Case Reports in Gastrointestinal Medicine The latest articles from Hindawi Publishing Corporation © 2014 , Hindawi Publishing Corporation . 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. Debilitating Chronic Diarrhea Caused by Generalized Gastrointestinal Cytomegalovirus Infection in an Immunocompetent Adult Thu, 12 Jun 2014 07:16:43 +0000 Gastrointestinal cytomegalovirus (CMV) infection is a common opportunistic infection in immunocompromised patients, especially patients with acquired immunodeficiency syndrome and transplant recipients. In contrast, CMV infection of the gastrointestinal tract is rare in immunocompetent individuals. We report a case of severe, protracted, and debilitating diarrhea caused by generalized CMV infection of the gastrointestinal tract in an elderly woman with no apparent immunosuppression. An extensive diagnostic investigation demonstrated CMV-associated disease affecting both the upper and lower gastrointestinal tracts (esophagus, small intestine, and colon). Such extensive simultaneous involvement of the alimentary tract in an immunocompetent patient is rare and presents a diagnostic and therapeutic challenge. The diagnosis was based on a combination of endoscopic, histopathological, serological, and polymerase chain reaction analysis findings and our patient was successfully treated with intravenous ganciclovir. Our case demonstrates that gastrointestinal CMV infection should be considered in the differential diagnosis of severe chronic diarrhea in immunocompetent patients and that antiviral treatment may be justified in this setting. Emmanouil Telakis, Eftychia Tsironi, Konstantinos Papatheodorou, and Dimitrios Nikolakis Copyright © 2014 Emmanouil Telakis et al. All rights reserved. Combined Liver and Kidney Transplant in a Patient with Budd-Chiari Syndrome Secondary to Autosomal Dominant Polycystic Kidney Disease Associated with Polycystic Liver Disease: Report of a Case with a 9-Year Follow-Up Sun, 01 Jun 2014 08:56:39 +0000 Polycystic liver disease (PLD) is a hereditary disease inherited by autosomal dominant trait that occurs as a frequent extrarenal manifestation of autosomal dominant polycystic kidney disease (ADPKD). We report a case of a 59-year-old woman diagnosed with ADPKD associated with PLD. End-stage chronic renal failure with a secondary Budd-Chiari syndrome developed during the patient’s clinical course. She underwent combined liver and kidney transplantation, with a successful response over a 9-year follow-up period. Patricia Ramírez de la Piscina, Ileana Duca, Silvia Estrada, Rosario Calderón, Idoia Ganchegui, Amaia Campos, Katerina Spicakova, Leire Urtasun, Marta Salvador, Elvira Delgado, Raquel Bengoa, and Francisco García-Campos Copyright © 2014 Patricia Ramírez de la Piscina et al. All rights reserved. A Novel Use of Early Radiation Therapy in the Treatment of Hyperbilirubinemia in a Patient with Primary Hepatic Lymphoma and Chronic Hepatitis C Tue, 29 Apr 2014 09:53:20 +0000 Lymphomas arising in the liver are extremely rare. Here, we describe a case of Hepatitis C virus infection with primary hepatic lymphoma (PHL) presenting with hyperbilirubinemia. A 45-year-old African American male presented with abdominal pain, pruritus, and itching for two days. CT of abdomen and pelvis with contrast showed numerous masses in the liver. The liver biopsy was consistent with diffuse large B cell lymphoma (DLBCL). Conventional chemotherapy was avoided initially because of hyperbilirubinemia. Hence, radiation therapy was given initially to reduce his bilirubin levels and tumor size. The patient was able to complete six cycles of rituximab combined with cyclophosphamide, adriamycin, vincristine, and prednisone (R-CHOP) chemotherapy and achieved a complete response verified by positron emission tomography-computed tomography (PET-CT). PHL should be considered when there are numerous space occupying liver lesions seen on imaging. Hyperbilirubinemia may be a reason for delay in treatment for some of these patients. Hence, the role of radiation therapy prior to treatment with R-CHOP is an alternative to management for stage IV diffuse large B cell lymphoma. Venkata S. Tammana, Rehana Begum, Patricia Oneal, Hemamalini