Case Reports in Gastrointestinal Medicine The latest articles from Hindawi Publishing Corporation © 2015 , Hindawi Publishing Corporation . All rights reserved. Clinical Outcome of a Portosplenomesenteric Venous Thrombosis in Necrotizing Acute Pancreatitis with Protein C and S Deficiency Treated by Anticoagulation Therapy Alone Thu, 10 Sep 2015 12:43:55 +0000 Cases of splanchnic venous thrombosis have not been described in Cameroon. Their prevalence in acute pancreatitis is variable. With the emergence of acute intra-abdominal infections including typhoid fever and peritoneal tuberculosis in situations of acquired immunodeficiency syndrome, these cases will become frequent. We report the case of a portosplenomesenteric venous thrombosis related to necrotizing acute pancreatitis associated with proteins C and S deficiency, in a 46-year-old Cameroonian man, without particular past medical history. He was admitted for abdominal pain which had been evolving for 3 weeks and accompanied by vomiting. In the absence of hemorrhagic risk factor, the patient received low molecular weight heparin followed by oral warfarin. The abdominal ultrasound check on the 12th day showed a partial recanalization of venous thrombosis. The abdominal contrast-enhanced CT scanner at day 30 on oral anticoagulation therapy showed collateral vessels and small bowel edema. At the same time the upper gastrointestinal endoscopy showed grade II esophageal varices. We have maintained oral anticoagulation therapy. This case highlights that an early effective anticoagulation heparin therapy is needed for a clear benefit in case of suspected PSMVT. It is certain that the sooner the treatment is given, the better outcome will be. Firmin Ankouane, Mathurin Kowo, Bernadette Ngo Nonga, Eric Magny, Edith Hell Medjo, and Elie Claude Ndjitoyap Ndam Copyright © 2015 Firmin Ankouane et al. All rights reserved. The “Endothelialized Muscularis Mucosae”: A Case Report Describing a Large Cavernous Hemangioma at the Terminal Ileum and a New Histologic Clue for Preoperative Diagnosis from Endoscopic Biopsy Wed, 09 Sep 2015 08:18:08 +0000 Cavernous hemangiomas of the gastrointestinal tract are quite rare and, until now, have been difficult to diagnose preoperatively due their nonspecific presentations and imaging features, as well as a lack of histologic description pertaining to small superficial biopsies such as those obtained endoscopically. We report a unique case of a 4 cm transmural cavernous hemangioma in the terminal ileum with literature review and describe a new histologic finding—the “endothelialized muscularis mucosae,” which was discovered upon review of the endoscopic biopsy and could potentially facilitate preoperative diagnosis of these lesions from endoscopic biopsies in the future. These lesions have classically required surgical resection in order to make a definitive diagnosis and rule out malignancy, with which they share many historical and radiographic features. Due to their potential to cause bowel obstruction, intussusception, perforation, and hemorrhage, these lesions may ultimately require surgical resection to relieve symptoms or prevent or treat complications—however, surgical planning and patient counseling could be greatly improved by a preoperative diagnosis. Therefore, gastroenterologists, pathologists, and surgeons should be aware of the “endothelialized muscularis mucosae” which can be very helpful in diagnosing GI cavernous hemangiomas from endoscopic biopsies. Erin K. Purdy-Payne, Jean F. Miner, Brandon Foles, and Tien-Anh N. Tran Copyright © 2015 Erin K. Purdy-Payne et al. All rights reserved. IgG4-Seronegative Autoimmune Pancreatitis and Sclerosing Cholangitis Tue, 25 Aug 2015 09:16:13 +0000 IgG4-related disease is a relatively novel clinical entity whose gastrointestinal manifestations include type 1 autoimmune pancreatitis (AIP) and IgG4-associated sclerosing cholangitis. The presence of elevated serum IgG4 is suggestive but not essential for the diagnosis of type 1 AIP and is a pervasive feature of the proposed diagnostic criteria. The differential diagnosis of type 1 AIP includes malignant conditions, emphasizing the importance of a deliberate, comprehensive evaluation. Management of patients with a suggestive clinical presentation, but without serum IgG4 elevation, is difficult. Here we present three cases of IgG4-seronegative AIP and sclerosing cholangitis that responded to empiric steroid therapy and discuss approach considerations. These cases demonstrate the value of meticulous application of existing diagnostic algorithms to achieve a clinical diagnosis and avoid surgical intervention. Allon Kahn, Anitha D. Yadav, and