Case Reports in Gastrointestinal Medicine The latest articles from Hindawi Publishing Corporation © 2015 , Hindawi Publishing Corporation . All rights reserved. Magnetic Resonance Enterography: The Test of Choice in Diagnosing Intestinal “Zebras” Mon, 26 Jan 2015 10:10:25 +0000 Small bowel tumors and other rare intestinal disorders are often exceedingly difficult to identify. Even cutting-edge technologies, such as push enteroscopy and capsule endoscopy, can fail to determine the cause of a patient’s symptoms. At our institution magnetic resonance enterography (MRE) has become an increasingly reliable tool in the difficult-to-diagnose or difficult-to-monitor patient. In this retrospective case series, we discuss four patients with four rare intestinal disorders that were successfully diagnosed using MRE after failing to be diagnosed using more routine technologies, such as CT scans and flexible sigmoidoscopies. With the discussion of these four cases we demonstrate that MRE is a useful diagnostic modality in patients whose surveillance is difficult or to diagnose rare colorectal disease phenomena, colloquially referred to as “zebras.” Anjali S. Kumar, Jasna Coralic, Reid Vegeler, Kirthi Kolli, John Liang, Allison Estep, Allen P. Chudzinski, and James D. McFadden Copyright © 2015 Anjali S. Kumar et al. All rights reserved. Severe Gastroparesis following Radiofrequency Catheter Ablation for Atrial Fibrillation: Suggestion for Diagnosis, Treatment, and Device for Gastroparesis after RFCA Tue, 30 Dec 2014 00:10:14 +0000 Gastroparesis following radiofrequency catheter ablation (RFCA) is a very rare complication, as only two cases have been reported in the English literature. A 42-year-old man underwent RFCA due to recurrent drug-resistant symptomatic atrial fibrillation. The patient complained of indigestion and early satiety 2 days after the procedure. Contrast-enhanced computed tomography and an upper gastrointestinal series of the abdomen showed a large amount of material remaining in the stomach area. All food material was removed by endoscopy, and the patient received medical treatment. We suggest a flow chart for diagnosis and treatment of AFGS based on the present case and previous cases. Endoscopic medical patent was designed on the basis of this case. Dong Seok Lee and Sang Jin Lee Copyright © 2014 Dong Seok Lee and Sang Jin Lee. All rights reserved. Acute Onset Collagenous Colitis with Unique Endoscopic Findings Thu, 25 Dec 2014 00:10:10 +0000 We experienced a rare case of 72-year-old woman with acute onset collagenous colitis (CC) induced by lansoprazole. The patient developed acute abdominal pain, watery diarrhea, and melena that are quite rare in usual CC. We could find the characteristic colonoscopic findings such as active long liner ulcers in the patient. We also observed the healing courses of these unique findings. Our case indicates two important points of view. (1) CC sometimes develops with acute onset symptoms which resemble those of ischemic colitis. (2) Colonoscopy would be useful and necessary to distinguish acute onset CC and ischemic colitis. Rintaro Moroi, Katsuya Endo, Masatake Kuhroha, Hisashi Shiga, Yoichi Kakuta, Yoshitaka Kinouchi, and Tooru Shimosegawa Copyright © 2014 Rintaro Moroi et al. All rights reserved. Metastatic Hepatocellular Carcinoma in a Patient with Crohn’s Disease Treated with Azathioprine and Infliximab: A Case Report and Literature Review Mon, 22 Dec 2014 08:00:37 +0000 Hepatocellular carcinoma most commonly occurs in patients with underlying liver disease or cirrhosis. We describe a case of hepatocellular carcinoma in a 34-year-old man with Crohn’s disease treated with azathioprine and infliximab. The patient had no history of liver disease and a complete autoimmune and viral workup was unremarkable. Unfortunately, the patient developed widespread metastatic disease and passed away 5 months after his initial diagnosis. The mechanism of hepatocellular carcinoma in patients’ with Crohn’s disease is poorly understood and may include both autoimmunity and treatment-related complications. Previous case reports suggest the possibility of a concerning association between azathioprine therapy and the development of hepatocellular carcinoma in patients with Crohn’s disease. Clinicians may consider early imaging in patients with Crohn’s disease presenting with concerning symptomatology or abnormal liver enzymes, especially in those being treated with azathioprine alone or in combination with infliximab. Future research may help to uncover additional risk factors for this exceedingly rare diagnosis in this