Case Reports in Gastrointestinal Medicine The latest articles from Hindawi Publishing Corporation © 2015 , Hindawi Publishing Corporation . 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. Acute Cholangitis following Intraductal Migration of Surgical Clips 10 Years after Laparoscopic Cholecystectomy Sun, 22 Mar 2015 13:38:56 +0000 Background. Laparoscopic cholecystectomy represents the gold standard approach for treatment of symptomatic gallstones. Surgery-associated complications include bleeding, bile duct injury, and retained stones. Migration of surgical clips after cholecystectomy is a rare complication and may result in gallstone formation “clip cholelithiasis”. Case Report. We report a case of a 55-year-old female patient who presented with right upper quadrant pain and severe sepsis having undergone an uncomplicated laparoscopic cholecystectomy 10 years earlier. Computed tomography (CT) imaging revealed hyperdense material in the common bile duct (CBD) compatible with retained calculus. Endoscopic retrograde cholangiopancreatography (ERCP) revealed appearances in keeping with a migrated surgical clip within the CBD. Balloon trawl successfully extracted this, alleviating the patient’s jaundice and sepsis. Conclusion. Intraductal clip migration is a rarely encountered complication after laparoscopic cholecystectomy which may lead to choledocholithiasis. Appropriate management requires timely identification and ERCP. Natalie E. Cookson, Reza Mirnezami, and Paul Ziprin Copyright © 2015 Natalie E. Cookson et al. All rights reserved. Acute on Chronic Pancreatitis Causing a Highway to the Colon with Subsequent Road Closure: Pancreatic Colonic Fistula Presenting as a Large Bowel Obstruction Treated with Pancreatic Duct Stenting Tue, 17 Mar 2015 09:54:48 +0000 Context. Colonic complications associated with acute pancreatitis have a low incidence but carry an increased risk of mortality with delayed diagnosis and treatment. Pancreatic colonic fistula is most commonly associated with walled off pancreatic necrosis or abscess formation and rarely forms spontaneously. Classic clinical manifestations for pancreatic colonic fistula include diarrhea, hematochezia, and fever. Uncommonly pancreatic colonic fistula presents as large bowel obstruction. Case. We report a case of a woman with a history of recurrent episodes of acute pancreatitis who presented with large bowel obstruction secondary to pancreatic colonic fistula. Resolution of large bowel obstruction and pancreatic colonic fistula was achieved with pancreatic duct stenting. Conclusion. Pancreatic colonic fistula can present as large bowel obstruction. Patients with resolved acute pancreatitis who have radiographic evidence of splenic flexure obstruction, but without evidence of mechanical obstruction on colonoscopy, should be considered for ERCP to evaluate for PCF. PCF not associated with walled off pancreatic necrosis or peritoneal abscess can be treated conservatively with pancreatic duct stenting. Justin Cochrane and Greg Schlepp Copyright © 2015 Justin Cochrane and Greg Schlepp. All rights reserved. Postoperative Megarectum in an Adult Patient with Imperforate Anus and Rectourethral Fistula Sun, 15 Mar 2015 13:56:54 +0000 This report presents a surgical case of postoperative megarectum in an adult patient with imperforate anus/anorectal malformations. A 71-year-old Japanese male presented with a mass in the lower abdomen which was 15 × 12 × 8 cm in diameter, edema in the right lower extremity, and frequent urination. He had undergone sigmoid loop colostomy for an imperforate anus as a newborn infant. At 28 years of age, the sigmoid loop colostomy was changed to sigmoid divided colostomy in the left lower abdomen. Computed tomography revealed a large cystic mass in the lower abdomen. Retrograde urethrography indicated a rectourethral fistula and megarectum with stones. A small laparotomy incision was created in the right lower abdomen, and the wall of the megarectum was identified. Approximately 2,300 mL of gray muddy fluid was identified and drained. A mucous fistula of the upper rectum was created in the right lower abdomen. This is an extremely rare case of postoperative megarectum in an adult patient with an imperforate anus and rectourethral fistula. Yoshifumi Nakayama, Toshihito Uehara, Masaki Akiyama, Noritaka