Case Reports in Gastrointestinal Medicine The latest articles from Hindawi Publishing Corporation © 2016 , Hindawi Publishing Corporation . All rights reserved. Herpes Simplex Virus-2 Esophagitis in a Young Immunocompetent Adult Tue, 19 Apr 2016 11:02:44 +0000 Herpes simplex esophagitis (HSE) is commonly identified in immunosuppressed patients. It is rare among immunocompetent patients and almost all of the reported cases are due to HSV-1 infection. HSV-2 esophagitis is extremely rare. We report the case of a young immunocompetent male who presented with dysphagia, odynophagia, and epigastric pain. Endoscopy showed multitudes of white nummular lesions in the distal esophagus initially suspected to be candida esophagitis. However, classic histopathological findings of multinucleated giant cells with eosinophilic intranuclear inclusions and positive HSV-2 IgM confirmed the diagnosis of HSV-2 esophagitis. The patient rapidly responded to acyclovir treatment. Although HSV-2 is predominantly associated with genital herpes, it can cause infections in other parts of the body previously attributed to only HSV-1 infection. Deepak K. Kadayakkara, Angela Candelaria, Ye Eun Kwak, and Caroline Loeser Copyright © 2016 Deepak K. Kadayakkara et al. All rights reserved. Urticarial Vasculitis-Associated Intestinal Ischemia Sun, 17 Apr 2016 13:56:11 +0000 Urticarial vasculitis (UV) is a rare small vessel vasculitis. UV is often idiopathic but can also present in the context of autoimmune disorders such as systemic lupus erythematosus, drug reactions, infections, or a paraneoplastic syndrome. Extracutaneous complications include intestinal ischemic injuries, in UV patients with nonspecific gastrointestinal symptoms such as abdominal pain and nausea. Prompt recognition and treatment can minimize morbidity and mortality. This paper describes a case of urticarial vasculitis-associated intestinal ischemia. Uni Wong, Harris Yfantis, and Guofeng Xie Copyright © 2016 Uni Wong et al. All rights reserved. CMV Colitis in Immunocompetent Patients: 2 Cases of a Diagnostic Challenge Tue, 12 Apr 2016 11:25:35 +0000 CMV infections are generally thought to be opportunistic by immunosuppression. Many literature cases though indicate that CMV infections can be also observed in immunocompetent patients. We present an unusual case of an extensive concentric benign stenosis due to CMV colitis and a case of coexistence with Crohn’s Disease, both observed in nonimmunosuppressed individuals. The right diagnosis was set after implementation of multiple unsuccessful treatment strategies. Our purpose is therefore to familiarize clinicians involved with the diagnosis and treatment of gastroenterological diseases with this entity. Maria Paparoupa, Viola Schmidt, Helgard Weckauf, Huy Ho, and Frank Schuppert Copyright © 2016 Maria Paparoupa et al. All rights reserved. The Role of PCR in Diagnosis of a Rare Appendicular Tuberculosis and Mini Literature Review Thu, 31 Mar 2016 18:03:14 +0000 Tuberculosis is a prevalent public health problem especially in the poor developing countries and results in significant mortality. Albeit tuberculosis almost always affects any organ or system of the body, abdominal tuberculosis is less frequent; moreover, tuberculous appendicitis is very rare with an incidence estimated at about 0.1–0.6% of all gastrointestinal tuberculosis. The purpose of this report was to present an unusual case of primary tuberculous appendicitis and the approach used for accurate diagnosis as well as a current update on the disease. We are reporting a 30-year-old male who presented with acute abdominal pain, fever, and vomiting and was admitted with the clinical diagnosis of acute appendicitis. Patient was investigated thoroughly and histopathologic examination was strongly suggestive of tuberculous appendicitis; however, Ziehl-Neelsen (ZN) was negative in tissue section. To confirm the diagnosis, molecular biology [polymerase chain reaction (PCR)] study was performed from the formalin fixed paraffin embedded (FFPE) appendicular tissue and revealed presence of Mycobacterium tuberculosis. As there are numerous differential diagnoses in granulomatous lesions of appendix and due to the fact that appendicular tuberculosis is a rare phenomenon; verification etiologic agent is crucial for appropriate management of the disease. Asmerom Tesfamariam Sengal, Ahmed Abdalla Mohamedani, Hanan Hasaan Hussein, and Alaa Kamal Copyright © 2016 