patient population. Kyle J. Fortinsky, Ali Alali, Khursheed Jeejeebhoy, Sandra Fischer, Morris Sherman, and Scott Fung Copyright © 2014 Kyle J. Fortinsky et al. All rights reserved. Does Gastrointestinal Dysmotility Predispose to Recurrent or Severe Forms of Clostridium difficile Infections? Thu, 11 Dec 2014 08:52:58 +0000 Clostridium difficile infection (CDI) is the most common cause of hospital-acquired diarrhea. A limited number of studies have looked at the risk factors for recurrent CDI. Mitochondrial NeuroGastroIntestinal Encephalopathy (MNGIE) is a rare multisystemic disorder that causes gastrointestinal dysmotility. Herein we present a patient with MNGIE who suffered recurrent and severe C. difficile infection despite appropriate treatment. We aim to bring the gastroenterologist’s attention to gastrointestinal dysmotility as a possible risk factor for the development of recurrent or severe forms of C. difficile infections. Abdul wahab Hritani, Ahmad Alkaddour, and Jeff House Copyright © 2014 Abdul wahab Hritani et al. All rights reserved. Gastric Metastasis of Ectopic Breast Cancer Mimicking Axillary Metastasis of Primary Gastric Cancer Thu, 11 Dec 2014 06:09:08 +0000 Ectopic breast tissue has the ability to undergo all the pathological changes of the normal breast, including breast cancer. Gastrointestinal metastasis of breast cancer is rarely observed and it is very difficult to differentiate gastric metastases from primary gastric cancer. We present a case of 52-year-old female, who suffered from abdominal pain. Physical examination showed a palpable mass in the left anterior axilla and computerized tomography revealed gastric wall thickening with linitis plastica. When gastroscopic biopsy showed no signs of malignancy, excisional biopsy was performed in the left axilla. Histological examination revealed invasive lobular carcinoma of the breast, consistent with ectopic breast cancer. Further gastroscopic submucosal biopsies and immunohistochemical studies revealed gastric metastases of invasive lobular carcinoma. Axillary ectopic breast tissue carcinomas can mimic axillary lymphadenopathies. Additionally, gastric metastasis of breast cancer is an uncommon but possible condition. To the best of our knowledge, this is the first report of ectopic breast cancer with gastric metastasis. Selami Ilgaz Kayılıoğlu, Cihangir Akyol, Ebru Esen, Cevriye Cansız-Ersöz, Akın Fırat Kocaay, Volkan Genç, İlknur Kepenekçi, and Seher Demirer Copyright © 2014 Selami Ilgaz Kayılıoğlu et al. All rights reserved. Epigenetic Alterations in a Gastric Leiomyoma Thu, 04 Dec 2014 08:21:20 +0000 Leiomyomas constitute 2.5% of all resected neoplasms of the stomach. They are usually asymptomatic, but may present mucosal ulceration. Aberrant DNA methylation is a well-defined epigenetic change in human neoplasms; however, gene-acquired methylation may not necessarily be related with a malignant phenotype. In this report we analyzed in a gastric leiomyoma, the methylation status of 84 CpGI in tumor suppressor and DNA repair genes. We analyzed the tumor center (TC) and tumor periphery (TP) separately. We found aberrant methylation in 2/84 CpGI in the TC portion, that is, MLH1 and MSH3, and 5/84 CpGI in the TP, that is, MLH1, MSH3, APC, MSH6, and MGMT. The gene with the highest methylation percentage in the TC and TP was MLH1. Given that MLH1 methylation has been associated with microsatellite instability, we analyzed the status of the microsatellite Bat-26. We found that neither the TC nor the TP presented instability. The methylation of MLH1, MGMT, and APC has been described in GISTs, but to the best of our knowledge this is the first time that the methylation of these genes has been associated with gastric leiomyoma. Further research should be conducted to identify reliable molecular markers that could differentiate between GISTs and gastric leiomyomas. M. T. Branham, M. Pellicer, E. Campoy, M. Palma, A. Correa, and M. Roqué Copyright © 2014 M. T. Branham et al. All rights reserved. Appendiceal Diverticulitis Clinically Masquerading as an Appendiceal Carcinoma Wed, 03 Dec 2014 13:05:46 +0000 Appendiceal diverticulosis is a rare condition. Herein reported is a case of appendiceal diverticulosis and diverticulitis clinically masquerading as appendiceal carcinoma. A 62-year-old woman presented with abdominal pain. US and CT showed a tumor measuring 5 × 4 × 4 cm in vermiform appendix. Colon endoscopy showed mucosal elevation and irregularity in the orifice of vermiform appendix. A biopsy of the appendiceal mucosa showed no significant changes. Clinical diagnosis was appendiceal