Karpurapu, Amruta Muley, Sri Lakshmi Hyndavi Yeruva, Jacquelyn Dunmore-Griffith, Eyasu Mekonen, and Nabhani Hasan Copyright © 2014 Venkata S. Tammana et al. All rights reserved. Metachronous Bilateral Isolated Adrenal Metastasis from Rectal Adenocarcinoma: A Case Report Tue, 22 Apr 2014 14:00:24 +0000 We report a case of adrenal metastasis from colorectal cancer in a 54-year-old woman. Nine months after resection for advanced rectal carcinoma, a computed tomography scan revealed bilateral adrenal metastasis. The level of serum carcinoembryonic antigen was normal. A bilateral adrenalectomy was performed after chemotherapy. Histopathological examination showed adenocarcinoma, compatible with metastasis from the rectal cancer. Adrenal metastasis should be considered in the patients’ follow-up for colorectal cancer. H. Jabir, N. Tawfiq, M. Moukhlissi, M. Akssim, A. Guensi, B. Kadiri, Z. Bouchbika, A. Taleb, N. Benchekroun, H. Jouhadi, S. Sahraoui, S. Zamiati, and A. Benider Copyright © 2014 H. Jabir et al. All rights reserved. Primary Hepatic Lymphoma Is Difficult to Discriminate from a Liver Abscess Sun, 16 Mar 2014 11:35:35 +0000 An 82-year-old woman presented with a high-grade fever of 40°C and was admitted to our institution for intensive examination and treatment. Noncontrast abdominal computed tomography (CT) revealed low-density masses at segments 5 and 8, suggestive of a liver abscess. On further examination, a contrast-enhanced abdominal CT showed a  mm mass with an enhanced margin at segment 8 in the arterial phase; the contrast agents were washed out in the venous phase. In addition, a  mm mass with a density lower than that of liver parenchyma was observed at segment 8 in the portal phase. On the basis of these findings, either a liver abscess or hepatocellular carcinoma was suspected. To confirm the diagnosis, a fine needle biopsy was scheduled. Histopathological analysis of the biopsied specimens confirmed the diagnosis of diffuse large B-cell lymphoma. Chemotherapy was not indicated owing to the patient’s age and poor performance status; thus, best supportive care was planned. On day 22 after admission, the patient died of pneumonia. We experienced a case of PHL that was difficult to discriminate from a liver abscess. Imaging alone is insufficient to diagnose PHL; therefore, fine needle biopsy is recommended for a definitive diagnosis. Nobuhiro Takeuchi and Kazuyoshi Naba Copyright © 2014 Nobuhiro Takeuchi and Kazuyoshi Naba. All rights reserved. NonHodgkin's Lymphoma with Peritoneal Localization Sun, 09 Mar 2014 11:50:54 +0000 The gastrointestinal tract is the most common extranodal site involved with lymphoma accounting for 5–20% of all cases. Lymphoma can occur at any site of the body, but diffuse and extensive involvement of the peritoneal cavity is unusual and rare. We report a case of diffuse large B-cell lymphoma in a 57-year-old female infiltrating the peritoneum and omentum and presenting with ascites and pleural effusion. The performed examinations did not discover any pathological findings affecting the digestive tract or parenchymal organs, except for diffuse thickening of the peritoneum and omentum. Peripheral, mediastinal, or retroperitoneal lymphadenopathy was not registered. The blood count revealed only elevated leukocytes and on examination there were no immature blood cells in the peripheral blood. The cytology from the ascites and pleural effusion did not detect any malignant cells. Due to the rapid disease progression the patient died after twenty-two days of admission. The diagnosis was discovered postmortem with the histological examination and immunohistochemical study of the material taken during the surgical laparoscopy performed four days before the lethal outcome. Although cytology is diagnostic in most cases, laparoscopy with peritoneal biopsy is the only procedure which can establish the definitive diagnosis of peritoneal lymphomatosis. E. Curakova, M. Genadieva-Dimitrova, J. Misevski, V. Caloska-Ivanova, V. Andreevski, B. Todorovska, U. Isahi, M. Trajkovska, P. Misevska, N. Joksimovic, S. Genadieva-Stavric, S. Antovic, and N. Jankulovski Copyright © 2014 E. Curakova et al. All rights reserved. Olmesartan Associated Sprue-Like