Asmerom Tesfamariam Sengal et al. All rights reserved. Multiple Giant Splenic Artery Aneurysms Causing Sinistral (Left-Sided) Portal Hypertension Sun, 27 Mar 2016 13:40:34 +0000 Background. Splenic artery aneurysm is the most common type of visceral aneurysms. They are usually asymptomatic and have a potential for rupture and therefore life-threatening hemorrhage. It is rare for them to cause sinistral portal hypertension. Case Report. A 23-year-old female patient presented to our clinic with gastric varices, splenomegaly, pancytopenia, and normal liver functions. She was thus diagnosed with left-sided portal hypertension. Radiologic evaluation showed splenomegaly, splenic vein obstruction, and multiple aneurysms along the splenic artery ranging from 2.5 cm to 7 cm. Splenic artery aneurysm was thought to be the cause of portal hypertension and hypersplenism. We decided splenectomy is the best course of treatment. Pancytopenia could not be corrected preoperatively despite the transfusion treatment. Surgical exploration revealed multiple aneurysms deeply embedded in pancreas. Thrombocyte and erythrocyte transfusion was performed after splenic artery ligation to correct pancytopenia before further intervention. Splenic artery, spleen, and distal pancreas were resected en bloc. Patient’s blood parameters became normal within first postoperative day. Patient had an uneventful postoperative course and was discharged without incident. Conclusion. Splenic artery aneurysms are rare but potentially life-threatening incidents. Therefore, it is important to know the unusual presentations and prepare accordingly. Kemal Beksac and Derya Karakoc Copyright © 2016 Kemal Beksac and Derya Karakoc. All rights reserved. Peculiar Presentation of Ulcerative Colitis Sun, 06 Mar 2016 09:22:13 +0000 Ulcerative colitis (UC) is a chronic inflammatory and recurrent disorder that is characterized by bowel inflammation. Among the extraintestinal manifestations (EIMs) that associate UC are the joints and renal manifestations. Joint affection in the form of arthritis can precede the intestinal manifestations of UC. However, renal affection with amyloidosis does not precede the UC diagnosis. Herein, we report a case of 26-year-old male diagnosed with UC after having peripheral arthritis for long time in addition to spondylitis and kidney amyloidosis. Hamdy M. A. Ahmed, Amany Diab, Ayman Ahmed, Samar Abohamad, and Hala Elgendy Copyright © 2016 Hamdy M. A. Ahmed et al. All rights reserved. A Case of Advanced Descending Colon Cancer in an Adult Patient with Intestinal Malrotation Thu, 03 Mar 2016 07:59:37 +0000 This report presents an operative case of advanced descending colon cancer in an adult patient with intestinal malrotation. A 63-year-old Japanese male was suffering from left side abdominal pain, abdominal distension, and constipation. An endoscopic examination revealed an advanced tumor in the descending colon. Computed tomography (CT) of the abdomen revealed the thickening of the descending colon wall and superior mesenteric vein rotation. An opaque enema detected severe stenosis of the descending colon. An abdominal X-ray examination revealed the dilation of the colon and small intestine with niveau. At the insertion of an ileus tube, the C-loop of the duodenum was observed to be absent and the small intestine was located on the right side of the abdomen. After the decompression of the bowel contents, laparotomy was performed. Descending colon cancer was observed to have directly invaded the left side of the transverse colon. Left hemicolectomy, lymph node dissection, and appendectomy were performed. The patient had an uneventful recovery and was discharged from the hospital on the 16th day after surgery. This report presents a rare operative case of descending colon cancer in an adult patient with intestinal malrotation. Yoshifumi Nakayama, Masaki Akiyama, Yusuke Sawatsubashi, Noritaka Minagawa, Takayuki Torigoe, and Keiji Hirata Copyright © 2016 Yoshifumi Nakayama et al. All rights reserved. Gastric and Duodenal Pseudomelanosis: An Extended Unusual Finding in a Patient with End Stage Kidney Disease Wed, 02 Mar 2016 06:35:33 +0000 Gastric and duodenal pseudomelanosis is a rare endoscopic mucosal finding, characterized by the accumulation of iron in macrophages of the lamina propria of the stomach and duodenum. The clinical significance and long term sequelae have not been clarified yet. However, this benign