carcinoma and wide excision of terminal ileum, appendix, cecum, and ascending colon was performed. Grossly, the appendix showed a tumor measuring 5 × 3 × 4 cm. The appendiceal lumen was opened, and the appendiceal mucosa was elevated and irregular. The periappendiceal tissue showed thickening. Microscopically, the lesion was multiple appendiceal diverticula. The diverticula were penetrating the muscle layer. The mucosa showed erosions in places. Much fibrosis, abscess formations, and lymphocytic infiltration were seen in the subserosa. Abscesses were also seen in the diverticular lumens. Some diverticula penetrated into the subserosa. The pathologic diagnosis was appendiceal diverticulitis. When they encounter an appendiceal mass, clinicians should consider appendiceal diverticulitis as a differential diagnosis. Tadashi Terada Copyright © 2014 Tadashi Terada. All rights reserved. Pancreatic Mass Leading to Left-Sided Portal Hypertension, Causing Bleeding from Isolated Gastric Varices Sun, 30 Nov 2014 07:08:14 +0000 Mucinous cystic neoplasms (MCN) are an uncommon form of exocrine neoplasms of the pancreas. Symptoms are most often vague and this makes the diagnosis more difficult. The current case is one of three cases yet reported where the MCN caused left-sided portal hypertension leading to the formation of isolated gastric varices and subsequent bleeding from the varices. In the previously reported cases the main symptom was hematemesis. However in the current case the patient experienced no hematemesis, only isolated incidents of dark coloured diarrhea, but the main symptoms were those of iron-deficiency anemia. We present the case report of a 34-year-old woman who presented with dizziness and lethargy and was found to have 12 cm MCN in the pancreas. Helga Thrainsdottir, Vigdis Petursdottir, Sigurdur Blöndal, and Einar S. Björnsson Copyright © 2014 Helga Thrainsdottir et al. All rights reserved. Treatment of a Gastric Lactobezoar with N-Acetylcysteine Sun, 23 Nov 2014 00:00:00 +0000 Lactobezoars are a rare finding with potentially serious sequelae in pediatric patients with feeding intolerance. Aggressive treatment may be preferred to traditional treatments to avoid complications in medically complex patients. In our patient, N-acetylcysteine lavage was a safe and effective alternative that resulted in rapid resolution of his feeding intolerance. Brandon Sparks and Anil Kesavan Copyright © 2014 Brandon Sparks and Anil Kesavan. All rights reserved. Biliary Cystadenoma: An Unusual Cause of Acute Pancreatitis and Indication for Mesohepatectomy Tue, 18 Nov 2014 12:21:13 +0000 The classic presentation of cystic hepatobiliary lesions is usually nonspecific and often identified incidentally. Here we describe the case of a patient presenting with acute pancreatitis resulting from a large centrally located biliary cystadenoma compressing the pancreas. Determination of the origin of the cystic lesion was difficult on imaging studies. Due to the difficult location of the lesion, a complete surgical resection was achieved with mesohepatectomy and the suspected diagnosis confirmed by pathology. The patient continues to do well 2 years post-op with no signs of recurrence. Bilal Munir, Michael Meschino, Ashley Mercado, and Roberto Hernandez-Alejandro Copyright © 2014 Bilal Munir et al. All rights reserved. Leclercia adecarboxylata Bacteremia in a Patient with Ulcerative Colitis Tue, 28 Oct 2014 00:00:00 +0000 Patients with inflammatory bowel disease (IBD) are a high risk population for bacteremia. Derangement in the mucosal architecture of the gastrointestinal (GI) tract and frequent endoscopic interventions in immunocompromised individuals are considered primary causes. Isolation of opportunistic microorganisms from the bloodstream of IBD patients has been increasingly reported in recent years. Leclercia adecarboxylata is a ubiquitous, aerobic, motile, gram-negative bacillus. The human GI tract is known to harbor this rarely pathogenic microorganism. There are only a few case reports of bacteremia with this microorganism; the majority are either polymicrobial or associated with immunocompromised patients. We describe a case of monomicrobial L. adecarboxylata bacteremia in a 43-year-old female who presented with bloody diarrhea. Colonoscopy revealed diffuse colonic mucosal inflammation with numerous ulcers, and histopathology revealed crypt abscesses. Following an episode of rectal bleeding, two sets of blood cultures grew L. adecarboxylata, which was treated with intravenous ceftriaxone. After a complicated hospital course, she was eventually diagnosed