M. Edwyn Harrison Copyright © 2015 Allon Kahn et al. All rights reserved. Upper Gastrointestinal Bleeding from Gastric Amyloidosis in a Patient with Smoldering Multiple Myeloma Sun, 23 Aug 2015 06:00:16 +0000 Amyloidosis is a common complication of patients with monoclonal gammopathy of undetermined significance (MGUS), smoldering multiple myeloma (SMM), and multiple myeloma (MM). This proteinaceous material can be deposited intercellularly in any organ system, including the gastrointestinal (GI) tract. In the GI tract, amyloidosis affects the duodenum most commonly, followed by the stomach and colorectum. Gastric amyloidosis causes symptoms of nausea, vomiting, early satiety, abdominal pain, and GI bleeding. A case of upper GI bleeding from gastric amyloidosis is presented in a patient with SMM. Esophagogastroduodenoscopy (EGD) revealed a gastric mass. Endoscopic biopsies revealed amyloid deposition in the lamina propria, consistent with gastric amyloidosis. Liquid chromatography tandem mass spectrometry performed on peptides extracted from Congo red-positive microdissected areas of paraffin-embedded stomach specimens revealed a peptide profile consistent with AL- (lambda-) type amyloidosis. Based on this and multiple other case reports, we recommend that patients with GI bleeding and MGUS, SMM, or MM undergo EGD and pathologic examination of endoscopic biopsies of identified lesions using Congo red stains for amyloidosis for early diagnosis and treatment. Mihajlo Gjeorgjievski, Treta Purohit, Mitual B. Amin, Paul J. Kurtin, and Mitchell S. Cappell Copyright © 2015 Mihajlo Gjeorgjievski et al. All rights reserved. Ulcerating Ileocolitis in Severe Amatoxin Poisoning Tue, 18 Aug 2015 12:10:33 +0000 Amatoxin poisoning is still associated with a great potential for complications and a high mortality. While the occurrence of acute gastroenteritis within the first 24 hours after amatoxin ingestion is well described, only very few descriptions of late gastrointestinal complications of amatoxin poisoning exist worldwide. We present the case of a 57-year-old female patient with severe amatoxin poisoning causing fulminant but reversible hepatic failure that on day 8 after mushroom ingestion developed severe abdominal pain and watery diarrhea. Ulcerating ileocolitis was identified by computed tomography identifying a thickening of the bowel wall of the entire ileum and biopsies taken from the ileum and large bowel revealing distinct ileitis and proximally accentuated colitis. The absence of discernible alternative etiologies such as infectious agents makes a causal relationship between the ulcerating ileocolitis and the amatoxin poisoning likely. Diarrhea and varying abdominal pain persisted over several weeks and clinical follow-up after six months showed a completely symptom-free patient. The case presented highlights the importance to consider the possibility of rare complications of Amanita intoxication in order to be able to respond to them early and adequately. Matthias Peter Hilty, Marcel Halama, Anne-Katrin Zimmermann, Marco Maggiorini, and Andreas Geier Copyright © 2015 Matthias Peter Hilty et al. All rights reserved. Intestinal Amyloidosis in Common Variable Immunodeficiency and Rheumatoid Arthritis Sun, 16 Aug 2015 11:43:44 +0000 We present a case of reactive amyloidosis that developed secondary to common variable immunodeficiency and rheumatoid arthritis. A 66-year-old woman, with prior history of common variable immunodeficiency and rheumatoid arthritis, was referred to our clinic for chronic diarrhea investigation. The patient was submitted to colonoscopy with ileoscopy, which did not show relevant endoscopic alterations. However, undertaken biopsies revealed amyloid deposition. Since amyloidosis with GI involvement is a rare cause of chronic diarrhea, this pathology should be considered in etiologic investigation, especially when associated with chronic inflammatory diseases. T. Meira, R. Sousa, A. Cordeiro, R. Ilgenfritz, and P. Borralho Copyright © 2015 T. Meira et al. All rights reserved. Superior Mesenteric Artery Syndrome Associated with Rapid Weight Loss Attributed to Amphetamine Abuse Thu, 13 Aug 2015 16:07:19 +0000 Superior mesenteric artery (SMA) syndrome arises from a reduction in the angle formed between the SMA and the aorta, thereby compressing the third portion of the duodenum. This phenomenon may be caused by a number of factors, one of which being acute weight loss. We report a case of a female patient presenting with abdominal pain and vomiting who developed superior mesenteric artery (SMA) syndrome as a result of rapid weight loss, thought to be secondary to amphetamine abuse. This