condition is associated with a variety of clinical conditions, such as essential hypertension, chronic renal failure, diabetes mellitus, long term intake of iron supplements, and furosemide. Duodenal pseudomelanosis appears to be more common than gastric pseudomelanosis given the fact that a few cases of gastric pseudomelanosis have been reported in the literature so far. We report a case of 88-year-old lady with ESRD who is maintained on hemodialysis and presented with abdominal pain. An upper GI endoscopy showed discoloration of the antrum of the stomach and most portion of her duodenum. Histopathology report confirmed the presence of iron laden macrophages in the lamina propria of both stomach and duodenum. Noor Ul Ain Qureshi, Muhammad Faraz Younus, Kourosh Alavi, and Muhammad Yasin Sheikh Copyright © 2016 Noor Ul Ain Qureshi et al. All rights reserved. Small Intestinal and Mesenteric Multiple Gastrointestinal Stromal Tumors Causing Occult Bleeding Tue, 16 Feb 2016 16:21:57 +0000 Gastrointestinal stromal tumors are the meseancymal neoplasms which may involve any part of gastrointestinal tract. C-Kit and platelet derived factor receptor alpha polypeptide are believed to be responsible for the genetic basis. This case presentation aimed to discuss the diagnostic and therapeutic modality of multiple small intestinal, omental, and mesenteric GISTs with different sizes which caused occult bleeding in a 43-year-old male patient. Tolga Dinc, Selami Ilgaz Kayilioglu, Ahmet Erdogan, Erdinc Cetinkaya, Ozgur Akgul, and Faruk Coskun Copyright © 2016 Tolga Dinc et al. All rights reserved. Mixed Adenoneuroendocrine Carcinoma Is a Rare but Important Tumour Found in the Oesophagus Wed, 03 Feb 2016 09:53:24 +0000 Mixed adenoneuroendocrine carcinoma (MANEC) is a rare tumour of the gastrointestinal tract that consists of a dual adenocarcinomatous and neuroendocrine differentiation, each component representing at least 30% of the tumour. We report a case of a 68-year-old man who presented with two-month history of postprandial pain and vomiting. Gastric endoscopy revealed a polypoid mass in the lower part of the oesophagus. In contrast to the majority of these tumours, this biopsy was immunohistochemically positive for chromogranin A, and synaptophysin and Ki-67 index was 50% and the tumour was diagnosed as poorly differentiated neuroendocrine carcinoma of the oesophagus. The patient underwent surgery and lower oesophagus resection was performed. Based on the histopathology and immunohistochemistry of the tumour in the oesophagogastrectomy specimen, a mixed adenoneuroendocrine carcinoma (MANEC) was diagnosed. The objective of this case report is to advocate for the focus on the MANEC diagnosis as such patients need to be referred to a centre of excellence with expertise in NET tumours, to have the correct diagnostic work-up, treatment, and secondary diagnostic procedures performed at progression, as this will have paramount influence of the choice of treatment. Mohammad Murad Kasim Kadhim, Marie Louise Jespersen, Hans Kristian Pilegaard, Marianne Nordsmark, and Gerda Elisabeth Villadsen Copyright © 2016 Mohammad Murad Kasim Kadhim et al. All rights reserved. Agenesis of the Gallbladder in Monozygotic Twin Sisters Tue, 26 Jan 2016 12:57:10 +0000 Agenesis of the gallbladder, a rare anomaly, is generally regarded as an organogenic failure. Several reports suggest that this congenital defect is inherited but that supposition remains controversial. We described agenesis of the gallbladder in identical twins. A 21-year-old female presented with a history of acute pain in the epigastrium and right hypochondrium. Various imaging modalities showed “gallbladder agenesis.” Moreover, her older identical twin sister had also no visualized gallbladder in imaging modalities. This case report strongly suggested that agenesis of the gallbladder would be caused by a genetic abnormality. Koki Hoshi, Atsushi Irisawa, Goro Shibukawa, Akane Yamabe, Mariko Fujisawa, Ryo Igarashi, Ai Sato, and Takumi Maki Copyright © 2016 Koki Hoshi et al. All rights reserved. A Timely Intervention: Endoscopic Retrieval of a Swallowed Magnetized Activity Watch Tue, 19 Jan 2016 12:47:05 +0000 The accidental ingestion of a foreign object often presents a difficult scenario for the clinician. This includes not only the decision to retrieve the material but also the appropriate technique to use. We present the case of a young asymptomatic girl