with ulcerative colitis and enteropathic arthritis, treated with intravenous methylprednisolone, mesalamine, and infliximab which resulted in resolution of her symptoms. In our previously immunocompetent patient, derangement of the gut mucosal barrier was the likely cause of bacteremia, yet performing endoscopic intervention may have contributed to bacterial translocation. Amir Kashani, Morteza Chitsazan, Kendrick Che, and Roger C. Garrison Copyright © 2014 Amir Kashani et al. All rights reserved. Dieulafoy Lesion in the Ascending Colon Presenting with Gastrointestinal Bleeding and Severe Anemia Complicated by a Coexisting Severe Resistant Chronic Idiopathic Thrombocytopenic Purpura Thu, 23 Oct 2014 10:40:26 +0000 Background. GI (gastrointestinal) bleeding can be due to a variety of etiologies ranging from being common like bleeding peptic ulcer disease or esophageal varices. One of the rarely documented causes is the Dieulafoy lesion which is known as an abnormally large ectatic artery that penetrates the gut wall, occasionally eroding through the mucosa causing massive bleeding. In addition to that, we refer to the uncommon presentation of Dieulafoy lesion itself as it is well known to be found in the stomach, esophagus, duodenum, and jejunum but not the ascending colon as in our case. The patient had a coexisting ITP (idiopathic thrombocytopenic purpura) that was resistant to different therapies. Case Report. We report a case of a 48-year-old Egyptian female known for chronic ITP resistant to treatment. The patient presented with bright red bleeding per rectum and severe life threatening anemia. Endoscopic study showed a Dieulafoy lesion. Endoscopic clipping was successful in controlling the bleeding. Conclusion. Dieulafoy lesion is a rare reason for GI bleeding and can present in common or unexpected places. Also extreme caution should be used in patients with bleeding tendency due to different reasons, like ITP in our case. Sherif Ali Eltawansy, Brag Thyagarajan, and Nadeem Baig Copyright © 2014 Sherif Ali Eltawansy et al. All rights reserved. Colonic Dieulafoy’s Lesion: A Rare Cause of Lower Gastrointestinal Hemorrhage and Review of Endoscopic Management Sun, 19 Oct 2014 09:46:24 +0000 Dieulafoy’s lesions are a rare cause of gastrointestinal hemorrhage. Extragastric Dieulafoy’s lesions are even more uncommon. We report the case of a 75-year-old woman who presented with gastrointestinal bleeding from a transverse colonic Dieulafoy’s lesion. She presented with two episodes of melena followed by one episode of fresh blood per rectum. In addition, there was associated presyncope and anemia (hemoglobin 69 g/L) in the setting of supratherapeutic warfarin anticoagulation (INR 6.2) for nonvalvular atrial fibrillation. Esophagogastroduodenoscopy was negative for an upper GI source of bleeding but on colonoscopy an actively oozing Dieulafoy’s lesion was identified in the transverse colon. Bipolar cautery and hemostatic endoclips were applied to achieve hemostasis. Clinicians should consider this rare entity as a potential cause of potentially life-threatening lower gastrointestinal bleeding and we review the endoscopic modalities effective for managing colonic Dieulafoy’s lesions. Christopher Ma, Rajveer Hundal, and Edwin J. Cheng Copyright © 2014 Christopher Ma et al. All rights reserved. Self-Expandable Metal Stent Placement for Closure of a Leak after Total Gastrectomy for Gastric Cancer: Report on Three Cases and Review of the Literature Thu, 09 Oct 2014 08:10:24 +0000 In the setting of the curative oncological surgery, the gastric surgery is exposed to complicated upper gastrointestinal leaks, and consequently the management of this problem has become more critically focused than was previously possible. We report here three cases of placement of a partially silicone-coated SEMS (Evolution Controlled Release Esophageal Stent System, Cook Medical, Winston-Salem, NC, USA) in patients who underwent total gastrectomy with Roux-en-Y end-to-side esophagojejunostomy for a gastric adenocarcinoma. The promising results of our report, despite the small number of patients, suggest that early stenting (through a partially silicone-coated SEMS) is a feasible alternative to surgical treatment in this subset of patients. In fact, in the treatment of leakage after total gastrectomy, plastic stents and totally covered metallic stents may not adhere sufficiently to the esophagojejunal walls and, as a result, migrate beyond the anastomosis. However, prospective studies with a larger number of patients might assess the real effectiveness and safety of this