Case Reports in Gastrointestinal Medicine The latest articles from Hindawi © 2017 , Hindawi Limited . All rights reserved. A Calcium Enterolith in a Patient with Crohn’s Disease and Its In Vitro Dissolubility in Citric Acid Thu, 07 Sep 2017 08:01:57 +0000 The microstructure and dissolubility of a calcified enterolith and enterolith pieces removed from a 26-year-old Japanese woman with Crohn’s disease were analyzed using scanning electron microscopy and energy dispersive X-ray spectroscopy. The enterolith showed a multilayered structure with fatty acid calcium and magnesium phosphate. The amount of calcium, magnesium, and phosphate decreased after they were immersed in a citric acid solution, suggesting a potential contribution of acidic aqueous solution to elute inorganic substances contained in calcified enteroliths. This is the first study to investigate the in vitro dissolubility of calcified enteroliths induced by citric acid solution. Masaya Iwamuro, Haruo Urata, Sakiko Hiraoka, Masayasu Ohmori, Yoshitaka Kondo, Yoshiro Kawahara, and Hiroyuki Okada Copyright © 2017 Masaya Iwamuro et al. All rights reserved. Asymptomatic Pancreatic Metastasis from Renal Cell Carcinoma Diagnosed 21 Years after Nephrectomy Wed, 30 Aug 2017 10:08:19 +0000 This report presents our experience with a case of pancreatic metastasis of renal cell carcinoma (RCC) at a long-term follow-up after nephrectomy. A 73-year-old man underwent nephrectomy for right RCC 21 years ago; computed tomography (CT) scanning on routine follow-up revealed a solid mass in the tail of the pancreas, and magnetic resonance imaging (MRI) showed some tumors in the head and tail of the pancreas. The patient was asymptomatic and allergic to contrast medium. Therefore we could not perform contrast CT/MRI for further examination to diagnose pancreatic tumors. We undertook endoscopic ultrasonography (EUS) and detected a hypervascular and low echoic mass; tumor tissues were obtained by EUS-guided fine-needle aspiration (EUS-FNA). Pathological diagnosis revealed pancreatic metastasis of clear cell RCC; this was similar to the pathological findings of tumor tissues initially obtained by nephrectomy. EUS-FNA was extremely useful for the definitive diagnosis of a rare type of pancreatic tumor. Megumi Zianne, Naoki Takahashi, Akihiko Tsujibata, Kazuhiro Miwa, Yoshinori Goto, and Yutaka Matano Copyright © 2017 Megumi Zianne et al. All rights reserved. Gastric Metastasis from Renal Cell Carcinoma, Clear Cell Type, Presenting with Gastrointestinal Bleeding Tue, 29 Aug 2017 00:00:00 +0000 Renal cell carcinoma (RCC) accounts for 80–85% of all primary renal neoplasms. Although RCC can metastasize to any organ, gastric metastases from RCC are exceedingly rare. A 67-year-old male presented with melena and acute blood loss anemia. The patient had a history of RCC that had been treated with a radical nephrectomy. He had a recent myocardial infarction and was receiving double antiplatelet therapy. After hemodynamic stabilization, esophagogastroduodenoscopy showed a polypoid mass in the gastric fundus. The mass was excised. Histological and immunohistochemical evaluation were consistent with clear cell RCC. The polypoid lesion is consistent with a late solitary metastasis. Mouhanna Abu Ghanimeh, Ayman Qasrawi, Omar Abughanimeh, Sakher Albadarin, and John H. Helzberg Copyright © 2017 Mouhanna Abu Ghanimeh et al. All rights reserved. Percutaneous Endoscopic Management for Oriental Cholangiohepatitis: A Case Report and a Brief Review of the Literature Sun, 27 Aug 2017 00:00:00 +0000 Oriental cholangiohepatitis (OCH) is a disease characterized by intrabiliary pigment stone formation, resulting in recurrent bouts of cholangitis. OCH is found mostly in Southeast Asia but it is occasionally recognized in Western societies. OCH etiology is largely unknown. We report our experience with a patient who presented with acute cholecystitis. Following laparoscopic cholecystectomy, she developed acute cholangitis due to multiple biliary tree stones. She underwent ERCP to clear the stones from common bile duct. For the intrahepatic stones, she underwent novel hybrid percutaneous endoscopic technique. The procedure resulted in complete clearance of biliary tree stones and resolution of her symptoms. The aim of this case is to increase