who swallowed a magnetic activity watch, which was then successfully retrieved with an endoscopic snare. To our knowledge, this is the first documented case of salvaging an operational watch from the stomach using an endoscopic technique. Jason S. Radowsky, Joseph S. Lee, and Andrew T. Schlussel Copyright © 2016 Jason S. Radowsky et al. All rights reserved. Protein Loosing Enteropathy Secondary to Strongyloidiasis: Case Report and Review of the Literature Wed, 06 Jan 2016 08:36:50 +0000 Strongyloidiasis is a helminthic disease which affects millions around the world resulting in a significant burden in certain high risk groups. It is rarely reported in the Lebanese population probably due to the low index of suspicion in common practice. We are reporting a case of strongyloidiasis that was found in an elderly patient presenting initially with dyspnea followed by skin rash, protein loosing enteropathy, diarrhea, and abdominal pain while on corticosteroid therapy. The diagnosis was suspected based on clinical presentation in addition to peripheral eosinophilia. We will also describe the upper and lower endoscopic aspects of the disease, as well as histologic findings on duodenal and colonic biopsies. Weam El Hajj, Gilbert Nakad, and Antoine Abou Rached Copyright © 2016 Weam El Hajj et al. All rights reserved. Left Colon Diverticulitis Presenting as Perforated Lumbar Abscess: A Case Report and Review of the Current Literature Thu, 31 Dec 2015 07:02:23 +0000 Diverticular perforation is a common complication of diverticulitis and can lead to the creation of abscesses. The presence of such abscesses on the abdominal wall is rare and can lead to misdiagnosis. We present the case of a patient with abdominal pain and the formation of a large left lumbar abscess due to perforation of a diverticulum of the left colon and our surgical treatment of choice with favorable results. Daniel Paramythiotis, Konstantinia Kofina, Vassileios N. Papadopoulos, and Antonios Michalopoulos Copyright © 2015 Daniel Paramythiotis et al. All rights reserved. Sonographic and Endoscopic Findings in Cocaine-Induced Ischemic Colitis Mon, 21 Dec 2015 14:11:19 +0000 Cocaine-induced ischemic colitis is a recognized entity. The diagnosis is based on clinical and endoscopic findings. However, diagnostic imaging is helpful in the evaluation of abdominal symptoms and prior studies have suggested specific sonographic findings in ischemic colitis. We report sonographic and endoscopic images along with abdominal computed tomography in a case of cocaine-induced ischemic colitis. Thomas Leth, Rune Wilkens, and Ole K. Bonderup Copyright © 2015 Thomas Leth et al. All rights reserved. Recurrent Hepatocellular Carcinoma in Patient with Crohn’s Disease: Incidental or Expected Outcome of Azathioprine? Mon, 14 Dec 2015 07:13:30 +0000 Hepatocellular carcinoma (HCC) usually occurs in patients with underlying risk factors such as liver cirrhosis and chronic hepatitis B. Although patients with Crohn’s disease (CD) are at an increased risk to develop malignancies such as colon cancer, the incidence of HCC in this population is extremely rare. We report a case of 62-year-old male with long history of CD treated with azathioprine (AZA) and aminosalicylic acid (ASA) who was incidentally diagnosed with HCC, for which left hepatectomy was done. Four years later during routine follow-up, patient had another hepatic lesion and underwent resection of the mass. The mechanism of occurrence of HCC in patient with CD is still controversial and may include immune mediated changes and medication related complications. AZA was reported in all case reports of CD that developed HCC. Through this report we hope to explore the complex pathophysiological mechanisms contributing to the development of HCC in the Crohn’s disease patient population. Youssef Botros, Mary Mathews, Hiren Patel, Nihar Shah, Walid Baddoura, and Andrew de la Torre Copyright © 2015 Youssef Botros et al. All rights reserved. Lanreotide Autogel in the Treatment of Persistent Diarrhea following a Total Colectomy Sun, 06 Dec 2015 12:01:06 +0000 Diarrhea is one of the most common complications following colectomy in patients with slow transit constipation (STC). Early postoperative diarrhea is usually treated with opioid agonists; however, to date, published data on the management of persistent diarrhea after colectomy for STC are scarce. Here, we report a case of severe diarrhea after a total