procedure. Dario Raimondo, Emanuele Sinagra, Tiziana Facella, Francesca Rossi, Marco Messina, Massimiliano Spada, Guido Martorana, Pier Enrico Marchesa, Rosario Squatrito, Giovanni Tomasello, Attilio Ignazio Lo Monte, Giancarlo Pompei, and Ennio La Rocca Copyright © 2014 Dario Raimondo et al. All rights reserved. Immediate Free Jejunum Transfer for Salvage Surgery of Gastric Tube Necrosis Wed, 01 Oct 2014 10:01:14 +0000 Gastric tube necrosis after esophagus cancer surgery is a rare but critical situation. Salvage reconstruction of the esophagus remains a challenging procedure for head and neck surgeons. Historically, surgeons have employed a two-stage salvage surgery consisting of debridement followed by reconstruction. While this procedure generates good results, the time to restart oral alimentation is long. The present report describes the case of a 62-year-old male who developed gastric tube necrosis 3 days after undergoing surgery for thoracic-cervical esophageal cancer and immediate reconstruction with the retrosternal gastric pullup technique. He was treated with debridement and simultaneous free jejunum transfer 4 days after the primary surgery. He was able to restart oral alimentation 10 days after the salvage surgery. This rapid return to oral alimentation is a major advantage of the one-stage immediate esophagus salvage reconstruction. Another advantage is the ease of the reconstructive procedure: the absence of scarring and prolonged inflammation, which are disadvantages of the two-stage procedure, meant that recipient vessel selection and anastomosis were uncomplicated. The one-step procedure may be particularly useful in cases where the inflammation is discovered early. Hiroki Umezawa, Takeshi Matsutani, Rei Ogawa, and Hiko Hyakusoku Copyright © 2014 Hiroki Umezawa et al. All rights reserved. Gallstone Ileus following Endoscopic Stone Extraction Sun, 28 Sep 2014 13:08:40 +0000 An 85-year-old woman was an outpatient treated at Tokyo Rosai Hospital for cirrhosis caused by hepatitis B. She had previously been diagnosed as having common bile duct stones, for which she underwent endoscopic retrograde cholangiopancreatography (ERCP). However, as stone removal was unsuccessful, a plastic stent was placed after endoscopic sphincterotomy. In October 2012, the stent was replaced endoscopically because she developed cholangitis due to stent occlusion. Seven days later, we performed ERCP to treat recurring cholangitis. During the procedure, the stone was successfully removed by a balloon catheter when cleaning the common bile duct. The next day, the patient developed abdominal pain, abdominal distension, and nausea and was diagnosed as having gallstone ileus based on abdominal computed tomography (CT) and abdominal ultrasonography findings of an incarcerated stone in the terminal ileum. Although colonoscopy was performed after inserting an ileus tube, no stone was visible. Subsequent CT imaging verified the disappearance of the incarcerated stone from the ileum, suggesting that the stone had been evacuated naturally via the transanal route. Although it is extremely rare for gallstone ileus to develop as a complication of ERCP, physicians should be aware of gallstone ileus and follow patients carefully, especially after removing huge stones. Yoshiya Yamauchi, Noritaka Wakui, Yasutsugu Asai, Nobuhiro Dan, Yuki Takeda, Nobuo Ueki, Takahumi Otsuka, Nobuyuki Oba, Shuta Nisinakagawa, and Tatsuya Kojima Copyright © 2014 Yoshiya Yamauchi et al. All rights reserved. Combined Use of Clips and Nylon Snare (“Tulip-Bundle”) as a Rescue Endoscopic Bleeding Control in a Mallory-Weiss Syndrome Thu, 25 Sep 2014 09:03:07 +0000 Mallory-Weiss syndrome (MWS) accounts for 6–14% of all cases of upper gastrointestinal bleeding. Prognosis of patients with MWS is generally good, with a benign course and rare recurrence of bleeding. However, no strict recommendations exist in regard to the mode of action after a failure of primary endoscopic hemostasis. We report a case of an 83-year-old male with MWS and rebleeding after the initial endoscopic treatment with epinephrine and clips. The final endoscopic control of bleeding was achieved by a combined application of clips and a nylon snare in a “tulip-bundle” fashion. The patient had an uneventful postprocedural clinical course and was discharged from the hospital five days later. To the best of our knowledge, this is the first case report showing the “tulip-bundle” technique as a rescue endoscopic bleeding control in the esophagus. Hrvoje Ivekovic, Bojana Radulovic, Suzana Jankovic, Pave Markos, and Nadan Rustemovic Copyright © 