awareness of this disease when patients from endemic areas present with biliary stones. Khalil Aloreidi, Prince Sethi, Terry Yeager, and Muslim Atiq Copyright © 2017 Khalil Aloreidi et al. All rights reserved. Metastatic Melanoma of the Gallbladder in an Asymptomatic Patient Tue, 22 Aug 2017 06:58:06 +0000 Malignant Melanoma (MM) is among the most dangerous malignancies with some of the least known survival rates. Melanoma most commonly metastasizes to regional lymph nodes, the lungs, and brain. Metastatic disease of the gallbladder (GB) is exceptionally rare making it difficult to diagnose. The fact that typically patients do not present until they are symptomatic—only after widespread metastatic disease has already occurred—is further complicating the diagnosis of MM of the GB. For this reason, MM of the GB is rarely discovered in living patients. In fact, review of the literature showed only 40 instances in which metastatic disease of the GB was reported in living patients. We describe the presentation and management of a patient who had metastatic disease of the GB. However, our case is unique because his malignancy was discovered incidentally while he was asymptomatic. He was successfully treated with an open cholecystectomy. We have presented this case in order to make the necessity of meticulous investigation of potential metastasis in patients with a known history of cutaneous melanoma clear. Asad Khan, Sejal Patel, Daniel J. Zaccarini, and Mary McGrath Copyright © 2017 Asad Khan et al. All rights reserved. Isolated Splenic Cold Abscesses with Perisplenic Extension: Treated Successfully without Splenectomy Sun, 20 Aug 2017 08:01:02 +0000 Splenic tuberculosis (TB) in the form of multiple splenic cold abscesses with perisplenic extensions is a rare disease, especially in an immunocompetent host. It demonstrates diagnostic complexity, which makes identification of the disease difficult. We report a case of an immunocompetent adult male who presented with fever, pain in the left lower chest, decreased appetite, and significant weight loss. On physical examination, he had tenderness in the left lower infra-axillary region and Traube’s space dullness without palpable spleen. Ultrasound-guided aspiration of the abscess fluid revealed Mycobacterium tuberculosis (MTB) by polymerase chain reaction (PCR). No primary focus of the infection was detected in the lungs or any other organs. The patient was successfully treated with antitubercular therapy (ATT). Mohan Khadka and Ravi Pradhan Copyright © 2017 Mohan Khadka and Ravi Pradhan. All rights reserved. Caecal Perforation from Primary Intestinal Tuberculosis in Pregnancy Thu, 17 Aug 2017 08:15:06 +0000 The incidence of tuberculosis (TB) is rising worldwide, despite the efficacy of the BCG vaccination. Populations at greatest risk of contracting TB are migrant communities, as well as immunocompromised individuals. The diagnosis of extrapulmonary TB (EPTB) can often present as a diagnostic conundrum, due to its nonspecific and varied presentation, often mimicking inflammatory bowel disease or malignancy. We present a case of caecal TB in pregnancy, which resulted in caecal perforation, a right hemicolectomy, and severe preterm delivery. The aim of this case report is to discuss the diagnosis of extrapulmonary TB, as well as its subsequent management in pregnancy. Soe Lwin, Nina Lau Lee Jing, Haris Suharjono, Mardiana binti Kipli, Tin Moe Nwe, Myat San Yi, and Lucas Luk Tien Wee Copyright © 2017 Soe Lwin et al. All rights reserved. An Endoscopic Nasomediastinal Approach to a Mediastinal Abscess Developing after Zenker’s Diverticulectomy Wed, 02 Aug 2017 06:30:54 +0000 Zenker’s diverticulum is the most frequent symptomatic diverticulum of the esophagus, but the prevalence is <0.1%. The optimal treatment is surgery. Here, we present a nasomediastinal drainage approach to treatment of a mediastinal abscess, developing in the late postoperative period and attributable to leakage from the staple line. Fatih Altintoprak, Kemal Gundogdu, Ahmet Tarik Eminler, Erkan Parlak, Guner Cakmak, and Yener Uzunoglu Mustafa Copyright © 2017 Fatih Altintoprak et al. All rights reserved. Synchronous Upper Squamous and Lower Adenocarcinoma of the Oesophagus: A Rarely Reported Case Treated with Palliative Chemotherapy and Stenting