pancreatic necrosis or abscess formation and rarely forms spontaneously. Classic clinical manifestations for pancreatic colonic fistula include diarrhea, hematochezia, and fever. Uncommonly pancreatic colonic fistula presents as large bowel obstruction. Case. We report a case of a woman with a history of recurrent episodes of acute pancreatitis who presented with large bowel obstruction secondary to pancreatic colonic fistula. Resolution of large bowel obstruction and pancreatic colonic fistula was achieved with pancreatic duct stenting. Conclusion. Pancreatic colonic fistula can present as large bowel obstruction. Patients with resolved acute pancreatitis who have radiographic evidence of splenic flexure obstruction, but without evidence of mechanical obstruction on colonoscopy, should be considered for ERCP to evaluate for PCF. PCF not associated with walled off pancreatic necrosis or peritoneal abscess can be treated conservatively with pancreatic duct stenting. Justin Cochrane and Greg Schlepp Copyright © 2015 Justin Cochrane and Greg Schlepp. All rights reserved. Postoperative Megarectum in an Adult Patient with Imperforate Anus and Rectourethral Fistula Sun, 15 Mar 2015 13:56:54 +0000 This report presents a surgical case of postoperative megarectum in an adult patient with imperforate anus/anorectal malformations. A 71-year-old Japanese male presented with a mass in the lower abdomen which was 15 × 12 × 8 cm in diameter, edema in the right lower extremity, and frequent urination. He had undergone sigmoid loop colostomy for an imperforate anus as a newborn infant. At 28 years of age, the sigmoid loop colostomy was changed to sigmoid divided colostomy in the left lower abdomen. Computed tomography revealed a large cystic mass in the lower abdomen. Retrograde urethrography indicated a rectourethral fistula and megarectum with stones. A small laparotomy incision was created in the right lower abdomen, and the wall of the megarectum was identified. Approximately 2,300 mL of gray muddy fluid was identified and drained. A mucous fistula of the upper rectum was created in the right lower abdomen. This is an extremely rare case of postoperative megarectum in an adult patient with an imperforate anus and rectourethral fistula. Yoshifumi Nakayama, Toshihito Uehara, Masaki Akiyama, Noritaka Minagawa, Takayuki Torigoe, and Naohiro Fujimoto Copyright © 2015 Yoshifumi Nakayama et al. All rights reserved. Fulminant Hepatic Failure Secondary to Primary Hepatic Angiosarcoma Sat, 28 Feb 2015 10:26:41 +0000 Background. Hepatic angiosarcoma is a rare and aggressive tumor that often presents at an advanced stage with nonspecific symptoms. Objective. To report a case of primary hepatic angiosarcoma in an otherwise healthy man with normal liver function tests two months prior to presenting with a short period of jaundice that progressed to fulminant hepatic failure. Methods. Case report and review of literature. Conclusion. This case illustrates the rapidity of progression to death after the onset of symptoms in a patient with hepatic angiosarcoma. Research on early diagnostic strategies and newer therapies are needed to improve prognosis in this rare and poorly understood malignancy with limited treatment options. Ayokunle T. Abegunde, Efe Aisien, Benjamin Mba, Rohini Chennuri, and Marin Sekosan Copyright © 2015 Ayokunle T. Abegunde et al. All rights reserved. A Rare Cause of Acute Dysphagia: Abscess of the Base of the Tongue Mon, 23 Feb 2015 16:07:49 +0000 Dysphagia represents a difficulty in passage of solid or liquid foods from the oral cavity into the stomach and is considered as an alarm symptom of gastrointestinal system. It often indicates an organic disease and needs to be explained. In this paper, a case of 61-year-old man with posterior tongue abscess is presented. Gulsum Teke Ozgur, Mehmet Volkan Akdogan, Gulhan Kanat Unler, and Huseyin Savas Gokturk Copyright © 2015 Gulsum Teke Ozgur et al. All rights reserved. Acute Pancreatitis and Splenic Vein Thrombosis due to Hypertriglyceridemia Mon, 23 Feb 2015 10:46:46 +0000 Acute pancreatitis (AP) is a condition characterised by the activation of the normally inactive digestive enzymes due to an etiological factor and digestion of the pancreatic tissues, resulting in extensive inflammation and leading to local, regional, and systemic complications in the organism. It may vary from the mild edematous to the hemorrhagic and severely necrotising form. The most common causes are biliary stones and alcohol abuse. In this case study, we would like to present a patient with AP due to hypertriglyceridemia (HPTG), which is a rare cause of pancreatitis, and splenic vein thrombosis, which is a rare complication of pancreatitis. Ercan Gündüz, Recep Dursun, Mustafa İçer, Yılmaz Zengin, and Cahfer Güloğlu Copyright © 2015 Ercan Gündüz et al. All rights reserved. A Novel SMAD4 Mutation Causing Severe Juvenile Polyposis Syndrome with Protein Losing Enteropathy, Immunodeficiency, and Hereditary Haemorrhagic Telangiectasia Sun, 01 Feb 2015 09:48:01 +0000 Juvenile polyposis syndrome (JPS) is a rare genetic disorder characterized by juvenile polyps of the gastrointestinal tract. We present a new pathogenic mutation of the SMAD4 gene and illustrate the need for a multidisciplinary health care approach to facilitate the correct diagnosis. The patient, a 47-year-old Caucasian woman, was diagnosed with anaemia at the age of 12. During the following 30 years, she developed numerous