association can often be overlooked and, to our knowledge, has not been previously reported. Richard M. Fazio, On Chen, and Wael Eldarawy Copyright © 2015 Richard M. Fazio et al. All rights reserved. Focal Intramucosal Adenocarcinoma Occurring in Gastric Hyperplastic Polyps: Two Case Reports Tue, 04 Aug 2015 12:51:24 +0000 Gastric hyperplastic polyps are generally considered benign lesions, although rare cases of adenocarcinoma have been reported. Two cases of intramucosal adenocarcinoma originating from gastric hyperplastic polyps that were successfully removed by endoscopic mucosal resection or endoscopic submucosal dissection are reported. On pathological examination, adenocarcinoma limited to the hyperplastic foveolar epithelial mucosa of the gastric hyperplastic polyps was observed. Keisuke Taniuchi, Mitsuo Okada, and Hiroshi Sakaeda Copyright © 2015 Keisuke Taniuchi et al. All rights reserved. A Rare Cause of Intestinal Obstruction in Infants: Ileum Duplication Cyst and Literature Review Thu, 30 Jul 2015 13:00:40 +0000 Cases of neonatal gastrointestinal system (GIS) obstruction are quite complex for pediatric surgery clinics. A rare cause of intestinal obstruction is the duplication cyst (DC). A three-day-old male patient presented at our clinic with a history of abdominal distension and bilious vomiting on the second day following birth. Although pathology had not yet been determined from observation and examination, surgery was performed when the patient could not tolerate oral feeding. An ileal DC forming an incomplete obstruction was observed. Ileoileal anastomosis was performed on the patient. Because DCs can present with different clinical symptoms, it is quite difficult to diagnose them in neonate patients. Lacking an imaging method that can provide an exact diagnosis, the diagnostic laparotomy is a suitable approach for both diagnosis and treatment to avoid delays in treatment. Mehmet Serif Arslan, Erol Basuguy, Hikmet Zeytun, Serkan Arslan, Bahattin Aydogdu, Mehmet Hanifi Okur, Mariah Ozkir, Ibrahim Ibiloglu, and Ibrahim Uygun Copyright © 2015 Mehmet Serif Arslan et al. All rights reserved. Acute Portomesenteric Venous Thrombosis following Laparoscopic Small Bowel Resection and Ventral Hernia Repair Wed, 29 Jul 2015 13:16:16 +0000 Acute portomesenteric venous thrombosis is a rare but life-threatening complication of laparoscopic surgery that has been described in literature. Prompt diagnosis and early initiation of treatment are vital to prevent life-threatening complications such as mesenteric ischemia and infarction. A 51-year-old lady had laparoscopic small bowel resection and primary anastomosis with ventral hernia repair 4 weeks earlier for partial small bowel obstruction. Her postoperative period was uneventful and she was discharged home. Four weeks after surgery she developed watery diarrhea and generalized abdominal pain for four-day duration. A computed tomography of the abdomen revealed portomesenteric venous thrombosis although a computed tomography of abdomen before surgery 4 weeks back did not show any portomesenteric venous thrombosis. We are reporting a case of acute portomesenteric venous thrombosis as a complication of laparoscopic surgery. Bhradeev Sivasambu, Meera Yogarajah, and Thomas Wilson Copyright © 2015 Bhradeev Sivasambu et al. All rights reserved. Cannabinoid Hyperemesis Syndrome: A Paradoxical Cannabis Effect Wed, 22 Jul 2015 10:05:38 +0000 Despite well-established antiemetic properties of marijuana, there has been increasing evidence of a paradoxical effect in the gastrointestinal tract and central nervous system, given rise to a new and underrecognized clinical entity called the Cannabinoid Hyperemesis Syndrome. Reported cases in the medical literature have established a series of patients exhibiting a classical triad of symptoms: cyclic vomiting, chronic marijuana use, and compulsive bathing. We present a case of a 29-year-old man whose clinical presentation strongly correlates with cannabinoid hyperemesis syndrome. Despite a diagnosis of exclusion, this syndrome should be considered plausible in the setting of a patient with recurrent intractable vomiting and a strong history of cannabis use as presented in this case. Ivonne Marie Figueroa-Rivera, Rodolfo Estremera-Marcial, Marielly Sierra-Mercado, José Gutiérrez-Núñez, and Doris H. Toro Copyright © 2015 Ivonne Marie Figueroa-Rivera et al. All rights reserved. A Rare Cause of Acute Abdomen: Perforation of Double Meckel’s Diverticulum Wed, 22 Jul 2015 08:19:02 +0000 Meckel’s diverticulum is the most common congenital anomaly of the gastrointestinal tract. In this report, we aimed to represent a case of intestinal