2014 Hrvoje Ivekovic et al. All rights reserved. Acute Abdomen Resulting from Concurrent Thrombosis of Celiac Trunk and Superior Mesenteric Artery Tue, 23 Sep 2014 00:00:00 +0000 Mesenteric ischemia is one of the most mortal diseases of the gastrointestinal system causing acute abdomen. In most of the patients, the etiological factor is the obstructive embolism or thrombosis of superior mesenteric artery. In the literature, there have been reports regarding also celiac trunk occlusion in rare situations. The gold standard treatment relies on early diagnosis. The originality of our report relies on the concurrent obstruction of both vascular structures. Savaş Bayrak, Hasan Bektas, Yigit Duzkoylu, Ayhan Guneyi, and Ekrem Cakar Copyright © 2014 Savaş Bayrak et al. All rights reserved. Stomach Carcinoma Presenting with a Synchronous Liver Cancer: A Case Report and Literature Review Mon, 22 Sep 2014 08:52:41 +0000 Multiple primary malignant neoplasms are two or more malignancies in an individual without any relationship between the tumors. Multiple primary malignancies are relatively rare but have increased in recent decades. Two cancers are commonly observed among those with multiple primary malignancies, but two malignancies of stomach and liver are relatively rare to be reported. Mechanisms of the tumors were unclear; we described a patient who had stomach carcinoma presenting with a synchronous liver cancer and investigated his family history; we suggest that family history may be a key risk factor and early detection for additional primary malignancies should be needed for patients who had specific cancer history in their pedigree. Early diagnosis may be the key risk factor affecting prognosis. Yong Wang and Xiao-ting Wu Copyright © 2014 Yong Wang and Xiao-ting Wu. All rights reserved. Psoas Muscle Infiltration Masquerading Distant Adenocarcinoma Mon, 22 Sep 2014 00:00:00 +0000 Malignant metastasis to the psoas muscle is rare. We report a case that clinically mimicked psoas abscess that was subsequently proven to be from metastatic disease secondary to adenocarcinoma of the duodenum. A 62-year-old male presented with a seven-month history of right lower quadrant abdominal pain and progressive dysphagia. CT scan of abdomen-pelvis revealed a right psoas infiltration not amenable to surgical drainage. Patient was treated with two courses of oral antibiotics without improvement. Repeated CT scan showed ill-defined low-density area with inflammatory changes involving the right psoas muscle. Using CT guidance, a fine needle aspiration biopsy of the right psoas was performed that reported metastatic undifferentiated adenocarcinoma. Patient underwent upper endoscopy, which showed a duodenal mass that was biopsied which also reported poorly differentiated adenocarcinoma. In this case, unresponsiveness to medical therapy or lack of improvement in imaging studies warrants consideration of differential diagnosis such as malignancy. Iliopsoas metastases have shown to mimic psoas abscess on their clinical presentation and in imaging studies. To facilitate early diagnosis and improve prognosis, patients who embody strong risk factors and symptoms compatible with underlying malignancies who present with psoas imaging concerning for abscess should have further investigations. Kamel A. Gharaibeh, Arnaldo Lopez-Ruiz, and Tauqeer Yousuf Copyright © 2014 Kamel A. Gharaibeh et al. All rights reserved. A Rare Presentation of Hepatitis A Infection with Extrahepatic Manifestations Sun, 14 Sep 2014 00:00:00 +0000 Hepatitis A has a variety of associated extrahepatic manifestations that clinicians should be aware of for early diagnosis and treatment. We report a unique case of hepatitis A presenting with multiple extrahepatic manifestations not previously described in a single patient. A 34-year-old male presented with sudden onset of left sided facial pain, swelling, and skin rash, with diffuse body pains and muscle weakness, and was found to be positive for hepatitis A immunoglobulin M (IgM). He was initially started on antibiotics for concerns of bacterial parotitis but did not show any improvement. A punch biopsy of his mandibular rash and swelling was done which showed lymphohistiocytic infiltration with a few eosinophils. A trial of prednisone resulted in improvement of his symptoms. Clinicians should be aware to look for hepatitis A infection in a patient with atypical clinical picture causing a widespread systemic inflammatory response. Treatment with prednisone may result in resolution. Geetika Bhatt, Varrinder S. Sandhu, and Charlene K. Mitchell Copyright © 2014 