gastrointestinal polyps. The patient underwent several operations, and suffered chronic abdominal pain, malnutrition, and multiple infections. Screening of the SMAD4 gene revealed a novel, disease-causing mutation. In 2012, the patient suffered hypoalbuminemia and a large polyp in the small bowel was found. Gamma globulin was given but the patient responded with fever and influenza-like symptoms and refused more treatment. The patient underwent surgery in 2014 and made an uneventful recovery. At follow-up two months later albumin was 38 g/L and IgG was 6.9 g/L. Accurate diagnosis is essential for medical care. For patients with complex symptomatology, often with rare diseases, this is best provided by multidisciplinary teams including representatives from clinical genetics. Patients with a SMAD4 mutation should be followed up both for JPS and haemorrhagic hereditary telangiectasia and may develop protein loosing enteropathy and immunodeficiency. Joel Johansson, Christofer Sahin, Rebecka Pestoff, Simone Ignatova, Pia Forsberg, Anders Edsjö, Mattias Ekstedt, and Marie Stenmark Askmalm Copyright © 2015 Joel Johansson et al. All rights reserved. Littoral Cell Angioma in a Patient with Crohn’s Disease Thu, 29 Jan 2015 12:03:38 +0000 Littoral cell angioma is a rare vascular tumor of the spleen. The pathogenesis is unknown but the lesion is associated with several malignancies and immunological disorders. The diagnosis requires histopathological examination. The malignant potential of this lesion is unknown, which is why splenectomy is recommend for all cases. Symptomatic cases generally suffer from hypersplenism and pyrexia. A previously healthy 20-year-old female was diagnosed with colonic Crohn’s disease; as part of the work-up a magnetic resonance enterography was performed which showed multiple signal changes of the spleen. The patient reported chronic abdominal pain in the left upper quadrant, malaise, and fever. The unknown splenic lesions prompted a laparoscopic splenectomy; pathology revealed a littoral cell angioma. The abdominal pain and malaise remitted but the fever persisted one year despite adequate treatment of the patient’s Crohn’s disease. Littoral cell angioma is associated with immune-dysregulation including Crohn’s disease with several reported cases. Signs and symptoms of hypersplenism and splenic lesions on imaging should raise suspicion of littoral cell angioma in patients with Crohn’s disease. Magnetic resonance enterography to assess disease severity in Crohn’s disease may provide an opportunity to study the prevalence and natural history of this rare splenic tumor. Joel Johansson, Bergthor Björnsson, Simone Ignatova, Per Sandström, and Mattias Ekstedt Copyright © 2015 Joel Johansson et al. All rights reserved. Deciphering Autoimmune Pancreatitis, a Great Mimicker: Case Report and Review of the Literature Thu, 29 Jan 2015 06:02:44 +0000 Background. Autoimmune pancreatitis (AIP) is an atypical chronic inflammatory pancreatic disease that appears to involve autoimmune mechanisms. In recent years, AIP has presented as a new clinical entity with its protean pancreaticobiliary and systemic presentations. Its unique pathology and overlap of clinical and radiological features and absence of serological markers foster the disease’s unique position. We report a case of diffuse type 1 autoimmune pancreatitis with obstructive jaundice managed with biliary sphincterotomy, stent placement, and corticosteroids. A 50-year-old Caucasian woman presented to our hospital with epigastric pain, nausea, vomiting, and jaundice. Workup showed elevated liver function tests (LFT) suggestive of obstructive jaundice, MRCP done showed diffusely enlarged abnormal appearing pancreas with loss of normal lobulated contours, and IgG4 antibody level was 765 mg/dL. EUS revealed a diffusely hypoechoic and rounded pancreatic parenchyma with distal common bile duct (CBD) stricture and dilated proximal CBD and common hepatic duct (CHD). ERCP showed tight mid to distal CBD stricture that needed dilatation, sphincterotomy, and placement of stent that led to significant improvement in the symptoms and bilirubin level. Based on clinical, radiological, and immunological findings, a definitive diagnosis of AIP was made. Patient was started on prednisone 40 mg/day and she clinically responded in 4 weeks. Satya Allaparthi, Mohammed Sageer, and Mark J. Sterling Copyright © 2015 Satya Allaparthi et al. All rights reserved. Rapid Progression of Primary Sclerosing Cholangitis Complicated with Ulcerative Colitis Wed, 28 Jan 2015 14:35:30 +0000 Primary sclerosing cholangitis is a cholestatic condition with unknown etiology and long-standing, progressive course, leading to cirrhosis and requiring orthotropic liver transplant. In approximately 80%, primary sclerosing cholangitis is accompanied by inflammatory bowel disease, and in most cases the recognition of bowel disease precedes the diagnosis of primary sclerosing cholangitis. We describe a case of 22-year-old male diagnosed simultaneously with primary sclerosing cholangitis and ulcerative colitis, with a medical history suggesting uncommon prior development of the liver disease. Five months after the initial diagnosis, we observed advanced lesions of bile tree due to progression of primary sclerosing cholangitis, which led to the unusually fast necessity for the orthotopic liver transplant. Piotr Pardak, Ewa Walczak, and Rafał S. Filip Copyright © 2015 Piotr Pardak et al. All rights reserved.