Case Reports in Gastrointestinal Medicine The latest articles from Hindawi Publishing Corporation © 2016 , Hindawi Publishing Corporation . All rights reserved. Listeria Rhombencephalitis Complicating Anti-TNF Treatment during an Acute Flare of Crohn’s Colitis Mon, 29 Aug 2016 16:29:40 +0000 Patients with Crohn’s disease often require the use of immunosuppressant drugs to control disease activity. Such medication includes steroids, azathioprine, and biologic therapy. These suppress the immune response, and the patient is more susceptible to infection. We present a case of a 69-year-old gentleman with a history of Crohn’s colitis who had ongoing symptoms of diarrhoea in spite of standard treatment. Biologic therapy was considered to be the next step, and screening for infection was undertaken prior to use. Three days following anti-TNF treatment, he became drowsy, and examination revealed pyrexia, slurred speech, and nystagmus. Investigation revealed presence of Listeria rhombencephalitis. He demonstrated poor neurological recovery. Listeria monocytogenes is an infection commonly associated with food sources. Some patients develop a self-limiting diarrhoeal illness, but in the immunosuppressed population, the clinical features may be more sinister. Cotrimoxazole prophylaxis is already recommended for those on triple immunosuppression. We propose the early initiation of this treatment, including where biologic use is anticipated. In those on multiple immunosuppressants, a diet similar to that followed in pregnancy may minimise risk of acquiring this infection. Clinicians must always have a high index of suspicion for opportunistic infection in such immunocompromised patients. L. Stratton and G. R. Caddy Copyright © 2016 L. Stratton and G. R. Caddy. All rights reserved. Primary versus Metastatic Gastrointestinal Melanoma: A Rare Case and Review of Current Literature Mon, 29 Aug 2016 13:05:12 +0000 Gastrointestinal (GI) melanomas are a rare diagnostic entity. Although there have been cases of melanomas solely in the GI tract, many debate their true origin: the gut versus a distant, undetected primary lesion that regressed known as melanoma of unknown primary. We present a case that involved diagnosing a GI melanoma and then backtracking to find a possible primary source. We review the most recent literature regarding possible etiologies of primary GI melanomas and how to differentiate whether it has a primary, metastatic, or unknown origin. Malorie Simons, Jason Ferreira, Rashna Meunier, and Steven Moss Copyright © 2016 Malorie Simons et al. All rights reserved. Pneumatosis Cystoides Intestinalis in Patients with Systemic Sclerosis: A Case Report and Review of 39 Japanese Cases Mon, 29 Aug 2016 12:01:45 +0000 Pneumatosis cystoides intestinalis (PCI) is a rare gastrointestinal complication of systemic sclerosis (SSc) characterized by intramural accumulation of gas within thin-walled cysts. We report the case of an 82-year-old female patient with pneumoperitoneum due to PCI associated with SSc and review the features of the 39 Japanese cases. The median patient age was 57 years (range 24–83 years) and the male/female ratio was 1 : 12. In the recent decade, 14 out of 15 cases (93.3%) evaluated with CT scans were diagnosed with PCI. The results suggest that CT scan may be a useful diagnostic tool for detecting PCI. PCI in patients with SSc is usually benign and requires only conservative therapy. However, two patients (5.1%) with signs of peritoneal irritation required surgery. When peritoneal irritation secondary to additional pathology is observed, surgical treatment may be warranted; a precise diagnosis for this condition is therefore essential. Manabu Kaneko, Shin Sasaki, Shuzo Teruya, Kosuke Ozaki, Kazuhiro Ishimaru, Emi Terai, Hiroshi Nakayama, and Toshiyuki Watanabe Copyright © 2016 Manabu Kaneko et al. All rights reserved. An Unusual Cause of Acute Upper Gastrointestinal Bleeding: Acute Esophageal Necrosis Tue, 23 Aug 2016 14:10:19 +0000 Acute esophageal necrosis (AEN), also called “black esophagus,” is a condition characterized by circumferential necrosis of the esophagus with universal distal involvement and variable proximal extension with clear demarcation at the gastroesophageal junction. It is an unusual cause of upper gastrointestinal bleeding and is recognized with distinct and striking mucosal findings on endoscopy. The patients are usually older and are critically ill with shared comorbidities, which include atherosclerotic cardiovascular disease, diabetes mellitus, hypertension, chronic renal insufficiency, and malnutrition. Alcoholism and substance abuse could be seen in younger patients. Patients usually have systemic hypotension along with upper abdominal pain in the background of clinical presentation of hematemesis and melena. The endoscopic findings confirm the diagnosis and biopsy is not always necessary unless clinically indicated in atypical presentations. Herein we present two cases with distinct clinical presentation and