Minagawa, Takayuki Torigoe, and Naohiro Fujimoto Copyright © 2015 Yoshifumi Nakayama et al. All rights reserved. Fulminant Hepatic Failure Secondary to Primary Hepatic Angiosarcoma Sat, 28 Feb 2015 10:26:41 +0000 Background. Hepatic angiosarcoma is a rare and aggressive tumor that often presents at an advanced stage with nonspecific symptoms. Objective. To report a case of primary hepatic angiosarcoma in an otherwise healthy man with normal liver function tests two months prior to presenting with a short period of jaundice that progressed to fulminant hepatic failure. Methods. Case report and review of literature. Conclusion. This case illustrates the rapidity of progression to death after the onset of symptoms in a patient with hepatic angiosarcoma. Research on early diagnostic strategies and newer therapies are needed to improve prognosis in this rare and poorly understood malignancy with limited treatment options. Ayokunle T. Abegunde, Efe Aisien, Benjamin Mba, Rohini Chennuri, and Marin Sekosan Copyright © 2015 Ayokunle T. Abegunde et al. All rights reserved. A Rare Cause of Acute Dysphagia: Abscess of the Base of the Tongue Mon, 23 Feb 2015 16:07:49 +0000 Dysphagia represents a difficulty in passage of solid or liquid foods from the oral cavity into the stomach and is considered as an alarm symptom of gastrointestinal system. It often indicates an organic disease and needs to be explained. In this paper, a case of 61-year-old man with posterior tongue abscess is presented. Gulsum Teke Ozgur, Mehmet Volkan Akdogan, Gulhan Kanat Unler, and Huseyin Savas Gokturk Copyright © 2015 Gulsum Teke Ozgur et al. All rights reserved. Acute Pancreatitis and Splenic Vein Thrombosis due to Hypertriglyceridemia Mon, 23 Feb 2015 10:46:46 +0000 Acute pancreatitis (AP) is a condition characterised by the activation of the normally inactive digestive enzymes due to an etiological factor and digestion of the pancreatic tissues, resulting in extensive inflammation and leading to local, regional, and systemic complications in the organism. It may vary from the mild edematous to the hemorrhagic and severely necrotising form. The most common causes are biliary stones and alcohol abuse. In this case study, we would like to present a patient with AP due to hypertriglyceridemia (HPTG), which is a rare cause of pancreatitis, and splenic vein thrombosis, which is a rare complication of pancreatitis. Ercan Gündüz, Recep Dursun, Mustafa İçer, Yılmaz Zengin, and Cahfer Güloğlu Copyright © 2015 Ercan Gündüz et al. All rights reserved. A Novel SMAD4 Mutation Causing Severe Juvenile Polyposis Syndrome with Protein Losing Enteropathy, Immunodeficiency, and Hereditary Haemorrhagic Telangiectasia Sun, 01 Feb 2015 09:48:01 +0000 Juvenile polyposis syndrome (JPS) is a rare genetic disorder characterized by juvenile polyps of the gastrointestinal tract. We present a new pathogenic mutation of the SMAD4 gene and illustrate the need for a multidisciplinary health care approach to facilitate the correct diagnosis. The patient, a 47-year-old Caucasian woman, was diagnosed with anaemia at the age of 12. During the following 30 years, she developed numerous gastrointestinal polyps. The patient underwent several operations, and suffered chronic abdominal pain, malnutrition, and multiple infections. Screening of the SMAD4 gene revealed a novel, disease-causing mutation. In 2012, the patient suffered hypoalbuminemia and a large polyp in the small bowel was found. Gamma globulin was given but the patient responded with fever and influenza-like symptoms and refused more treatment. The patient underwent surgery in 2014 and made an uneventful recovery. At follow-up two months later albumin was 38 g/L and IgG was 6.9 g/L. Accurate diagnosis is essential for medical care. For patients with complex symptomatology, often with rare diseases, this is best provided by multidisciplinary teams including representatives from clinical genetics. Patients with a SMAD4 mutation should be followed up both for JPS and haemorrhagic hereditary telangiectasia and may develop protein loosing enteropathy and immunodeficiency. Joel Johansson, Christofer Sahin, Rebecka Pestoff, Simone Ignatova, Pia Forsberg, Anders Edsjö, Mattias Ekstedt, and Marie Stenmark Askmalm Copyright © 2015 Joel Johansson et al. All rights reserved. Littoral Cell Angioma in a