perforation, caused by double Meckel’s diverticulum, which is a very rare entity in surgical practice. The patient was a 20-year-old Caucasian man, admitted to hospital with complaints of abdominal pain, nausea, and vomitting during the last 3 days. Physical examination indicated tenderness, rebound, and guarding in the right lower quadrant of abdomen. Abdominal X-ray revealed a few air-liquid levels in the left upper quadrant. In the operation, 2 Meckel’s diverticula were observed, one at the antimesenteric side, at 70 cm distance to the ileocecal valve, approximately in 3 cm size, and the other between the mesenteric and antimesenteric sides, approximately in 5 cm size. The first one had been perforated at the tip and wrapped with omentum. A 30 cm ileal resection, including both diverticula with end-to-end anastomosis, was performed. The diagnosis of symptomatic Meckel’s diverticulum is considerably hard, especially when it is complicated. Diverticulectomy or segmentary resections are therapeutic options. In patients with acute abdomen clinic, Meckel’s diverticulum and its complications should be kept in mind, and the intestines should be observed for an extra diverticulum for caution although it is a very rare condition. İlhan Tas, Serdar Culcu, Yigit Duzkoylu, Sadik Eryilmaz, Mehmet Mehdi Deniz, and Deniz Yilmaz Copyright © 2015 İlhan Tas et al. All rights reserved. A Novel Endoscopic Method to Relieve Food Impaction Using an Inflatable Balloon Tue, 21 Jul 2015 14:15:38 +0000 Food impaction in the esophagus is a relatively common medical emergency. Most of these food impactions are relieved spontaneously. But for complete esophageal food impactions or impactions not relieved spontaneously, traditional endoscopic methods like using a Roth net, polypectomy snare, or rat or alligator tooth forceps are used to gently manipulate the food material into the stomach. However, these methods may not work in certain circumstances. We present a case of proximal esophageal food impaction that was relieved using an inflatable balloon after the conventional methods proved unsuccessful. Rohit Anand, Shashank Garg, Ethan Dubin, and Sudhir Dutta Copyright © 2015 Rohit Anand et al. All rights reserved. Coccidioidomycosis Masquerading as Eosinophilic Ascites Tue, 21 Jul 2015 13:04:35 +0000 Endemic to the southwestern parts of the United States, coccidioidomycosis, also known as “Valley Fever,” is a common fungal infection that primarily affects the lungs in both acute and chronic forms. Disseminated coccidioidomycosis is the most severe but very uncommon and usually occurs in immunocompromised individuals. It can affect the central nervous system, bones, joints, skin, and, very rarely, the abdomen. This is the first case report of a patient with coccidioidal dissemination to the peritoneum presenting as eosinophilic ascites (EA). A 27-year-old male presented with acute abdominal pain and distention from ascites. He had eosinophilia of 11.1% with negative testing for stool studies, HIV, and tuberculosis infection. Ascitic fluid exam was remarkable for low serum-ascites albumin gradient (SAAG), PMN count >250/mm3, and eosinophils of 62%. Abdominal imaging showed thickened small bowel and endoscopic testing negative for gastric and small bowel biopsies. He was treated empirically for spontaneous bacterial peritonitis, but no definitive diagnosis could be made until coccidioidal serology returned positive. We noted complete resolution of symptoms with oral fluconazole during outpatient follow-up. Disseminated coccidioidomycosis can present in an atypical fashion and may manifest as peritonitis with low SAAG EA. The finding of EA in an endemic area should raise the suspicion of coccidioidal dissemination. Kourosh Alavi, Pradeep R. Atla, Tahmina Haq, and Muhammad Y. Sheikh Copyright © 2015 Kourosh Alavi et al. All rights reserved. Characteristics of Small Bowel Polyps Detected in Cowden Syndrome by Capsule Endoscopy Wed, 24 Jun 2015 11:23:03 +0000 Cowden syndrome is an uncommon, autosomal dominant disease characterized by multiple hamartomas and hyperplastic lesions in the skin, mucous membrane, brain, breast, thyroid, and gastrointestinal tract. About 30% of Cowden syndrome cases are reportedly complicated by malignant diseases. Hamartomatous polyps occur throughout the gastrointestinal tract, the most common sites being the stomach, colon, esophagus, and duodenum. Small bowel polyps can occur in Cowden syndrome; however, they are difficult to detect by conventional examination, including double-contrast X-ray study. Here, we report three cases of Cowden syndrome with small bowel polyps, which were detected by capsule endoscopy. The