Geetika Bhatt et al. All rights reserved. Lupus Enteritis as an Initial Presentation of Systemic Lupus Erythematosus Thu, 11 Sep 2014 09:34:35 +0000 Systemic lupus erythematosus (SLE) is an autoimmune disorder which can affect multiple organs and clinical presentation is often a myriad of symptoms; therefore, the index of suspicion should rise when evaluating patients with multiorgan symptomatology. Lupus enteritis is a distinct subset of SLE, defined as either vasculitis or inflammation of the small bowel, with supportive image and/or biopsy findings. The clinical picture of lupus enteritis is often nonspecific, with mild to severe abdominal pain, diarrhea, and vomiting being the cardinal manifestations. Although considered a form of visceral or serosal vasculitis, lupus enteritis is seldom confirmed on histology, making computerized tomography (CT) the gold standard for diagnosis. Lupus enteritis is generally steroid-responsive, and the route of administration is based on clinical status and organ involvement, with preference for intravenous (IV) route in flares with significant tissue edema. The following case describes a young woman presenting with lupus enteritis and lupus panniculitis as an initial manifestation of SLE, the utilization of abdominal CT in diagnosis, and current treatment protocols used for lupus enteritis. Sisira Sran, Manpreet Sran, Narmisha Patel, and Prachi Anand Copyright © 2014 Sisira Sran et al. All rights reserved. An Esophagogastroduodenal Crohn’s-Like Disease in a Long-Standing Pan-Ulcerative Colitis Patient Wed, 10 Sep 2014 07:16:26 +0000 Inflammatory bowel disease (IBD) comprises the principal subtypes Crohn’s disease (CD) and ulcerative colitis (UC), with a fraction remaining as IBD unclassified (IBDU). Given the complexity of IBD manifestations in a patient over time and our increasing understanding of IBD biology, a modification in subtype diagnosis can also occur. Herein is a case of a 27-year-old female with well-controlled and long-standing pan-UC, who developed Crohn’s-like esophagogastroduodenitis. The difficulty in classifying IBD into a single traditional subtype, and the debated presentation of a coexistent IBD will be discussed. Christopher Moore, Shriram Jakate, and Ali Keshavarzian Copyright © 2014 Christopher Moore et al. All rights reserved. Obstructive Pseudotumor of Tuberculosis in a Young Woman: A Rare Presentation Tue, 02 Sep 2014 12:18:28 +0000 Retroperitoneal pseudotumor is an extremely rare presentation of extrapulmonary tuberculosis. The diagnosis of this paucibacillary disease is difficult which is usually misdiagnosed as a malignant tumor. High index of suspicion is required for early diagnosis and treatment of retroperitoneal pseudotumor which can affect prognosis of this disease. Because of its rarity and difficult diagnosis, we report an 18-year-old immunocompetent girl who presented with abdominal pain and vomiting. Upper endoscopy showed an exudative mass between the second and third parts of duodenum. Abdominal computed tomography (CT) revealed a large retroperitoneal mass with extension into small bowel. Exploratory laparotomy and histopathological examination of tissue showed calcified granuloma. Ziehl-Neelsen staining and PCR confirmed the tuberculosis. The patient was successfully treated with standard antituberculosis therapy. Seyyed Reza Fatemi, M. Ghobakhlou, and L. Alizadeh Copyright © 2014 Seyyed Reza Fatemi et al. All rights reserved. Unawareness of a Prolonged Retained Capsule Endoscopy: The Importance of Careful Follow-Up and Cooperation between Medical Institutions Tue, 02 Sep 2014 00:00:00 +0000 A 50-year-old man with anemia was referred to our hospital to undergo capsule endoscopy (CE), which revealed small intestinal ulcers. After 5 months of CE, he returned because of recurrent anemia without abdominal symptoms. Abdominal X-ray and computed tomography showed capsule retention in the small intestine at the pelvic cavity. The capsule remained at the same place for 7 days. We performed capsule retrieval by laparoscopy-assisted surgery with resection of the involved small intestine, including an ileal stricture. Resected specimen showed double ulcers with different morphologies, an ulcer scar with stricture, and a wide ulcer at the proximal side of the others. Each ulcer had different histopathological findings such as the degree of fibrosis and monocyte infiltration. These differences led us to consider that the proximal ulcer may have been secondarily induced by capsule retention. Our experience indicated that careful follow-up and the cooperation between medical