Patient with Crohn’s Disease Thu, 29 Jan 2015 12:03:38 +0000 Littoral cell angioma is a rare vascular tumor of the spleen. The pathogenesis is unknown but the lesion is associated with several malignancies and immunological disorders. The diagnosis requires histopathological examination. The malignant potential of this lesion is unknown, which is why splenectomy is recommend for all cases. Symptomatic cases generally suffer from hypersplenism and pyrexia. A previously healthy 20-year-old female was diagnosed with colonic Crohn’s disease; as part of the work-up a magnetic resonance enterography was performed which showed multiple signal changes of the spleen. The patient reported chronic abdominal pain in the left upper quadrant, malaise, and fever. The unknown splenic lesions prompted a laparoscopic splenectomy; pathology revealed a littoral cell angioma. The abdominal pain and malaise remitted but the fever persisted one year despite adequate treatment of the patient’s Crohn’s disease. Littoral cell angioma is associated with immune-dysregulation including Crohn’s disease with several reported cases. Signs and symptoms of hypersplenism and splenic lesions on imaging should raise suspicion of littoral cell angioma in patients with Crohn’s disease. Magnetic resonance enterography to assess disease severity in Crohn’s disease may provide an opportunity to study the prevalence and natural history of this rare splenic tumor. Joel Johansson, Bergthor Björnsson, Simone Ignatova, Per Sandström, and Mattias Ekstedt Copyright © 2015 Joel Johansson et al. All rights reserved. Deciphering Autoimmune Pancreatitis, a Great Mimicker: Case Report and Review of the Literature Thu, 29 Jan 2015 06:02:44 +0000 Background. Autoimmune pancreatitis (AIP) is an atypical chronic inflammatory pancreatic disease that appears to involve autoimmune mechanisms. In recent years, AIP has presented as a new clinical entity with its protean pancreaticobiliary and systemic presentations. Its unique pathology and overlap of clinical and radiological features and absence of serological markers foster the disease’s unique position. We report a case of diffuse type 1 autoimmune pancreatitis with obstructive jaundice managed with biliary sphincterotomy, stent placement, and corticosteroids. A 50-year-old Caucasian woman presented to our hospital with epigastric pain, nausea, vomiting, and jaundice. Workup showed elevated liver function tests (LFT) suggestive of obstructive jaundice, MRCP done showed diffusely enlarged abnormal appearing pancreas with loss of normal lobulated contours, and IgG4 antibody level was 765 mg/dL. EUS revealed a diffusely hypoechoic and rounded pancreatic parenchyma with distal common bile duct (CBD) stricture and dilated proximal CBD and common hepatic duct (CHD). ERCP showed tight mid to distal CBD stricture that needed dilatation, sphincterotomy, and placement of stent that led to significant improvement in the symptoms and bilirubin level. Based on clinical, radiological, and immunological findings, a definitive diagnosis of AIP was made. Patient was started on prednisone 40 mg/day and she clinically responded in 4 weeks. Satya Allaparthi, Mohammed Sageer, and Mark J. Sterling Copyright © 2015 Satya Allaparthi et al. All rights reserved. Rapid Progression of Primary Sclerosing Cholangitis Complicated with Ulcerative Colitis Wed, 28 Jan 2015 14:35:30 +0000 Primary sclerosing cholangitis is a cholestatic condition with unknown etiology and long-standing, progressive course, leading to cirrhosis and requiring orthotropic liver transplant. In approximately 80%, primary sclerosing cholangitis is accompanied by inflammatory bowel disease, and in most cases the recognition of bowel disease precedes the diagnosis of primary sclerosing cholangitis. We describe a case of 22-year-old male diagnosed simultaneously with primary sclerosing cholangitis and ulcerative colitis, with a medical history suggesting uncommon prior development of the liver disease. Five months after the initial diagnosis, we observed advanced lesions of bile tree due to progression of primary sclerosing cholangitis, which led to the unusually fast necessity for the orthotopic liver transplant. Piotr Pardak, Ewa Walczak, and Rafał S. Filip Copyright © 2015 Piotr Pardak et al. 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.