small bowel polyps of Cowden syndrome frequently occur at the oral end of the small bowel, especially in the duodenum and jejunum, and their color is similar to that of the surrounding mucosa; additionally, the polyps are relatively small (2–5 mm). Capsule endoscopy is useful for detecting small bowel polyps in Cowden syndrome. Keita Saito, Eiki Nomura, Yu Sasaki, Yasuhiko Abe, Nana Kanno, Naoko Mizumoto, Rika Shibuya, Kazuhiro Sakuta, Makoto Yagi, Kazuya Yoshizawa, Daisuke Iwano, Takeshi Sato, Shoichi Nishise, and Yoshiyuki Ueno Copyright © 2015 Keita Saito et al. All rights reserved. Scrotal Swelling as a Complication of Hydrochlorothiazide Induced Acute Pancreatitis Wed, 24 Jun 2015 08:06:44 +0000 Background. Scrotal swelling is a rare complication of acute pancreatitis with few reported cases in the literature. In this case report, we present a 59-year-old male with hydrochlorothiazide induced pancreatitis who developed scrotal swelling. Case Presentation. A 59-year-old male presented to the emergency department with sharp epigastric abdominal pain that radiated to the back and chest. On physical examination, he had abdominal tenderness and distention with hypoactive bowel sounds. Computed tomography (CT) scan of the abdomen showed acute pancreatitis. The patient’s condition deteriorated and he was admitted to the intensive care unit (ICU). After he improved and was transferred out of the ICU, the patient developed swelling of the scrotum and penis. Ultrasound (US) of the scrotum showed large hydrocele bilaterally with no varicoceles or testicular masses. Good blood flow was observed for both testicles. The swelling diminished over the next eight days with the addition of Lasix and the patient was discharged home in stable condition. Conclusion. Scrotal swelling is a rare complication of acute pancreatitis. It usually resolves spontaneously with conservative medical management such as diuretics and elevation of the legs. Ivan Nikiforov, Qurat Mansoora, Hassan Al-Khalisy, Sarah Joseph, and Pramil Cheriyath Copyright © 2015 Ivan Nikiforov et al. All rights reserved. Obstructing Colonic Mass: A Case of Recurrent Endometrial Cancer Wed, 24 Jun 2015 06:59:41 +0000 A 71-year-old female with a history of endometrial cancer presented to our hospital with bilateral lower quadrant abdominal pain, which had been worsening over the past two months. The pain was associated with constipation, pencil-thin stools, and a 60 lb weight loss. On physical examination, the patient had suprapubic and left lower quadrant abdominal tenderness. Contrast-enhanced CT scan revealed a 6 cm pelvic mass in the left lower quadrant. It was unclear if this mass was arising from the sigmoid colon or abutting it. A colonoscopy to further investigate the mass was pursued and this revealed a moderate 5 cm long stenosis in the sigmoid colon starting at 15 cm from the anal verge. The stenosis was not ulcerated but had a bluish/purplish hue to it circumferentially. Multiple biopsies were obtained from that area and these revealed architectural changes with mild fibrosis but no malignancy. The mass was further explored with CT-guided fine needle aspiration. The results obtained were positive for cytokeratin-7, CA-125, estrogen receptor protein, and PAX-8 confirming that the mass was endometrial in origin. Victor Chedid, Mona Arasoghli, and Jana G. Hashash Copyright © 2015 Victor Chedid et al. All rights reserved. Gallbladder Agenesis with Refractory Choledocholithiasis Mon, 22 Jun 2015 12:09:09 +0000 Congenital agenesis of the gallbladder is a rare anomaly which is usually asymptomatic and found incidentally. In some cases, however, patients are symptomatic. Common symptoms include right upper quadrant abdominal pain, nausea, and vomiting. Jaundice is present in some symptomatic cases and is due to associated choledocholithiasis (Fiaschetti et al. 2009). In this case, a 63-year-old female presents with jaundice and episodic right upper quadrant abdominal pain with nausea and vomiting. Bilirubin and alkaline phosphatase were found to be markedly elevated. Upper endoscopic ultrasound (EUS) revealed choledocholithiasis, and the patient required multiple endoscopic retrograde cholangiopancreatography (ERCP) sessions before successful extraction of all stones. Subsequent surgical exploration revealed congenital agenesis of the gallbladder. Although this is a rare finding, patients with agenesis of the gallbladder are at increased risk of developing de novo choledocholithiasis which may be challenging to extract. Jamie Tjaden, Kevin Patel, and Aziz Aadam Copyright © 2015 Jamie Tjaden et al. All rights reserved. Acute Cholangitis following Biliary