Enteropathy and Colon Perforation Tue, 04 Mar 2014 08:38:02 +0000 We are reporting a unique case of olmesartan associated severe sprue-like enteropathy in a 52-year-old woman who presented to our hospital complaining of severe abdominal pain and nausea. At the emergency department she suffered from a cardiac arrest and was found to have a colon perforation. The patient was treated conservatively without surgical intervention and olmesartan was discontinued. After one month, she had complete resolution of her symptoms. Mahmoud Abdelghany, Luis Gonzalez III, John Slater, and Christopher Begley Copyright © 2014 Mahmoud Abdelghany et al. All rights reserved. Syncope as the Presenting Feature of Splenic Rupture after Colonoscopy Thu, 20 Feb 2014 06:29:07 +0000 Splenic rupture is a rare, catastrophic complication of colonoscopy and an exceptional cause of syncope. This injury is believed to be from direct trauma or tension on the splenocolic ligament with subsequent capsule avulsion or else from direct instrument-induced splenic injury. Diagnosis requires a high index of suspicion that may be absent because presentation can be subtle, nonspecific, and delayed anywhere from hours to days and therefore not easily attributed to a recent endoscopy. We describe a case of syncope as the initial manifestation of splenic rupture after colonoscopy. Our patient’s pain was delayed; his discomfort was mild and not localized to the left upper quadrant. Clinicians should consider syncope, lightheadedness, and drop in hemoglobin in absence of rectal bleeding following a colonoscopy as possible warning signs of imminent or emergent splenic injury. Daniel Jamorabo and Edward Feller Copyright © 2014 Daniel Jamorabo and Edward Feller. All rights reserved. Unique Presentation of Giant Metastatic Microcystic Serous Adenocarcinoma of the Pancreas Wed, 19 Feb 2014 09:11:01 +0000 Tumors of the pancreas that contain substantial cystic components include mainly mucinous cystic neoplasm, intraductal papillary mucinous neoplasm, solid pseudopapillary tumor, and cystadenomas (which encompass microcystic, macrocystic/oligocystic, and rare solid serous adenomas). Microcystic adenoma of the pancreas is a tumor that is benign in nature. Malignant transformation in the tumor with metastases is rare and only about 26 cases have been reported so far. Here we present a giant microcystic adenoma of the pancreas, possibly the largest ever malignant type in this group ever reported in the literature with extensive metastases to the liver and causing extensive compression and encasement on surrounding structures. Cyriac Abby Philips, Chetan Ramesh Kalal, Chhagan Bihari, Amrish Sahney, KN Chandan Kumar, and Archana Rastogi Copyright © 2014 Cyriac Abby Philips et al. All rights reserved. Entamoeba dispar: A Rare Case of Enteritis in a Patient Living in a Nonendemic Area Thu, 13 Feb 2014 06:13:31 +0000 Entamoeba dispar, a common noninvasive parasite, is indistinguishable in its cysts and trophozoite forms from Entamoeba histolytica, the cause of invasive amebiasis, by microscopy. To differentiate the two species seems to be a problem for laboratory diagnosis. Recent experimental studies showed that  E. dispar can be considered pathogenic too. We present a rare case of enteritis due to E. dispar. Rosalia Graffeo, Carola Maria Archibusacci, Silvia Soldini, Lucio Romano, and Luca Masucci Copyright © 2014 Rosalia Graffeo et al. All rights reserved. Severe Recurrent Pancreatitis in a Child with ADHD after Starting Treatment with Methylphenidate (Ritalin) Tue, 11 Feb 2014 12:20:23 +0000 We present a case of a 10-year-old boy, who had severe relapsing pancreatitis, three times in two months within 3 weeks after starting treatment with methylphenidate (Ritalin) due to attention deficit hyperactivity disorder (ADHD). Pancreatitis due to the use of (methylphenidate) Ritalin was never published before. Attention must be made by the physicians regarding this possible complication, and this complication should be taken into consideration in every patient with abdominal pain who was newly treated with Ritalin. Suheil Artul, Faozi Artoul, George Habib, William Nseir, Bishara Bisharat, and Yousif Nijim Copyright © 2014 Suheil Artul et