Mon, 31 Jul 2017 07:07:53 +0000 Oesophageal cancer is divided into two main subtypes, squamous and adenocarcinoma. It is the eighth most common cancer in the world with squamous more common in the developing world and adenocarcinoma most prevalent in the developed world. Incidences of concomitant squamous carcinoma with adenocarcinoma are exceedingly rare with only a few documented occurrences in the form of case reports existing. Here we report a case of synchronous squamous and adenocarcinoma of the oesophagus occurring in an 81-year-old lady with dysphagia, weight loss, and no identifiable risk factors. Niall Hardy, Justin Kelly, John Conneely, and Barry Kelleher Copyright © 2017 Niall Hardy et al. All rights reserved. Extensive Causative Esophagitis Caused by Thermal Injury: A Case Report and Review of the Literature Wed, 19 Jul 2017 00:00:00 +0000 Esophagus thermal injury is a rare case that can be easily overlooked by practitioners. We herein present a case of thermally induced diffuse corrosive esophagitis with complaints of dysphagia and retrosternal chest pain after having steamed pork. A thorough disease course was demonstrated by serials of endoscopy images and video. A comprehensive review of articles and a concise overview of esophageal thermal injury clinical manifestation, disease process, typical endoscopy features, pharmacomanagement option, and outcomes will be conducted in this article. Cherng Harng Lim, Hsu-Heng Yen, Wei-Wen Su, Cherng-Jyr Lim, Hao-Chien Tsai, and Shi-Ting Chen Copyright © 2017 Cherng Harng Lim et al. All rights reserved. Fatal Systemic Vasoconstriction in a Case of Metastatic Small-Intestinal NET Tue, 18 Jul 2017 09:02:38 +0000 An increased release of serotonin secreted by ileal NETs is thought to be the major factor causing the carcinoid syndrome. However, in acutely arising carcinoid crisis also other vasoactive factors may lead to hazardous fluctuations in blood pressure and bronchial constriction. In rare cases, systemic vasoconstriction can be observed, probably caused by catecholamines or similar acting substances. Here, we report a fatal case of fulminant systemic vasoconstriction possibly caused by catecholamines in a patient with metastasized ileal NET. The vasospasm was detected by CT-angiography, and hemodynamic monitoring revealed a high systemic vascular resistance. Epinephrine, norepinephrine, and chromogranin A levels in plasma were elevated as was the urinary 5-hydroxyindoleacetic acid (5-HIAA). The cause of death was heart failure due to severe circulatory insufficiency. The progression of the tumor disease was confirmed by autopsy. Stenzel Jochen, Noe Sebastian, Holzapfel Konstantin, Erlmeier Franziska, and Eyer Florian Copyright © 2017 Stenzel Jochen et al. All rights reserved. Metastatic Renal Cell Carcinoma Presenting as Gastric Ulcer: Case Report and Literature Review Wed, 21 Jun 2017 07:13:24 +0000 Renal cell carcinoma (RCC) accounts for approximately 3% of all adult malignancies. True gastrointestinal metastases, specifically to gastric wall, have been rarely observed. Herein we describe a case of delayed metastasis to gastric wall occurring more than a decade after previously curative nephrectomy for RCC. A 67-year-old male with history of right radical nephrectomy in 2001 for RCC was found to have an asymptomatic right lower lobe solitary lung mass upon routine follow-up in 2011, with final biopsy results showing metastatic RCC for which he was treated accordingly. In 2014, patient was evaluated for dyspepsia with microcytic anemia and underwent an esophagogastroduodenoscopy and colonoscopy. EGD revealed a solitary one-centimeter atypical ulcer in the posterior mid gastric body with biopsy results being consistent with metastatic RCC. Our literature review has yielded thirty-six reported cases of RCC in association with gastric wall metastases. Alhareth Al Juboori, Satinder Kaur, and Atigadda Reddy Copyright © 2017 Alhareth Al Juboori et al. All rights reserved. Diarrhea as a Presenting Symptom of Disseminated Toxoplasmosis Tue, 20 Jun 2017 00:00:00 +0000 Disseminated toxoplasmosis is uncommon in both immunocompetent and immunocompromised hosts with gastrointestinal involvement being rarely described. We report a case of disseminated gastrointestinal toxoplasmosis in an immunocompromised