Obstruction after Duodenal OTSC Placement in a Case of Large Chronic Duodenocutaneous Fistula Sun, 21 Jun 2015 12:08:27 +0000 Over-the-Scope Clip system, also called “Bear Claw,” is a novel endoscopic modality used for closure of gastrointestinal defect with high efficacy and safety. We present a patient with history of eosinophilic gastroenteritis and multiple abdominal surgeries including Billroth II gastrectomy complicated by a large chronic duodenocutaneous fistula from a Billroth II afferent limb to the abdominal wall. Bear Claw clip was used for closure of this fistula. The patient developed acute cholangitis one day after placement of the Bear Claw clip. Acute cholangitis due to papillary obstruction is a potential complication of Bear Claw placement at the dome of the duodenal stump (afferent limb) in patient with Billroth II surgery due to its close proximity to the major papilla. Yaseen Alastal, Tariq A. Hammad, Mohamad Nawras, Basmah W. Khalil, Osama Alaradi, and Ali Nawras Copyright © 2015 Yaseen Alastal et al. All rights reserved. Treatment of Hepatic Epithelioid Hemangioendothelioma: Finding Uses for Thalidomide in a New Era of Medicine Wed, 17 Jun 2015 12:50:41 +0000 Hepatic epithelioid hemangioendothelioma (HEH) is extremely rare, occurring in 1 to 2 per 100,000, with chemotherapy options not well defined. Our case involved a 49-year-old female who had hepatic masses and metastasis to the lungs with a liver biopsy revealing HEH. After developing a rash from sorafenib, thalidomide was started with the progression of disease stabilized. Resection is only an option in 10% of the cases; therefore, chemotherapy is the only line of treatment. Newer chemotherapy alternatives are targeting angiogenesis via the vascular endothelial growth factor. Thalidomide was first used as an antiemetic, but, sadly, soon linked to phocomelia birth defects. Given the mechanism of action against angiogenesis, thalidomide has a valid role in vascular tumors. In conclusion, the use of thalidomide as chemotherapy is novel and promising, especially in the setting of a rare vascular liver tumor such as HEH. Matthew P. Soape, Rashmi Verma, J. Drew Payne, Mitchell Wachtel, Fred Hardwicke, and Everardo Cobos Copyright © 2015 Matthew P. Soape et al. All rights reserved. Familial Abdominal and Intestinal Lipomatosis Presenting with Upper GI Bleeding Thu, 04 Jun 2015 08:50:04 +0000 Although lipomas are encapsulated benign tumors, systemic lipomatosis defines infiltrative nonencapsulated tumors resembling normal adipose tissue. Abdominal lipomatosis and intestinal lipomatosis are different clinicopathological entities with similar clinical symptoms. We describe here a case presenting with upper gastrointestinal bleeding from eroded submucosal lipoma at duodenum secondary to intestinal lipomatosis and abdominal lipomatosis. Yilmaz Bilgic, Hasan Baki Altinsoy, Nezahat Yildirim, Ozkan Alatas, Burhan Hakan Kanat, and Abdurrahman Sahin Copyright © 2015 Yilmaz Bilgic et al. All rights reserved. Large Bowel Obstruction Due to a Big Gallstone Successfully Treated with Endoscopic Mechanical Lithotripsy Tue, 02 Jun 2015 11:25:25 +0000 Colonic gallstone ileus in an uncommon mechanical bowel obstruction caused by intraluminal impaction of one or more gallstones. The surgical management of gallstone ileus is complex and is potentially of high risk. There have been reports of gallstone extractions using various endoscopic modalities to relieve the obstruction. In this report we present the technique employed to successfully perform a mechanical lithotripsy and extraction of a large gallstone embedded in a sigmoid colon affected by diverticular stenosis. We passed through the stenosis with a 11.3 mm videoscope with 3.7 mm channel. A large lithotripsy extraction basket was used to catch and break up the stone and fragments were removed using the same basket. The patient was discharged asymptomatic three days after the procedure. Using appropriate devices mechanical lithotripsy is a safe and effective method to treat colonic obstruction and avoid surgery in the setting of gallstone ileus even in case of big stones. Marco Balzarini, Laura Broglia, Giovanni Comi, and Calcedonio Calcara Copyright © 2015 Marco Balzarini et al. All rights reserved. Marked Direct Hyperbilirubinemia due to Ceftriaxone in an Adult with Sickle Cell Disease Mon, 25 May 2015 13:53:00 +0000 Drugs are a significant cause of liver injury. Drug-induced liver injury (DILI) can cause acute hepatitis, cholestasis, or a mixed pattern. Ceftriaxone is a commonly used antibiotic and has been associated with reversible biliary sludge, pseudolithiasis, and cholestasis. A 32-year-old