colectomy with ileorectal anastomosis. One year after the surgery, the patient presented with persistent diarrhea. Treatment with a long-acting somatostatin analogue, lanreotide Autogel, was initiated. One month after the first injection of lanreotide Autogel the diarrhea was resolved. The patient’s stool transit was markedly improved (type 4 or type 5 according to the Bristol Stool Chart compared to type 7 before the treatment), positively affecting the patient’s quality of life (mean score of 2.1 on the Irritable Bowel Syndrome Quality of Life questionnaire compared to 3.9 before the treatment). This case report describes a successful use of lanreotide Autogel in a patient with persistent diarrhea after a total colectomy. Patrick Schoeters and Karl De Pooter Copyright © 2015 Patrick Schoeters and Karl De Pooter. All rights reserved. A Lethal Complication of Endoscopic Therapy: Duodenal Intramural Hematoma Mon, 30 Nov 2015 10:56:44 +0000 Duodenal intramural hematoma (DIH) usually occurs in childhood and young adults following blunt abdominal trauma. It may also develop in the presence of coagulation disorders and may rarely be an iatrogenic outcome of endoscopic procedures. Management of DIH is usually a conservative approach. A case of intramural duodenal hematoma that developed following endoscopic epinephrine sclerotherapy and/or argon plasma coagulation and that was nonresponsive to conservative therapy in a patient with chronic renal failure who died from sepsis is being discussed in this report. Clinicians should be aware of such possible complications after endoscopic hemostasis in patients with coagulation disorders. Turan Calhan, Abdurrahman Sahin, Resul Kahraman, Barış Soydaş, Ali Tosun, and Egemen Cebeci Copyright © 2015 Turan Calhan et al. All rights reserved. Pegaspargase Induced Hypertriglyceridemia Resulting in Severe Fatal Pancreatitis Sun, 29 Nov 2015 12:53:45 +0000 Pegaspargase is used to treat acute lymphocytic leukemia (ALL). Pegaspargase definitely has its benefits in treating ALL; however we cannot lose sight of one of its very rare but potentially deadly complications, acute pancreatitis. Clinicians should monitor triglycerides while the patient is on treatment with Pegaspargase and suspect acute pancreatitis if the patient develops abdominal pain. If pancreatitis occurs, therapy should be stopped immediately and not reinstituted. For patients with hypertriglyceridemia without pancreatitis, discontinuation of therapy should be considered. Neil Vyas, Rafael Ching Companioni, Melik Tiba, Hassan Alkhawam, and Aaron Walfish Copyright © 2015 Neil Vyas et al. All rights reserved. Portal Vein Thrombosis due to Prothrombin Gene Mutation following Sleeve Gastrectomy Tue, 10 Nov 2015 14:17:27 +0000 Introduction. Portomesenteric thrombosis is increasingly recognized as a complication of laparoscopic sleeve gastrectomy (LSG). It often presents with abdominal pain. We present a mother and her son who both developed portal vein thrombosis (PVT) after LSG. Case Description. A 43-year-old woman presented complaining of sudden severe abdominal pain, two weeks after she had uncomplicated laparoscopic sleeve gastrectomy. CT scan of the abdomen and pelvis with IV contrast showed portal vein thrombosis and SMV thrombosis. Two weeks later her son had the same LSG for morbid obesity and presented with the same clinical picture. Thrombophilia workup showed heterozygous prothrombin gene mutation. Conclusions. A high index of suspicion is necessary to diagnose PVT; although rare, it can be potentially lethal. Anticoagulation therapy should be initiated immediately to limit the morbidities and improve the outcome. Patients with family history of thrombophilia should be investigated prior to any bariatric surgery and nonsurgical alternative treatments for morbid obesity should be strongly encouraged. Murad Baba, Jordan Fakhoury, and Amer Syed Copyright © 2015 Murad Baba et al. All rights reserved. Ischemic Colitis Caused by Intra-Aortic Balloon Pump Counterpulsation Sun, 01 Nov 2015 12:26:33 +0000 Intra-aortic balloon pump counterpulsation (IABP) has been shown to prolong life in critically ill cardiac patients. However, complications including distal emboli, balloon rupture, bleeding, limb loss, and bowel ischemia continue to be associated with them. We present a case of a 56-year-old male who suffered bowel ischemia as a result of a malpositioned IABP. While the benefit of such devices in