man who presented with one month of diarrhea and abdominal pain. Imaging showed thickening of the ascending colon and cecum. Esophagogastroduodenoscopy and colonoscopy biopsies revealed Toxoplasma gondii, confirmed by immunostain. Symptoms completely resolved following treatment with pyrimethamine, sulfadiazine, and leucovorin. This case highlights the importance of including toxoplasmosis in the differential diagnosis of any immunocompromised individual presenting with gastrointestinal symptoms. Matthew Glover, Zhouwen Tang, Robert Sealock, and Shilpa Jain Copyright © 2017 Matthew Glover et al. All rights reserved. Acute Esophageal Necrosis in an Alcoholic after Successful Resuscitation from Cardiac Arrest Mon, 19 Jun 2017 09:49:51 +0000 Introduction. We present a patient who presented to the ICU after successful resuscitation from cardiac arrest who was subsequently diagnosed with AEN. Case Presentation. A 66-year-old female presented after cardiac arrest in which return of spontaneous circulation was achieved within 7 minutes after the initiation of CPR. She was intubated on the scene and found to have coffee ground emesis in her bathroom when found unresponsive. Due to the hemodynamically significant GI bleed, patient was started on IV proton pump inhibitor, octreotide, and levophed. Subsequent endoscopy showed diffuse severe mucosal changes characterized by blackness, erythema, friability, granularity, inflammation, and decreased vascular pattern in the middle third of the esophagus and in the lower third of the esophagus. Discussion. AEN is a rare syndrome with a prevalence ranging from 0.001 to 0.2% of EGD. This patient is especially rare as this patient was female and had AEN in the middle esophagus along with lower esophagus. The pathophysiology in this patient is hypothesized that she had cardiac arrest secondary to acute upper GI hemorrhage. Subsequent low-flow state (cardiac arrest) in addition to being in the setting of severe alcohol abuse led to esophageal necrosis. Amish Shah, Viveksandeep Thoguluva Chandreskar, Ravi Doobay, Arundeep Kahlon, and Ioana Amzuta Copyright © 2017 Amish Shah et al. All rights reserved. Successful Endoscopic Treatment of Bouveret Syndrome in a Patient with Choledochoduodenal Fistula Complicating Duodenal Ulcer Mon, 19 Jun 2017 07:18:14 +0000 Introduction. Cholecystoduodenal fistulas represent the most common type of bilioenteric fistulas while choledochoduodenal fistulas account for only 1–25% of cases. Bilioenteric fistula cases are associated with cholelithiasis and are rarely associated with duodenal peptic ulcers. Here we present the first case of Bouveret syndrome secondary to choledochoduodenal fistula complicating peptic duodenal ulcer managed successfully via endoscopic mechanical lithotripsy. Case. 86-year-old male with a medical history significant for coronary artery disease and stage 3 colorectal cancer status after resection and chemoradiation presented with intractable sharp abdominal pain worse postprandially for one week in duration, associated with early satiety, anorexia, and 5 lbs weight loss in one week. CT abdomen showed possible choledochoduodenal fistula and a distended stomach. An esophagogastroduodenoscopy (EGD) was performed revealing a large 2.5–3 cm stone lodged in the duodenal bulb at the base of duodenal ulcer with a fistula opening beneath it. The stone was extracted in 2 pieces via mechanical lithotripsy. Endoscopic ultrasound of the CBD revealed Rigler’s triad. Conclusion. Bouveret syndrome is mostly associated with cholecystoduodenal fistula and has high mortality and morbidity due to underlying comorbid conditions and elderly age. Patients are not always fit for surgical management, and endoscopic management is not always successful. Syed Hasan, Zubair Khan, Umar Darr, Toseef Javaid, Nauman Siddiqui, Jamal Saleh, Abdallah Kobeissy, and Ali Nawras Copyright © 2017 Syed Hasan et al. All rights reserved. Total Parenteral Nutrition Successfully Treating Black Esophagus Secondary to Hypovolemic Shock Sun, 18 Jun 2017 00:00:00 +0000 We present a patient who developed black esophagus secondary to hypovolemic shock and was placed on total parenteral nutrition for three weeks after hospital discharge. The area of interest is the multimodal approach used in treatment of this