male with sickle cell disease was admitted to the hospital for acute sickle cell crisis. On the second day of hospitalization, he developed cough and rhonchi with chest X-ray revealing right middle lobe infiltrates. Ceftriaxone and azithromycin were initiated. Subsequently, he developed conjugated hyperbilirubinemia and mild transaminitis. His total bilirubin trended upwards from 3.3 mg/dL on admission to 17 mg/dL. It was predominantly conjugated bilirubin, with preadmission bilirubin levels of 3-4 mg/dL. His transaminases were mildly elevated as well compared to previous levels. Extensive workup for bilirubin elevation was unremarkable. Ceftriaxone was switched to levofloxacin and the hyperbilirubinemia improved. On ambulatory follow-up, his bilirubin remained below 4 mg/dL. Ceftriaxone may be associated with marked direct hyperbilirubinemia particularly in sickle cell patients with chronic liver chemistry abnormalities. In the case of elevated bilirubin with concomitant ceftriaxone use, elimination of the offending agent should be considered. Daniyeh Khurram, Leonid Shamban, Robert Kornas, and Maryann Paul Copyright © 2015 Daniyeh Khurram et al. All rights reserved. Solitary Colonic Ganglioneuroma: A Rare Incidental Finding of Hematochezia Thu, 14 May 2015 11:18:12 +0000 Ganglioneuromas (GNs) are hamartomatous tumors derived from the autonomic nervous system. It is rare to encounter GN in the gastrointestinal tract. Patients with these tumors usually present with abdominal pain, constipation, ileus, weight loss, or even bleeding. GNs are categorized into three different morphological subtypes, namely, polypoid GN, ganglioneuromatous polyposis, and diffuse ganglioneuromatosis. We present a case of hematochezia from GN in a colon polyp discovered on diagnostic colonoscopy. Due to a lack of guidelines, we reviewed the literature to discuss treatment and other associated conditions for GN. George Abraham and Sateesh R. Prakash Copyright © 2015 George Abraham and Sateesh R. Prakash. All rights reserved. Visceral Kaposi’s Sarcoma Presenting as Upper Gastrointestinal Bleeding Wed, 06 May 2015 09:42:03 +0000 Since the advent of highly active antiretroviral therapy (HAART), the incidence of acquired immunodeficiency syndrome- (AIDS-) related Kaposi’s sarcoma (KS) has decreased dramatically. While cutaneous KS is the most common and well-known manifestation, knowledge of alternative sites such as the gastrointestinal (GI) tract is important. GI-KS is particularly dangerous because of its potential for serious complications including perforation, obstruction, or bleeding. We report a rare case of GI-KS presenting as upper GI bleeding in a human immunodeficiency virus- (HIV-) infected transgendered individual. Prompt diagnosis and early initiation of therapy are the cornerstones for management of this potentially severe disease. Naomi Hauser, Devon McKenzie, Xavier Fonseca, and Jose Orsini Copyright © 2015 Naomi Hauser et al. All rights reserved. Eosinophilic Gastroenteritis: Case Report and Review in Search for Diagnostic Key Points Tue, 05 May 2015 12:31:26 +0000 Eosinophilic gastroenteritis is considered an uncommon disease with a low incidence rate that remains as a diagnostic challenge for the clinician, in spite of the fact that seventy years have passed since its original description. Hereby we present the case of a 29-year-old male without history of allergies who was evaluated for unspecific gastrointestinal symptoms, without relevant findings on physical examination and presenting an initial complete blood count (CBC) with severe eosinophilia. The patient was evaluated and the diagnosis of eosinophilic gastroenteritis was confirmed by histopathological findings. The relevance of the case resides in highlighting the lack of guidelines or consensus for histological diagnosis being virtually the only one available. To a similar extent, treatment evidence is based on case series with a reasonable number of patients and case reports. Guillermo López-Medina, Manuel Gallo, Alejandro Prado, Iliana Vicuña-Honorato, and Roxana Castillo Díaz de León Copyright © 2015 Guillermo López-Medina et al. All rights reserved. Metastatic Periampullary Tumor from Hepatocellular Carcinoma Presenting as Gastrointestinal Bleeding Wed, 29 Apr 2015 07:34:10 +0000 Periampullary tumors constitute a number of diverse neoplastic lesions located within 2 cm of the major duodenal papilla; among these, metastatic lesions account for only a small proportion of the periampullary tumors. To our knowledge, a metastatic periampullary tumor from hepatocellular carcinoma has never been reported. A 62-year-old male reported to our institute for fatigue