critically ill patients is not disputed, patients as well as clinicians should be aware of the potential side effects and patients undergoing IABP placement should be monitored for complications. H. El-Halawany, A. Bajwa, M. Shobassy, A. Qureini, and R. Chhabra Copyright © 2015 H. El-Halawany et al. All rights reserved. Resolution of Fundic Gland Polyposis following Laparoscopic Magnetic Sphincter Augmentation and Subsequent Cessation of Proton Pump Inhibitors Tue, 27 Oct 2015 09:55:17 +0000 Gastric polyps occur from a variety of sources and are found commonly on upper endoscopy. We present the case of a 49-year-old female who presented for evaluation for antireflux surgery with a history of fundic gland polyposis who required twice-daily proton pump inhibitors (PPIs) for control of her gastric reflux. After verifying that she met criteria for surgery, she underwent an uncomplicated laparoscopic magnetic sphincter augmentation placement. With the cessation of PPIs following surgery, the fundic gland polyposis resolved. Fundic gland polyps may occur sporadically or within certain syndromes, such as familial adenomatous polyposis. Multiple possible inciting factors exist, including the use of PPIs. This is the first reported case of the resolution of numerous fundic gland polyps following the completion of laparoscopic magnetic sphincter augmentation. Joel R. Brockmeyer, Erin E. Connolly, Richard J. Wittchow, and Shanu N. Kothari Copyright © 2015 Joel R. Brockmeyer et al. All rights reserved. Amyand’s Hernia: Rare Presentation of a Common Ailment Tue, 20 Oct 2015 12:11:09 +0000 Inguinal hernia with vermiform appendix as content is known as Amyand’s hernia. It is a rare entity but we encountered four cases within six months. A 52-year-old female had high grade fever and evidence of inflammatory pathology involving the ileocaecal region. She was initially managed conservatively and subsequently underwent exploratory laparatomy. The appendix was perforated and herniating in the inguinal canal. Appendectomy was done with herniorrhaphy without mesh placement. A 74-year-old male with bilateral inguinal hernia, of which, the right side was more symptomatic, underwent open exploration. Operative findings revealed a lipoma of the sac and a normal appearing appendix as content. Contents were reduced without appendectomy and mesh hernioplasty was performed. A 63-year-old male with an obstructed right sided hernia underwent emergency inguinal exploration which revealed edematous caecum and appendix as content without any inflammation. Contents were reduced without any resection. Herniorrhaphy was performed without mesh placement. A 66-year-old male with an uncomplicated right inguinal hernia underwent elective surgery. The sac revealed an appendix with adhesions at the neck. Contents were reduced after adhesiolysis and hernioplasty was performed with mesh placement. Emphasis is made to the rarity of disease, variation in presentation, and difference in treatment modalities depending upon the state of appendix. Sanjeev Singhal, Anu Singhal, Sanjay Singh Negi, Rahul Tugnait, Pankaj Kumar Arora, Bishwanath Tiwari, Pawan Malik, Lav Gupta, Amit Bimal, Abhishek Gupta, Rahul Gupta, Pushkar Chouhan, and ChandraKant Singh Copyright © 2015 Sanjeev Singhal et al. All rights reserved. Esophageal Cicatricial Pemphigoid as an Isolated Involvement Treated with Mycophenolate Mofetil Sun, 18 Oct 2015 13:05:30 +0000 Cicatricial pemphigoid (CP) is a rare blistering autoimmune disease. Esophageal involvement occurs in widespread disease and rarely appears as the only affected organ. We report a 67-year-old Caucasian female with esophageal dysphagia and weight loss. Several oral panendoscopies showed multiple exudative ulcerations with fibrin and webs in mid- and proximal esophagus and a peeling mucosa. There were no lesions in other organs. We established the diagnosis performing a direct immunofluorescence (DIF), demonstrating IgG3 and complement deposition along the basement membrane. As initial treatment the patient received prednisone 60 mg and 1 gr twice daily of mycophenolate mofetil (MMF) as a steroid-sparing agent due to its lower toxicity and its selective mechanism of action. Six months later there was a significant clinical improvement and the esophageal ulcerations had disappeared, developing cicatricial fibrous rings, although no stenosis was present. Four years later, the patient remains asymptomatic