noncompliant patient. Even with a high mortality rate, this case illustrates a successful outcome of a patient who responded to appropriate immediate therapy resulting in complete resolution of the necrosis with no further development of complications. Tony S. Brar, Richard Helton, and Zareen Zaidi Copyright © 2017 Tony S. Brar et al. All rights reserved. E. coli Sepsis: Red Flag for Colon Carcinoma—A Case Report and Review of the Literature Tue, 13 Jun 2017 00:00:00 +0000 We present an atypical case of newly diagnosed colon cancer and provide insight into the infectious predispositions of E. coli bacteremia to the development of colon adenocarcinoma. A 66-year-old female was admitted to the hospital with one-week symptoms of subjective fevers, chills, and lower back pain. Upon initial evaluation, her temperature was 101 degrees Fahrenheit with a white count of 12,000 K/mm3. Initial septic workup was positive for E. coli bacteremia. The patient was started on Aztreonam. Repeat blood culture 48 hours later was negative for any growth. However, later during hospital stay blood culture was repeated due to SIRS, which was positive again for E. coli. CT scan of the chest/abdomen/pelvis with contrast revealed no signs of colitis. Without clear etiology for recurrent E. coli bacteremia ultimately colonoscopy was performed which showed an ulcerated mass in the cecum. Biopsy showed moderately differentiated adenocarcinoma. E. coli strains B2 and D produce cyclomodulin toxins as part of their virulence, which interferes with the cell cycle regulation, promoting chromosomal instability, and increasing susceptibility to cancer. In patients with recurrent E. coli bacteremia with an unknown source, colonoscopy should be done to look for colon cancer. Hiren G. Patel, Seme Tabassum, and Sohail Shaikh Copyright © 2017 Hiren G. Patel et al. All rights reserved. A Case of Thermal Esophageal Injury Induced by Sodium Picosulfate with Magnesium Citrate Sun, 04 Jun 2017 06:40:00 +0000 Although thermal esophageal injuries caused by hot food or tea have been reported, thermal esophageal injury due to sodium picosulfate with magnesium citrate (PSMC) used for bowel preparation is rarely reported. We report the case of a 56-year-old man who presented with esophageal injury after ingestion of PSMC. Instead of dissolving the PSMC in water before ingestion, he drank water immediately after swallowing PSMC powder. As soon as he drank water, he developed severe chest pain and hematemesis. Upper endoscopy revealed severe hemorrhagic, ulcerative mucosal change from upper to mid-esophagus. He was hospitalized for nine days, received conservative treatment (fasting and parenteral nutrition), and recovered without complications. When PSMC is used as a colonic cleansing agent, patients should be educated to take it after dissolving it sufficiently in 150 mL of water to avoid esophageal thermal injury. Dong-Hyuk Yang, Byoung Wook Bang, Kye Sook Kwon, Hyung Kil Kim, and Yong Woon Shin Copyright © 2017 Dong-Hyuk Yang et al. All rights reserved. Two Cases of Rectal Xanthoma Presenting as Yellowish to Whitish Lesions during Colonoscopy Thu, 01 Jun 2017 10:48:10 +0000 Two cases of rectal xanthomas are described. One case is that of a 56-year-old Japanese man in whom multiple yellowish spots measuring approximately 3 to 5 mm were observed in the rectum during colonoscopy. The other case is that of a 78-year-old Japanese man in whom colonoscopy showed a whitish plaque of 4 mm in diameter in the rectum. Biopsy examinations performed on both patients revealed the deposition of xanthoma cells within the rectal mucosa. Within the gastrointestinal tract, xanthomas most frequently arise in the stomach, whereas the colorectum is rarely affected. Despite this infrequency, the two cases indicate that xanthomas should be recalled when yellowish to whitish lesions are observed in the colorectum. Masaya Iwamuro, Takehiro Tanaka, Daisuke Takei, Yuusaku Sugihara, Keita Harada, Sakiko Hiraoka, Yoshiro Kawahara, and Hiroyuki Okada Copyright © 2017 Masaya Iwamuro et al. All rights reserved. A Mass of Pancreatic and Gastric Heterotopia Causing a Small Bowel Obstruction in a 61-Year-Old Male Thu, 01 Jun 2017 00:00:00 +0000 Heterotopic tissue is a congenital anomaly that has been previously reported. Gastric and pancreatic