al. All rights reserved. Eosinophilic Ascites and Duodenal Obstruction in a Patient with Liver Cirrhosis Mon, 10 Feb 2014 12:36:54 +0000 Eosinophilic gastroenteritis (EG) is a rare disease characterized by eosinophilic infiltration of portions of the gastrointestinal tract. Eosinophilic ascites is probably the most unusual and rare presentation of EG and is generally associated with the serosal form of EG. Hereby, we report a case of eosinophilic ascites with duodenal obstruction in a patient with liver cirrhosis. A 50-year-old woman was admitted to our hospital because of abdominal pain, nausea, bloating, and constipation. She had a history of laparotomy because of duodenal obstruction 2 years ago. Based on clinical, radiological, endoscopic, and pathological findings, and given the excluding the other causes of peripheral eosinophilia, the diagnosis of eosinophilic gastroenteritis along with liver cirrhosis and spontaneous bacterial peritonitis was established. Based on the findings of the present case, it is highly recommended that, in the patients presented with liver cirrhosis associated with peripheral blood or ascitic fluid eosinophilia, performing gastrointestinal endoscopy and biopsy can probably reveal this rare disorder of EG. Nasrollah Maleki, Mohammadreza Kalantar Hormozi, Mehrzad Bahtouee, Zahra Tavosi, Hamidreza Mosallai Pour, and Seiiedeh Samaneh Taghiyan Jamaleddin Kolaii Copyright © 2014 Nasrollah Maleki et al. All rights reserved. An Unusual Case of Cirrhosis Tue, 04 Feb 2014 00:00:00 +0000 49-year-old white female with remote h/o sarcoidosis was referred to GI when her liver was noted to be nodular. Physical examination revealed normal vital signs and no icterus, spider nevi, clubbing, ascites, hepatosplenomegaly, or ankle edema. LFTs, hepatitis serologies, ANA, AMA, ASMA, Ferritin, Ceruloplasmin, and α1-AT, level were unremarkable. Liver biopsy showed cirrhosis. She developed worsening of baseline SOB and was hospitalized. She was eventually diagnosed with constrictive pericarditis. A diagnosis of cardiac cirrhosis was made. Ahmad Alkaddour, Kenneth J. Vega, and Adil Shujaat Copyright © 2014 Ahmad Alkaddour et al. All rights reserved. Liver Injury Secondary to Anti-TNF-Alpha Therapy in Inflammatory Bowel Disease: A Case Series and Review of the Literature Sun, 19 Jan 2014 08:08:37 +0000 Background. Biologic therapy to inhibit tumor necrosis factor-alpha (TNF-α) is an effective, safe treatment for patients with inflammatory bowel disease (IBD). All TNF-α inhibitors have been associated with liver toxicity, but many of these cases have been reported in patients receiving therapy for rheumatologic disease. Herein we report the first single-center case series of TNF-α antagonist related liver injury in patients with IBD. Methods. A retrospective case series was performed at the Henry Ford Inflammatory Bowel Diseases Center. IRB approval was obtained. Results. 2 patients were treated with infliximab, whereas the 3rd patient was treated with adalimumab for IBD. All 3 patients had negative viral markers, normal autoimmune serologies, and normal biliary imaging studies. Liver biopsy was performed in all 3 patients, and evidence of portal inflammation was seen. Liver enzymes normalized after discontinuation of therapy in all patients, and no long term effects have been observed. One patient was successfully transitioned from infliximab to adalimumab without relapse of either IBD or liver injury. Conclusion. Liver injury secondary to TNF-α antagonist is an underrecognized, important clinical entity with potentially serious consequences. The mechanism of drug-induced injury is idiosyncratic. Larger cohort studies are needed to establish risk factors and injury patterns related to hepatotoxicity in these patients. Ravish Parekh and Nirmal Kaur Copyright © 2014 Ravish Parekh and Nirmal Kaur. All rights reserved. Gastric Adenocarcinoma Presenting with Gastric Outlet Obstruction in a Child Tue, 14 Jan 2014 12:11:39 +0000 Gastric carcinoma is extremely rare in children representing only 0.05% of all gastrointestinal malignancies. Here, we report the first pediatric case of gastric cancer presenting with gastric outlet obstruction. Upper endoscopy revealed a markedly