with a low maintenance dose of MMF. Sandra Sánchez Prudencio, Daniel Domingo Senra, Daniel Martín Rodríguez, Belén Botella Mateu, Carlos Esteban Jiménez-Zarza, Felipe de la Morena López, José Jiménez Reyes, Manuel Nevado Santos, and Beatriz de Cuenca Morón Copyright © 2015 Sandra Sánchez Prudencio et al. All rights reserved. Clinical Outcome of a Portosplenomesenteric Venous Thrombosis in Necrotizing Acute Pancreatitis with Protein C and S Deficiency Treated by Anticoagulation Therapy Alone Thu, 10 Sep 2015 12:43:55 +0000 Cases of splanchnic venous thrombosis have not been described in Cameroon. Their prevalence in acute pancreatitis is variable. With the emergence of acute intra-abdominal infections including typhoid fever and peritoneal tuberculosis in situations of acquired immunodeficiency syndrome, these cases will become frequent. We report the case of a portosplenomesenteric venous thrombosis related to necrotizing acute pancreatitis associated with proteins C and S deficiency, in a 46-year-old Cameroonian man, without particular past medical history. He was admitted for abdominal pain which had been evolving for 3 weeks and accompanied by vomiting. In the absence of hemorrhagic risk factor, the patient received low molecular weight heparin followed by oral warfarin. The abdominal ultrasound check on the 12th day showed a partial recanalization of venous thrombosis. The abdominal contrast-enhanced CT scanner at day 30 on oral anticoagulation therapy showed collateral vessels and small bowel edema. At the same time the upper gastrointestinal endoscopy showed grade II esophageal varices. We have maintained oral anticoagulation therapy. This case highlights that an early effective anticoagulation heparin therapy is needed for a clear benefit in case of suspected PSMVT. It is certain that the sooner the treatment is given, the better outcome will be. Firmin Ankouane, Mathurin Kowo, Bernadette Ngo Nonga, Eric Magny, Edith Hell Medjo, and Elie Claude Ndjitoyap Ndam Copyright © 2015 Firmin Ankouane et al. All rights reserved. The “Endothelialized Muscularis Mucosae”: A Case Report Describing a Large Cavernous Hemangioma at the Terminal Ileum and a New Histologic Clue for Preoperative Diagnosis from Endoscopic Biopsy Wed, 09 Sep 2015 08:18:08 +0000 Cavernous hemangiomas of the gastrointestinal tract are quite rare and, until now, have been difficult to diagnose preoperatively due their nonspecific presentations and imaging features, as well as a lack of histologic description pertaining to small superficial biopsies such as those obtained endoscopically. We report a unique case of a 4 cm transmural cavernous hemangioma in the terminal ileum with literature review and describe a new histologic finding—the “endothelialized muscularis mucosae,” which was discovered upon review of the endoscopic biopsy and could potentially facilitate preoperative diagnosis of these lesions from endoscopic biopsies in the future. These lesions have classically required surgical resection in order to make a definitive diagnosis and rule out malignancy, with which they share many historical and radiographic features. Due to their potential to cause bowel obstruction, intussusception, perforation, and hemorrhage, these lesions may ultimately require surgical resection to relieve symptoms or prevent or treat complications—however, surgical planning and patient counseling could be greatly improved by a preoperative diagnosis. Therefore, gastroenterologists, pathologists, and surgeons should be aware of the “endothelialized muscularis mucosae” which can be very helpful in diagnosing GI cavernous hemangiomas from endoscopic biopsies. Erin K. Purdy-Payne, Jean F. Miner, Brandon Foles, and Tien-Anh N. Tran Copyright © 2015 Erin K. Purdy-Payne et al. All rights reserved. IgG4-Seronegative Autoimmune Pancreatitis and Sclerosing Cholangitis Tue, 25 Aug 2015 09:16:13 +0000 IgG4-related disease is a relatively novel clinical entity whose gastrointestinal manifestations include type 1 autoimmune pancreatitis (AIP) and IgG4-associated sclerosing cholangitis. The presence of elevated serum IgG4 is suggestive but not essential for the diagnosis of type 1 AIP and is a pervasive feature of the proposed diagnostic criteria. The differential diagnosis of type 1 AIP includes malignant conditions, emphasizing the importance of a deliberate, comprehensive evaluation. Management of patients with a suggestive clinical presentation, but