heterotopia are among the most studied ones. Herein, we describe a case of a combined pancreatic and gastric heterotopia that formed a mass and caused a small intestine obstruction in a 61-year-old male. We also did a brief literature review of cases with gastric and pancreatic heterotopia in adult patients. Majd Alfrejat, Bassem Khalil, Jordan Jackobs, William Anderson, and Jennifer Eschbacher Copyright © 2017 Majd Alfrejat et al. All rights reserved. A Rare Case of Esophageal Adenocarcinoma with Urinary Bladder Metastasis Wed, 31 May 2017 07:14:43 +0000 Metastatic esophageal adenocarcinoma to the urinary bladder is extremely rare. We describe a previously healthy 49-year-old female with recent diagnosis of adenocarcinoma of the gastroesophageal junction with metastatic disease to the liver. Biopsy was positive for human epidermal growth factor receptor 2 (HER2) by Fluorescence In Situ Hybridization (FISH). She received six cycles of Cisplatin, 5-Fluorouracil, and Herceptin and subsequently developed symptomatic anemia and hematuria. Cystoscopy with retroflexion was performed and she received a transurethral resection of bladder tumor with fulguration. Pathology of the bladder tumor revealed similar morphology to her liver metastasis and immunohistochemical stains were consistent with metastatic esophageal cancer. Three weeks after being diagnosed with metachronous urinary bladder metastasis from esophageal adenocarcinoma primary, she expired. She only received her first cycle of palliative chemotherapy with Ramucirumab and Paclitaxel. Heather Katz, Rahoma E. Saad, Krista Denning, and Toni O. Pacioles Copyright © 2017 Heather Katz et al. All rights reserved. Foreign Body Moves Retrograde through Ileocecal Valve during Colonoscopy Wed, 17 May 2017 00:00:00 +0000 Ingestion of foreign bodies and particularly of button or/and cylindrical batteries is frequent in children and adults with underlying psychiatric diseases. We present a case of a 30-year-old woman with unstable borderline disorder, where overall 4 button and 2 cylindrical batteries were endoscopically removed from her digestive system. During the last session of colonoscopy a peculiar incident was observed, as a cylindrical battery of 15 mm diameter and 43 mm length moved retrograde through ileocecal valve into the small bowel. The foreign body removal from terminal ileum was effective and safe using an endoscopic loop. This report suggests that endoscopic insertion in terminal ileum should be attempted in every colonoscopy session conducted under the indication of foreign body removal, as the possibility of retrograde movement of even large foreign bodies in the colon and through ileocecal valve is given. Maria Paparoupa and Markus Bruns-Toepler Copyright © 2017 Maria Paparoupa and Markus Bruns-Toepler. All rights reserved. An Unusual Case of Pancreatic Metastasis from Squamous Cell Carcinoma of the Lung Diagnosed by EUS-Guided Fine Needle Biopsy Wed, 17 May 2017 00:00:00 +0000 We report a case of a 70-year-old man who presented with abdominal pain and weight loss, with initial imaging showing simultaneous mass lesions in the pancreas and lungs along with extensive lymphadenopathy in the thorax up to the left supraclavicular region. Core biopsies of the left supraclavicular lymph node showed squamous cell carcinoma, which required differentiation between secondary and primary pancreatic neoplasms. Endoscopic ultrasound-guided sampling using a novel fine needle biopsy system was key to making a definite histological diagnosis and determining the best treatment plan. Takuya Ishikawa, Yoshiki Hirooka, Carolin J. Teman, Hidemi Goto, and Paul J. Belletrutti Copyright © 2017 Takuya Ishikawa et al. All rights reserved. Recurrent Enterolithiasis Small Bowel Obstruction: A Case Seldom Described Sun, 14 May 2017 09:32:44 +0000 Background. Enterolithiasis of the small bowel is a rare phenomenon in humans although it has been frequently described in equines. Primary enteroliths have been described including those occurring secondary to conditions like Crohn’s disease, small bowel diverticula, tuberculous or postoperative strictures, and blind loops but those occurring in an otherwise normal gut are exceedingly rare. Of even greater rarity is a recurrent small bowel enterolith presenting with