Case Reports in Gastrointestinal Medicine The latest articles from Hindawi Publishing Corporation © 2014 , Hindawi Publishing Corporation . 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. Intragastric Endoscopic Assisted Single Incision Surgery for Gastric Leiomyoma of the Esophagogastric Junction Thu, 12 Dec 2013 18:22:26 +0000 Single port laparoscopic surgery is becoming an alternative to conventional laparoscopic surgery as a new approach where all the conventional ports are gathered in just one multichannel port through only one incision. Appling this technical development, we have developed a new technique based on an intragastric approach using a single port device assisted by endoscopy (I-EASI: intragastric endoscopic assisted single incision surgery) in order to remove benign gastric lesions and GIST tumors placed in the posterior wall of the stomach or close to the esophagogastric junction or the gastroduodenal junction. We present a patient with a submucosal gastric tumor placed near the esophagogastric junction removed with this new approach. Salvador Morales-Conde, Isaias Alarcón, Carlos Ortiz-Moyano, Antonio Barranco, Francisco J. Padillo, and María Socas Copyright © 2013 Salvador Morales-Conde et al. All rights reserved. A Case of Extreme Gastroparesis due to an Occult Small Cell Cancer of the Lung Wed, 04 Dec 2013 15:04:40 +0000 A patient with gastroparesis is presented. Ultimately the diagnosis of paraneoplastic gastroparesis due to an occult small cell cancer of the lung was made. The difficulties in the diagnostic process and the pathogenesis of this very rare manifestation are discussed. J. A. C. M. Burger, B. Liberov, F. Yurd, and R. J. L. F. Loffeld Copyright © 2013 J. A. C. M. Burger et al. All rights reserved. Gastric Sarcoidosis: A Rare Clinical Presentation Wed, 04 Dec 2013 14:44:03 +0000 Gastrointestinal (GI) sarcoidosis is a very rare disease, which clinically presents along with systemic disease or as an isolated finding. Gastric sarcoidosis is the most common form of GI sarcoidosis. Symptomatic gastric sarcoidosis is rare and only few case reports have been described in the literature with well-documented histological evidence of noncaseating granulomas. We present an interesting case of gastric sarcoidosis in a 39-year-old Caucasian man with symptoms of epigastric pain and profound weight loss. His endoscopic gastric mucosal biopsies revealed noncaseating granulomas consistent with gastric sarcoidosis. Treatment with oral steroids alleviated his symptoms with no recurrence in 2 years. Gastric sarcoidosis should be considered in patients with history of sarcoidosis and GI symptoms. Hemasri Tokala, Karthik Polsani, and Jagadeesh K. Kalavakunta Copyright © 2013 Hemasri Tokala et al. All rights reserved. “Unsteady Gait”: An Uncommon Presentation and Course of Malignant Melanoma in Terminal Ileum—A Case Report and Review of Literature Thu, 28 Nov 2013 12:58:20 +0000 Malignant melanoma within the gastrointestinal tract is an uncommon neoplasm that is usually metastatic in origin, with primary melanomas being relatively uncommon. Embryologically melanocytes normally exist in the esophagus, stomach, small bowel, and anorectum and this theory supports the primary melanoma of the gastrointestinal tract that has been confirmed for lesions occurring through several published reports. However, most patients with brain metastases from malignant melanoma are diagnosed after treatment for known extracranial metastases and have poor outcomes. Our case is unique in that we discuss an unusual case of 69-year-old female patient presented with unsteady gait as the first symptom of disease and where the presumed primary lesion later was found in the terminal ileum on colonoscopy. Treatment consisted of surgical removal of the terminal ileal lesion with chemotherapy, whole-brain radiotherapy, and cyberknife radiosurgical procedure. Patient was in remission for more than 14 months and later succumbed to disease. Despite the advances in therapeutic options, prognosis for patients with melanoma brain metastases remains poor with a median survival time of six months after diagnosis. Satya Allaparthi and Khalid A. Alkimawi Copyright © 2013 Satya Allaparthi and Khalid A. Alkimawi. All rights reserved. Endoscopic Transmural Drainage of Pancreatic Pseudocysts: Technical Challenges in the Resource Poor Setting Wed, 27 Nov 2013 11:44:05 +0000 Although surgical drainage of pancreatic pseudocysts has been superseded by less invasive options, the requirement for specialized equipment, technical expertise, and consumables limits the options available in low resource settings. We describe the challenges experienced during endoscopic transmural drainage in a low resource setting and