thickened antral mucosa occluding the pylorus and a clean base ulcer 1.5 cm × 2 cm at the lesser curvature of the stomach. The narrowed antrum and pylorus underwent balloon dilation, and biopsy from the antrum showed evidence of Helicobacter pylori gastritis. The biopsy taken from the edge of the gastric ulcer demonstrated signet-ring-cell type infiltrate consistent with gastric adenocarcinoma. At laparotomy, there were metastases to the liver, head of pancreas, and mesenteric lymph nodes. Therefore, the gastric carcinoma was deemed unresectable. The patient died few months after initiation of chemotherapy due to advanced malignancy. In conclusion, this case report underscores the possibility of gastric adenocarcinoma occurring in children and presenting with gastric outlet obstruction. Abdulrahman Al-Hussaini, Salem AlGhamdi, Rasha Alsaaran, Fawaz Al-Kasim, Zakaria Habib, and Nouri Ourfali Copyright © 2014 Abdulrahman Al-Hussaini et al. All rights reserved. Metronidazole Induced Liver Injury: A Rare Immune Mediated Drug Reaction Mon, 23 Dec 2013 10:42:48 +0000 Drug induced liver injury (DILI) can result either from dose-dependent direct hepatotoxicity or from an unpredictable dose-independent idiosyncratic reaction. Incidence of idiosyncratic DILI is estimated to be approximately 10–15 per 100,000 patient years. Here we report an extremely rare case of metronidazole induced delayed immune-allergic hepatocellular liver injury masquerading as autoimmune hepatitis. A previously healthy 54-year-old Caucasian male, who was treated with metronidazole for Clostridium difficile associated diarrhea, presented 3 months later with right upper quadrant abdominal pain. Laboratory tests revealed total bilirubin level of 12.7 mg/dL, direct bilirubin of 7.2 mg/dL, alanine aminotransferase (ALT) of 973 IU/L, aspartate transaminase (AST) of 867 IU/L, alkaline phosphatase (AP) of 96 IU/L, and an INR of 1.9, suggestive of hepatocellular pattern of injury. A detailed workup for hepatitis revealed no other etiology. A clinical diagnosis of metronidazole induced liver injury was made. With a persistent rise in his bilirubin and transaminase levels, the patient was started on oral prednisone. At the 2-week posthospitalization follow-up visit, the patient reported a significant improvement in his overall sense of being well and liver functions tests trended down substantially (total bilirubin 7.2 mg/dL, ALT 420 IU/L, AST 276 IU/L, AP 183 IU/L, and INR 1.5). Dayakar Kancherla, Mahesh Gajendran, Priyanka Vallabhaneni, and Kishore Vipperla Copyright © 2013 Dayakar Kancherla et al. All rights reserved. Distal Humerus as Delayed Site of Metastasis from Small Cell Carcinoma of Gallbladder Sat, 14 Dec 2013 10:08:47 +0000 Background. Small cell carcinoma (SCC) of the gallbladder is a rare entity and is often seen in elderly women. SCC of gallbladder is typically a nonsecretory carcinoid tumor without overt clinical symptoms and is often discovered at advanced stages. SCC of gallbladder carries a dismal prognosis as compared to SCC of lung and adenocarcinoma of gallbladder. To date, only 73 case reports have been published in the world literature. Case Presentation. Herein, we report a case of a 73-year-old Saudi woman who presented with one week history of right upper quadrant abdominal pain and obstructive jaundice and was found to be a case of locally advanced, metastatic SCC of gallbladder cT4N1M1 (liver, para-aortic lymph nodes, and bone). The patient was treated with neoadjuvant etoposide and cisplatin (EP) chemotherapy three cycles after biliary stenting followed by radical cholecystectomy, lymphadenectomy, and adjuvant EP chemotherapy and then one year later developed distal humerus osseous metastasis. Conclusion. SCC of the gallbladder is very rare entity and is often seen at advanced stages. Osseous metastases of peripheral skeleton from SCC gallbladder are rarely reported. Surgery is curative option but only for early stage tumors. Incorporation of chemotherapy along with radical resection increases the survival. Mutahir A. Tunio, Mushabbab AlAsiri, Asma Mohammed F. Ali, Eyad Fawzi AlSaeed, Muhammad Shuja, and Hanadi Fatani Copyright © 2013 Mutahir A. Tunio et al. All rights reserved.