obstruction. This may be the first report of such kind. Case Presentation. A 70-year-old man undergoing treatment for stable alcoholic liver disease presented to the emergency with gradually progressive diffuse abdominal pain associated with vomiting and constipation for 7 days. He had gaseous abdominal distention but was not obstipated. He had a history of 2 laparotomies in the past for small bowel obstruction secondary to enterolith impaction. He was initially managed conservatively but since there was no significant clinical improvement, he underwent an exploratory laparotomy. A recurrent enterolith 5 × 5 cm in size was found impacted in the mid ileum with multiple dense serosal adhesions and bands. Adhesiolysis and enterotomy with removal of enterolith were performed. Conclusion. Recurrent enterolithiasis of the small bowel is a rare phenomenon and may present with recurrent obstruction. Definitive preoperative diagnosis is not always possible and a high index of suspicion is required to avoid table misdiagnosis. Surgery is the mainstay of treatment once conservative measures fail. Laparoscopic methods may help in diagnosis and avoid possibility of a subsequent adhesive bowel obstruction but are associated with technical challenges. Ashish Lal Shrestha and Pradita Shrestha Copyright © 2017 Ashish Lal Shrestha and Pradita Shrestha. All rights reserved. Gastric Schwannoma: A Tumor Must Be Included in Differential Diagnoses of Gastric Submucosal Tumors Tue, 09 May 2017 07:18:48 +0000 Gastric schwannoma (GS) is a rare neoplasm of the stomach. It accounts for 0.2% of all gastric tumors and is mostly benign, slow-growing, and asymptomatic. Due to its rarity, GS is not widely recognized by clinicians, and the precise differential diagnosis between GS and other gastric submucosal tumors remains difficult preoperatively. The present study reports a case of GS misdiagnosed as gastrointestinal stromal tumor and reviews the clinical, imaging, and pathological features, treatment, and follow-up of 221 patients with GS previously reported in the English literature. Although GS is rare, the case reported in the current study highlights the importance of including GS in differential diagnoses of gastric submucosal tumors. Furthermore, the findings of the review suggest that although many cases are asymptomatic, the most common symptoms are abdominal pain or discomfort, not gastrointestinal bleeding, and malignant GSs present with clinical symptoms more commonly. Although large-sample multicenter studies on the efficacy, safety, and oncological outcomes of minimally invasive techniques are required, the findings presented herein may be helpful for clinicians when diagnosing or treating GS. Bao-guang Hu, Feng-jie Wu, Jun Zhu, Xiao-mei Li, Yu-ming Li, Yan Feng, and He-sheng Li Copyright © 2017 Bao-guang Hu et al. All rights reserved. Diagnosis of Splenic Lymphoma by Endoscopic Ultrasound Guided Fine Needle Aspiration: A Case Report and Review of the Literature Sun, 30 Apr 2017 08:28:38 +0000 Introduction. Splenic tumor is usually found as an incidental finding on CT of abdomen. Traditionally, ultrasound (US) or computed tomography (CT) guided biopsies were employed for the purpose of sampling; however they have been reported to have a complication rate of 5.3%. Endoscopic ultrasound-fine needle aspiration (EUS-FNA) has been recently utilized for the purpose of sampling splenic tumors. In literature there are 7 reported instances where splenic lymphoma was diagnosed using EUS-FNA. We present a case of follicular B cell lymphoma of the spleen diagnosed using EUS-FNA. Case Report. 58-year-old female presented to her primary care physician for left upper quadrant abdominal pain for one week. Physical exam was significant for left upper quadrant tenderness. Her laboratory tests were within normal limits. She underwent CT scan of abdomen which revealed approximately 5 cm × 5 cm mass in spleen. EUS-FNA of the spleen revealed a large hypoechoic, heterogeneous, well-demarcated mass measuring 54.7 mm × 43.0 mm. Fine needle aspiration was performed, and the sample was submitted for cytology and flow cytometry. Flow cytometry revealed a lambda monotypic population of B cells displaying dim CD19 and CD10. Diagnosis of B cell non-Hodgkin low grade follicular lymphoma was