the methods used to overcome these barriers. Despite operating in a low resource environment, endoscopic drainage of pancreatic pseudocysts can be incorporated into our armamentarium with minimal change to the existing hardware. Careful patient selection by a dedicated multidisciplinary team should be observed in order to achieve good outcomes. Shamir O. Cawich, Trevor Murphy, Sundeep Shah, Phillip Barrow, Milton Arthurs, Michael J. Ramdass, and Peter B. Johnson Copyright © 2013 Shamir O. Cawich et al. All rights reserved. A Novel Case of Functional Gastric Neuroendocrine Carcinoma Occurred after Endoscopic Submucosal Dissection Wed, 06 Nov 2013 09:55:16 +0000 In Japan, endoscopic submucosal dissection (ESD) is becoming a standard treatment for intramucosal differentiated gastric cancer. Although ESD is associated with a high cure rate for patients with early gastric cancer, tumors may recur, albeit rarely. We performed ESD on an 80-year-old man with a small depressed type of gastric cancer of the posterior wall of the cardia, found to be locally invasive on histology. Thirty months later, local recurrence and multiple liver metastases were detected, accompanied by frequent severe hypoglycemia. Despite chemotherapy, the patient died 6 months after relapse. On autopsy, the recurrent gastric lesion and liver metastases were examined immunohistochemically. Several characteristic tumor cells were positive for chromogranin A, cluster of differentiation (CD) 56, Ki-67, and insulin-like growth factor (IGF)-II. Western blot analysis of the patient’s serum obtained during a hypoglycemic attack showed the high molecular weight form of IGF-II or “big” IGF-II. The patient was diagnosed with non-islet cell tumor hypoglycemia (NICTH), with “big” IGF-II being produced by the gastric neuroendocrine carcinoma. This is the novel case of a functional gastric neuroendocrine carcinoma that occurred after ESD and induced a hypoglycemic attack associated with NICTH. Yoshiaki Shibata, Yuji Ito, Hiroko Fujita, Yume Okada, Toshihiko Nagai, Hirohito Sano, and Kumiko Ito Copyright © 2013 Yoshiaki Shibata et al. All rights reserved. Loperamide-Induced Acute Pancreatitis Wed, 02 Oct 2013 14:40:30 +0000 Acute pancreatitis is a common disease leading to hospitalizations, most often caused by gallstones or alcohol. We present a case of a patient diagnosed with acute pancreatitis considered to be due to loperamide treatment for diarrhea. Halla Vidarsdottir, Hanna Vidarsdottir, Pall Helgi Moller, and Einar Stefan Bjornsson Copyright © 2013 Halla Vidarsdottir et al. All rights reserved. Metastatic Infiltrating Ductal Carcinoma of the Breast to the Colon: A Case Report and Literature Review Tue, 01 Oct 2013 13:29:35 +0000 True metastatic involvement of the colon is rare. Colonic metastases occur most commonly secondary to peritoneal metastases from intra-abdominal malignancies. Breast cancer is the most common malignancy that metastasizes hematogenously to the colon. Colonic metastatic disease mimics primary colonic tumors in its presentation. Colonic metastatic involvement is a poor prognostic sign, and the pathologist should be informed about the history of the primary breast cancer when examining the pathologic specimens. In this paper, we report a case of an ileocecal mass found to be histologically consistent with metastatic ductal breast cancer, and then we review the literature about breast cancer metastases to the gastrointestinal tract in general and colon in particular. Salih Samo, Muhammed Sherid, Husein Husein, Samian Sulaiman, Jeffrey V. Brower, Seth Alper, Margaret Yungbluth, and John A. Vainder Copyright © 2013 Salih Samo et al. All rights reserved. Visceral Arterial Aneurysms Complicating Endoscopic Retrograde Cholangiopancreatography Wed, 25 Sep 2013 11:39:25 +0000 We report this case of a 74-year-old man with altered anatomy secondary to Billroth-II surgery who underwent endoscopic retrograde cholangiopancreatography (ERCP) for choledocholithiasis and subsequently developed severe diffuse abdominal pain with drop in hemoglobin. Patient was found to have hemorrhagic shock requiring aggressive resuscitative measures. Patient was found to have large peripancreatic hematoma secondary to bleeding from gastroduodenal and superior pancreaticoduodenal artery pseudoaneurysms. Gastroduodenal artery aneurysm is the rarest of all the splanchnic artery aneurysms, and to our knowledge this is the only reported case of a gastroduodenal artery pseudoaneurysm complicating ERCP. Vinaya Gaduputi, Hassan Tariq, and Anil Dev Copyright © 2013 Vinaya Gaduputi et al. All rights reserved. Rapunzel Syndrome: A Rare Postpartum Case Thu, 19 Sep 2013 17:29:52 +0000 The Rapunzel syndrome describes a disorder in which a significant