and low hemoglobin. His medical history was remarkable for multifocal hepatocellular carcinoma (HCC) treated with selective transcatheter arterial chemoembolization (TACE). An esophagogastroduodenoscopy (EGD) was performed which revealed a periampullary mass. Histopathology was consistent with metastatic moderately differentiated HCC. Two endoloops were deployed around the base of the mass one month apart. The mass eventually sloughed off and patient’s hemoglobin level stabilized. We postulated that periampullary metastasis in this patient was the result of tumor fragments migration through the biliary tracts and that TACE which increases tumor fragments burden might have played a contributory role. Metastasis of HCC to the gastrointestinal (GI) tract should be considered as a cause of GI bleeding. Amir Kashani, Nicholas N. Nissen, Maha Guindi, and Laith H. Jamil Copyright © 2015 Amir Kashani et al. All rights reserved. Recurrent C. difficile in a Patient with IgG Deficiency Sun, 05 Apr 2015 13:17:06 +0000 IgG deficiency can predispose to recurrent pyogenic infections. The association of IgG deficiency with Clostridium difficile infection has been infrequently reported in the literature. We present a case of a middle-age woman with multiple hospitalizations for recurrent C. difficile in a short span of time which prompted consideration of a possible fecal transplant. On evaluation, she was found to have low total IgG, with subclass analysis revealing low IgG1 and IgG3. She was started on monthly infusions of immunoglobulins and one year after her last episode of C. difficile she has not had any recurrence. The role of immunoglobulin infusion in the treatment of recurrent C. difficile is controversial, with some studies revealing no clear evidence of benefit. Our case report suggests that the patients who have underlying IgG deficiency may benefit from immunoglobulin, as this can significantly reduce the incidence of recurrent infections and hence save the healthcare costs. Asad Jehangir, Kyle Bennett, Shoaib Bilal Fareedy, Andrew Rettew, Bilal Shaikh, Anam Qureshi, Qasim Jehangir, and Richard Alweis Copyright © 2015 Asad Jehangir et al. All rights reserved. Loss of HER2 Positivity after Trastuzumab in HER2-Positive Gastric Cancer: Is Change in HER2 Status Significantly Frequent? Sun, 29 Mar 2015 11:15:16 +0000 Trastuzumab has recently been introduced as a treatment for HER2-positive metastatic and/or unresectable gastric cancer (MUGC); however, compared with breast cancer, some issues concerning HER2 and trastuzumab therapy for gastric cancer remain unclear. A 74-year-old woman received trastuzumab-containing chemotherapy for HER2-positive MUGC. She had a marked response to 8 months of chemotherapy, and gastrectomy and hepatic metastasectomy with curative intent were performed. The resected specimen showed complete loss of HER2 positivity in the residual tumor. For MUGC, a change in HER2 status during the course of the disease with or without chemotherapy has rarely been reported. However, in breast cancer, a significant frequency of change in HER2 status during the course of disease has been reported, and reevaluation of HER2 positivity in metastatic/recurrent sites is recommended. The choice of trastuzumab for MUGC is currently based on the HER2 status of the primary tumor at the time of initial diagnosis, without reassessment of HER2 status during the course of disease and/or in metastatic/recurrent sites, on the assumption that HER2 status is stable. However, our case casts doubt on the stability of HER2 in gastric cancer. Yu Ishimine, Akira Goto, Yoshito Watanabe, Hidetaka Yajima, Suguru Nakagaki, Takashi Yabana, Takeya Adachi, Yoshihiro Kondo, and Kiyoshi Kasai Copyright © 2015 Yu Ishimine et al. All rights reserved. Osteogenesis Imperfecta, Pseudoachalasia, and Gastric Cancer Sun, 22 Mar 2015 14:24:15 +0000 Osteogenesis imperfecta (OI) is a rare, inherited skeletal disorder characterized by abnormalities of type 1 collagen. Malignancy is rarely reported in patients with OI and it was suggested that this disease can protect against cancer. Here, we report a 41-year-old woman with symptoms of achalasia where repeated treatment of pneumatic dilation and stent replacement was unsuccessful; therefore, surgery was performed. Pathology showed gastric adenocarcinoma unexpectedly. Chemotherapy was given after assessing dihydropyrimidine dehydrogenase (DPD) enzyme activity, which can be deficient in OI patients. This is the first report of gastric cancer mimicking achalasia in a patient with OI. Dilsa Mizrak, Ali Alkan, Batuhan Erdogdu, and Gungor Utkan Copyright © 2015 Dilsa Mizrak et al. All rights reserved.