made. Conclusion. Endoscopic ultrasound with fine needle aspiration is a very rare but safe, reliable method of diagnosis of splenic lymphomas. Umar Darr, Zubair Khan, Muhammad Ali Khan, Anas Renno, Turki Alkully, Sehrish Kamal, Tariq Hammad, Yaseen Alastal, Muhammad Imran Khan, and Ali Nawras Copyright © 2017 Umar Darr et al. All rights reserved. Identification of Abnormal Biliary Anatomy Utilizing Real-Time Near-Infrared Cholangiography: A Report of Two Cases Thu, 27 Apr 2017 07:34:39 +0000 Biliary duct anomalies are commonly encountered during laparoscopic cholecystectomy. Advancements in the field of surgery allow for enhanced intraoperative detection of these abnormalities. Fluorophore injection and near-infrared (NIR) imaging can provide real-time intraoperative anatomic feedback without intraoperative delays and ionizing radiation. This report details two cases where the PINPOINT Endoscopic Fluorescence Imaging System (NOVADAQ, Ontario, Canada) was used to identify anomalies of the biliary tree and guide operative decision-making. Joseph Bozzay, Diego Vicente, Elliot M. Jessie, and Carlos J. Rodriguez Copyright © 2017 Joseph Bozzay et al. All rights reserved. Mirrizi Syndrome and Markedly Elevated Levels of Carbohydrate Antigen 19-9 in the Absence of Malignant Disease Wed, 26 Apr 2017 09:21:37 +0000 Elevated carbohydrate antigen 19-9 (CA19-9) beyond 1000 U/L occurs in nonneoplastic conditions which is causing questioning of the use of CA19-9 as a marker for screening. We report a case where a 51-year-old male with Mirrizi Syndrome (MS) presented with markedly increased CA19-9 level (4,618 U/mL). MS is a rare complication characterized by compression of the common bile or hepatic duct caused by an impacted gallstone in the cystic duct or neck of the gallbladder. Biliary epithelial cells secrete CA19-9: it is hypothesized that increased proliferation of such cells caused by inflammation leads to increased secretion. CA19-9 should not be used as a diagnostic tool, but rather for surveillance. Natasha Shah, Eula Tetangco, Hafiz Muhammad Sharjeel Arshad, and Hareth Raddawi Copyright © 2017 Natasha Shah et al. All rights reserved. Aberrant Pancreatic Tissue in a Mediastinal Enteric Duplication Cyst: A Rarity with Review of Literature Wed, 26 Apr 2017 00:00:00 +0000 Mediastinal enteric duplication cysts are a rare congenital malformation encountered mainly in neonates and infants. It is a distinct entity within the family of foregut duplication cysts. It can present with respiratory distress due to mass effect and hence surgical excision is the preferred treatment. Histologically, it is characterised by a double layered smooth muscle wall with intestinal lining epithelium. We report a case of mediastinal enteric duplication cyst with aberrant pancreatic tissue in a neonate due to its rarity and early presentation. A neonate presented with respiratory distress and a cystic mass in the right posterior mediastinum. The lesion was excised and on histopathological analysis the diagnosis of mediastinal enteric duplication cyst was made. Also, aberrant pancreatic tissue which has been reported rarely was noted in this case. We discuss this case and review similar cases reported in literature. Meha Mansi, Nidhi Mahajan, Sonam Mahana, C. R. Gupta, and Anup Mohta Copyright © 2017 Meha Mansi et al. All rights reserved. Adenocarcinoma In Situ Arising from Brunner’s Gland Treated by Endoscopic Mucosal Resection Sun, 23 Apr 2017 09:50:28 +0000 An 86-year-old Japanese man was presented to our hospital for further investigation of duodenal adenocarcinoma. The tumor was endoscopically resected. Pathological analysis revealed coexistence of gastric foveolar metaplasia and a surrounding hyperplastic Brunner’s gland, in addition to an adenocarcinoma component. Immunostaining for MUC5AC and MUC6 confirmed the diagnosis of adenocarcinoma in situ arising from Brunner’s gland hyperplasia. This case suggests that although detailed preoperative evaluation is required to determine the depth of tumor invasion, endoscopic resection may be a promising option for the treatment of adenocarcinomas arising from Brunner’s gland hyperplasia. Masaya Iwamuro, Sayo Kobayashi, Nobuya Ohara, Seiji Kawano, Yoshiro Kawahara, and Hiroyuki Okada Copyright © 2017 Masaya Iwamuro et al. All rights reserved.