amount of hair is swallowed, forming a trichobezoar that extends past the stomach into the small intestines. Given the indigestible nature of hair, it subsequently leads to obstruction within the gastrointestinal system. Clinically, patients may present with symptoms of gastrointestinal obstruction, including abdominal complaints such as pain, nausea, vomiting, and diarrhea. However, due to its broad and nonspecific presenting symptoms, the diagnosis of Rapunzel syndrome warrants consideration once other common etiologies have been excluded. Surgical intervention is often required to remove the abdominal mass. This unusual syndrome is often associated with psychiatric disorders, affecting young women most commonly. In this report, we will discuss a unique case of Rapunzel syndrome in a one-month postpartum woman. Teshome Tegene, Yahia Foda, Omar Hussain, Kolawole Oloniyo, Ngoc-Tram Ha, and Geeta Manikonda Copyright © 2013 Teshome Tegene et al. All rights reserved. Anal Canal Duplication in an 11-Year-Old-Child Sun, 15 Sep 2013 09:32:06 +0000 Anal canal duplication (ACD) is the least frequent digestive duplication. Symptoms are often absent but tend to increase with age. Recognition is, however, important as almost half of the patients with ACD have concomitant malformations. We present the clinical history of an eleven-year-old girl with ACD followed by a review of symptoms, diagnosis, treatment, and prognosis based on all the reported cases in English literature. S. Van Biervliet, E. Maris, S. Vande Velde, D. Vande Putte, V. Meerschaut, N. Herregods, R. De Bruyne, M. Van Winckel, and K. Van Renterghem Copyright © 2013 S. Van Biervliet et al. All rights reserved. Rectal Ischemia Mimicked Tumor Mass Thu, 12 Sep 2013 11:44:53 +0000 Ischemic proctitis is a rare disease which is usually encountered in elderly with comorbidities. We present a case of an 80-year old man with severe coronary disease who presented with severe hematochezia and hypotension. Endoscopy revealed a rectal mass 3-4 cm above the dental line and rectosigmoid mucosal inflammation compatible with ischemic colitis. The rectal insult was so intense that it resembled a neoplasmatic lesion. We discuss the causes, the prognostic factors, and the clinical and therapeutic challenges of this rare, albeit life-threatening entity, and we review the relative literature. A percentage of 10%–20% of patients with ischemic colitis usually have a distal potentially obstructing lesion or disorder such as cancer, diverticulitis or fecal impaction. Ischemic colitis, when mucosal and submucosal edema is severe and hemorrhagic nodules are large enough, can mimic a neoplasmatic lesion. The best treatment approach is a conservative management initially with a close clinical followup and after stabilization a repetition of rectal endoscopy with new biopsies. Early recognition of this clinical entity is of paramount importance to implement appropriate therapy (conservative or surgical) and avoid potentially fatal treatment of presumed inflammatory or infectious bowel diseases. Nicolaos Zikos, Panagiota Aggeli, Evangelia Louka, and George Pappas-Gogos Copyright © 2013 Nicolaos Zikos et al. All rights reserved. Esophageal Plasmacytoma Diagnosed in a Patient Presenting with Cardiac Symptoms: A Novel Case Tue, 10 Sep 2013 16:33:03 +0000 Extramedullary plasmacytoma is the uncommon phenomenon of a plasma cell neoplasm occurring outside of the bone marrow. Primary plasmacytoma is a rare occurrence in the gastrointestinal tract and exceptional to originate in the esophagus. We present a novel case of a 62-year-old man who presented to our emergency department with chest pain. A cardiovascular workup was negative, and an endoscopy was subsequently performed. The endoscopy findings showed evidence of Grade IV esophagitis with ulcerations extending from 25 cm to 32 cm. Histopathological examination revealed marked acute and chronic inflammation, granulation tissue, and overlying necroinflammatory exudate. However, sheets of plasma cells, some with prominent nucleoli, were also seen. Immunohistochemically, the plasma cells expressed CD138 and MUM1 and were IgG kappa restricted. A bone marrow biopsy was performed which was negative for involvement. This is a novel case of esophageal plasmacytoma diagnosed on endoscopy in a patient presenting with acute chest pain. Cheryl Rimmer, Anup Hazra, Vito M. Gulli, Richard Siderits, Mark Castaldi, and Zafar Zamir Copyright © 2013 Cheryl Rimmer et al. All rights reserved. Recurrent Lower Gastrointestinal Bleeding: Ileal GIST Diagnosed by Video Capsule Endoscopy—A Case Report and Literature Review Wed, 21 Aug 2013 11:16:43 +0000 Introduction. Gastrointestinal stromal tumor (GIST) in the ileum is an extremely rare