institutions after CE examination should be undertaken for patients with incomplete examination, unknown excretion of the capsule, and/or ulcerative lesions despite the lack of abdominal symptoms. Additionally, a retained CE remaining over long periods and at the same place in the small intestine may lead to secondary ulceration. Susumu Saigusa, Masaki Ohi, Hiroki Imaoka, Tadanobu Shimura, Ryo Uratani, Yasuhiro Inoue, and Masato Kusunoki Copyright © 2014 Susumu Saigusa et al. All rights reserved. Collagenous Colitis Associated with Protein Losing Enteropathy in a Toddler Wed, 20 Aug 2014 09:22:42 +0000 Collagenous mucosal inflammatory disease is a rare gastrointestinal disorder that involves the columnar lining of gastric and intestinal mucosa and is characterized by a distinct subepithelial collagen deposition. Recent clinical and pathological evidence have indicated that collagenous mucosal inflammatory disease can be extensive disease that may concomitantly involve several gastrointestinal sites at the same time. This entity, however, occurs infrequently in children. It is even less common to find concomitant depositions of collagen in the mucosa of gastrointestinal sites other than the colon. Only two cases in pediatric literature reported concomitant involvement, one with gastric and colonic involvement and the other one with gastroduodenocolitis. We are reporting a 15-month-old boy who presented with severe diarrhea and diffuse edema secondary to hypoalbuminemia. Further testing documented protein losing enteropathy (PLE) associated with collagenous colitis. Osama F. Almadhoun, Philip J. Katzman, and Thomas Rossi Copyright © 2014 Osama F. Almadhoun et al. All rights reserved. Enteric Duplication Cyst Containing Squamous and Respiratory Epithelium: An Interesting Case of a Typically Pediatric Entity Presenting in an Adult Patient Wed, 20 Aug 2014 08:28:41 +0000 Enteric duplication cysts are rare congenital malformations that can occur at any point along the digestive tract, most commonly the small bowel. They are characterized by the presence of an outer layer of smooth muscle and an inner lining of mucosa that may resemble any portion of the digestive tract. Less commonly, cases have been reported that also contain mucosal components of nonintestinal origin. This entity is typically diagnosed in young children, but occasionally presents in adolescence and young adulthood. We present a rare case of a 21-year-old male who presented with nonspecific symptoms of abdominal discomfort and weight loss and was later found to have a 9 cm nonenhancing mass in the distal ileum on CT imaging. Laparoscopic dissection of the mass revealed a cystic lesion lined mainly by pseudostratified ciliated columnar respiratory-type epithelium, with patchy areas of squamous epithelium as well as villous columnar epithelium resembling small bowel. The unique histology and advanced patient age make this case a unique presentation of what is already a rare pathological entity. Jessica Leigh Baumann and Charmi Patel Copyright © 2014 Jessica Leigh Baumann and Charmi Patel. All rights reserved. Cutaneous Vasculitis, Interstitial Pneumonia with Crazy-Paving Appearance, and Positive pANCA in a Patient with Severe Crohn’s Disease Thu, 14 Aug 2014 12:29:07 +0000 Cutaneous vasculitis, interstitial pneumonia with crazy-paving appearance on high-resolution computed tomography, and repeated positive perinuclear anti-neutrophil cytoplasmic antibodies (pANCA) are rarely found together in patients with inflammatory bowel disease in the existing literature. We report the case of a Chinese patient previously diagnosed with cutaneous vasculitis and interstitial pneumonia, who presented with acute pain and mass in his right lower quadrant a couple of years later. The terminal ileum biopsy and postoperative pathology confirmed Crohn’s disease (CD). Guang-liang Chen, Juan Wang, Bao-zhen Li, Li-mei Li, Han-you Mo, and Shuang Ye Copyright © 2014 Guang-liang Chen et al. All rights reserved. Acute Pancreatitis as the Initial Presentation of Systematic Lupus Erythematosus Thu, 14 Aug 2014 07:22:04 +0000 Systematic lupus erythematosus (SLE) is a multisystem disease, including the gastrointestinal system in about half of SLE patients. As a rare complication of SLE, acute pancreatitis presents as generalized flare-ups in most cases of patients previously diagnosed with SLE. Here we report a rare case of acute pancreatitis as the initial presentation with later diagnosis of SLE. Yi Jia, Arleen Ortiz, Richard Mccallum, Hasan Salameh, and Pedro Serrato Copyright © 2014 Yi Jia et al. All rights reserved.