without serum IgG4 elevation, is difficult. Here we present three cases of IgG4-seronegative AIP and sclerosing cholangitis that responded to empiric steroid therapy and discuss approach considerations. These cases demonstrate the value of meticulous application of existing diagnostic algorithms to achieve a clinical diagnosis and avoid surgical intervention. Allon Kahn, Anitha D. Yadav, and M. Edwyn Harrison Copyright © 2015 Allon Kahn et al. All rights reserved. Upper Gastrointestinal Bleeding from Gastric Amyloidosis in a Patient with Smoldering Multiple Myeloma Sun, 23 Aug 2015 06:00:16 +0000 Amyloidosis is a common complication of patients with monoclonal gammopathy of undetermined significance (MGUS), smoldering multiple myeloma (SMM), and multiple myeloma (MM). This proteinaceous material can be deposited intercellularly in any organ system, including the gastrointestinal (GI) tract. In the GI tract, amyloidosis affects the duodenum most commonly, followed by the stomach and colorectum. Gastric amyloidosis causes symptoms of nausea, vomiting, early satiety, abdominal pain, and GI bleeding. A case of upper GI bleeding from gastric amyloidosis is presented in a patient with SMM. Esophagogastroduodenoscopy (EGD) revealed a gastric mass. Endoscopic biopsies revealed amyloid deposition in the lamina propria, consistent with gastric amyloidosis. Liquid chromatography tandem mass spectrometry performed on peptides extracted from Congo red-positive microdissected areas of paraffin-embedded stomach specimens revealed a peptide profile consistent with AL- (lambda-) type amyloidosis. Based on this and multiple other case reports, we recommend that patients with GI bleeding and MGUS, SMM, or MM undergo EGD and pathologic examination of endoscopic biopsies of identified lesions using Congo red stains for amyloidosis for early diagnosis and treatment. Mihajlo Gjeorgjievski, Treta Purohit, Mitual B. Amin, Paul J. Kurtin, and Mitchell S. Cappell Copyright © 2015 Mihajlo Gjeorgjievski et al. All rights reserved. Ulcerating Ileocolitis in Severe Amatoxin Poisoning Tue, 18 Aug 2015 12:10:33 +0000 Amatoxin poisoning is still associated with a great potential for complications and a high mortality. While the occurrence of acute gastroenteritis within the first 24 hours after amatoxin ingestion is well described, only very few descriptions of late gastrointestinal complications of amatoxin poisoning exist worldwide. We present the case of a 57-year-old female patient with severe amatoxin poisoning causing fulminant but reversible hepatic failure that on day 8 after mushroom ingestion developed severe abdominal pain and watery diarrhea. Ulcerating ileocolitis was identified by computed tomography identifying a thickening of the bowel wall of the entire ileum and biopsies taken from the ileum and large bowel revealing distinct ileitis and proximally accentuated colitis. The absence of discernible alternative etiologies such as infectious agents makes a causal relationship between the ulcerating ileocolitis and the amatoxin poisoning likely. Diarrhea and varying abdominal pain persisted over several weeks and clinical follow-up after six months showed a completely symptom-free patient. The case presented highlights the importance to consider the possibility of rare complications of Amanita intoxication in order to be able to respond to them early and adequately. Matthias Peter Hilty, Marcel Halama, Anne-Katrin Zimmermann, Marco Maggiorini, and Andreas Geier Copyright © 2015 Matthias Peter Hilty et al. All rights reserved. Intestinal Amyloidosis in Common Variable Immunodeficiency and Rheumatoid Arthritis Sun, 16 Aug 2015 11:43:44 +0000 We present a case of reactive amyloidosis that developed secondary to common variable immunodeficiency and rheumatoid arthritis. A 66-year-old woman, with prior history of common variable immunodeficiency and rheumatoid arthritis, was referred to our clinic for chronic diarrhea investigation. The patient was submitted to colonoscopy with ileoscopy, which did not show relevant endoscopic alterations. However, undertaken biopsies revealed amyloid deposition. Since amyloidosis with GI involvement is a rare cause of chronic diarrhea, this pathology should be considered in etiologic investigation, especially when associated with chronic inflammatory diseases. T. Meira, R. Sousa, A. Cordeiro, R. Ilgenfritz, and P. Borralho Copyright © 2015 T. Meira et al. All rights reserved.