cause of recurrent lower gastrointestinal bleeding (GIB). Case Report. An 89-year-old man was admitted with melana. He had extensive PMH of CAD post-CABG/AICD, AAA repair, chronic anemia, myelodysplastic syndrome, lung cancer after resection, and recurrent GIB. Prior EGDs, colonoscopies, and upper device-assisted enteroscopy showed duodenal ulcer, A-V malformation s/p cauterization, and angioectasia. On admission, Hb was 6.0 g/dL. An endoscopic capsule study showed an ulcerated tumor in the ileum. CT showed no distant metastasis. The lesion was resected successfully and confirmed as a high-grade GIST. The patient was discharged with no further bleeding. Discussion. Early diagnosis for patients with ileal GIST is often challenging. Video capsule endoscopy and double balloon enteroscopy could be useful diagnostic tools. Surgical removal is the first line for a resectable GIST. Imatinib has become the standard therapy. Conclusion. This is a unique case of an ileal GIST in a patient with recurrent GIB which was diagnosed by video capsule. Complicated medical comorbidities often lead to a significant delay in diagnosis. Therefore, we recommend that if GIB does not resolve after appropriate treatments for known causes, the alternative diagnosis for occult GIB must be considered, including malignancy such as GIST. Jie Ling, Marie Lamsen, Roger Coron, Danila Deliana, Sabah Siddiqui, Madhu Rangraj, and Stephen Jesmajian Copyright © 2013 Jie Ling et al. All rights reserved. A Rare Occurrence of Primary Hepatic Leiomyosarcoma Associated with Epstein Barr Virus Infection in an AIDs Patient Mon, 19 Aug 2013 12:36:01 +0000 Primary hepatic leiomyosarcoma is exceedingly rare accounting for less than 1% of the hepatic tumors. Close to 45 cases have been reported in the English literature. Presentation is usually nonspecific and diagnosis is often delayed until tumors reach a large size. This leads to a dismal prognosis. The tumors are not yet fully understood, hence the standard of care is not well defined. Curative resection remains the mainstay of management. Close association of Epstein Barr virus (EBV) induced soft tissue sarcomas is proven, especially in the presence of immunosuppression encountered in HIV/AIDS patients and in posttransplant patients. We herein present a case report of a 54-year-old man diagnosed to have HIV/AIDS and EBV infection admitted to our hospital with complaints of intractable hiccups for more than a week. Extensive workup revealed primary leiomyosarcoma of the liver. Haritha Chelimilla, Kanthi Badipatla, Ariyo Ihimoyan, and Masooma Niazi Copyright © 2013 Haritha Chelimilla et al. All rights reserved. Autoimmune Hepatitis: Diagnostic Dilemma in the Setting of Suspected Iron Overload Mon, 19 Aug 2013 10:37:33 +0000 Autoimmune hepatitis (AIH) is an inflammatory condition of the liver that has a multitude of clinical presentations from chronic hepatitis to acute fulminant hepatitis. AIH diagnosis is typically suspected after ruling out other causes of hepatitis (such as vial hepatitis, hemochromatosis, Wilson’s disease, and primary biliary cirrhosis) through serological tests and by findings of high titers of certain autoantibodies (ANA and anti-SMA for type 1 AIH and anti-LKM-1 for type 2 AIH). AIH like most inflammatory conditions is associated with increased ferritin levels (acute-phase reactant) but typically near-normal transferrin saturation. The presence of excessive ferritin level in absence of high-transferrin saturation helps differentiate secondary iron overload from hemochromatosis where transferrin saturation is typically high. We herein describe a case of AIH that presented with high ferritin levels and transferrin saturation suggesting a diagnosis of hemochromatosis and needed arduous work-up to arrive at accurate diagnosis of AIH. In Chul An, Ashish K. Tiwari, Srujan Ameda, and Heather S. Laird-Fick Copyright © 2013 In Chul An et al. All rights reserved. A Rare Complication of an Ingested Foreign Body: Gallbladder Perforation Tue, 30 Jul 2013 12:07:03 +0000 We present a 13-year-old child who admitted with a dull right upper quadrant pain that started 3 weeks before her referral. Several medications were given but they did not change the intensity and the frequency of the pain. Her physical examination was nonspecific except for slight right upper quadrant tenderness. The imaging studies revealed a sewing pin perforating the stomach and gallbladder. The patient was treated with a successful operation, and no postoperative complications were observed. To our knowledge, this is the first case of a sharp foreign body gallbladder perforation in a child. Safak Karacay, Koray Topçu, and Selami Sözübir Copyright © 2013 Safak Karacay et al. All rights reserved.