discuss the endoscopic findings along with a review of the published literature on the management of AEN. Nikhil R. Kalva, Madhusudhan R. Tokala, Sonu Dhillon, Watcoun-Nchinda Pisoh, Saqib Walayat, Vishwas Vanar, and Srinivas R. Puli Copyright © 2016 Nikhil R. Kalva et al. All rights reserved. Endoscopic Resection of a Pedunculated Brunner’s Gland Hamartoma of the Duodenum Mon, 08 Aug 2016 16:32:05 +0000 A 68-year-old Japanese woman presented with a solitary pedunculated polyp in the duodenum. Endoscopic ultrasonography showed multiple cystic structures in the polyp. The polyp was successfully resected by endoscopic snare polypectomy and pathologically diagnosed as Brunner’s gland hamartoma. Because hamartomatous components were not identified in the stalk of the polyp, we speculate that the stalk developed from traction of the normal duodenal mucosa. When a solitary, pedunculated polyp with cystic structure within the submucosa is found in the duodenum, Brunner’s gland hamartoma should be considered in the differential diagnosis, despite the rarity of the disease. This case underscores the usefulness of endoscopic ultrasonography for the diagnosis of duodenal subepithelial tumors. Masaya Iwamuro, Takehiro Tanaka, Satoko Ando, Tatsuhiro Gotoda, Hiromitsu Kanzaki, Seiji Kawano, Yoshiro Kawahara, and Hiroyuki Okada Copyright © 2016 Masaya Iwamuro et al. All rights reserved. Ischemic Gastropathic Ulcer Mimics Gastric Cancer Thu, 04 Aug 2016 13:56:37 +0000 Gastric ulcer due to mesenteric ischemia is a rare clinical finding. As a result, few reports of ischemic gastric ulcers have been reported in the literature. The diagnosis of ischemic gastropathy is seldom considered in patients presenting with abdominal pain and gastric ulcers. In this case report, we describe a patient with increasing abdominal pain, weight loss, and gastric ulcers, who underwent extensive medical evaluation and whose symptoms were resistant to medical interventions. Finally he was diagnosed with chronic mesenteric ischemia, and his clinical and endoscopic abnormalities resolved after surgical revascularization of both the superior mesenteric artery and the celiac trunk. Saleh Daher, Ziv Lahav, Ayman Abu Rmeileh, Meir Mizrahi, and Tawfik Khoury Copyright © 2016 Saleh Daher et al. All rights reserved. A Single Mass Forming Colonic Primary Mantle Cell Lymphoma Thu, 04 Aug 2016 09:59:20 +0000 Mantle cell lymphoma (MCL) is a subtype of non-Hodgkin’s lymphoma (NHL) comprising around 7% of adult NHL. It is characterized by a chromosomal translocation t(11:14) and overexpression of Cyclin D1. The incidence of secondary gastrointestinal tract involvement in MCL ranges from 10 to 28% in various series. However primary gastrointestinal MCL is very rare, accounting for only 1 to 4% of primary gastrointestinal lymphomas. The most common endoscopic feature of primary intestinal MCL is multiple lymphomatous polyposis. In rare cases it presents as protruded lesions or superficial lesions. Single colonic mass presentation is an extremely infrequent presentation. MCL has an aggressive course with quick progression, and most cases are discovered in the advanced stages. Colonic biopsies with histologic examination and specific immunohistochemical staining are the gold standard for a proper diagnosis. We report a case of a single mass forming mantle cell lymphoma of the ascending colon in a 57-year-old female patient with unusual colonoscopic and radiologic features and describe the therapy the patient received, thereby adding to the spectrum of clinical presentations of this aggressive lymphoproliferative disorder. Fady Daniel, Hazem I. Assi, Walid Karaoui, Jean El Cheikh, Sami Bannoura, and Samer Nassif Copyright © 2016 Fady Daniel et al. All rights reserved. The Association of Streptococcus gallolyticus Subspecies pasteurianus Bacteremia with the Detection of Premalignant and Malignant Colonic Lesions Sun, 31 Jul 2016 09:56:16 +0000 Streptococcus gallolyticus subspecies (subsp.) gallolyticus (formerly bovis biotype I) bacteremia has been associated with colonic adenocarcinoma. The bovis species underwent reclassification in 2003. Subtypes of gallolyticus are associated with colonic malignancy but are less frequent, resulting in less awareness. A 71-year-old male admitted with worsening lower back pain and fevers. Initial vital signs and laboratory data were within normal limits. MRI revealed lumbosacral osteomyelitis and antibiotics were initiated. Blood cultures showed Streptococcus species, prompting a transesophageal echocardiogram (TEE) revealing vegetations on the mitral and aortic valves. The etiology for his endocarditis was unclear. A colonoscopy was suggested, but his clinical instability made such a procedure intolerable. Final cultures revealed Streptococcus gallolyticus subsp. pasteurianus (previously bovis biotype II). After antibiotic completion he underwent aortic grafting with valve replacements. Later, he was readmitted for Streptococcus bacteremia. After a negative TEE, colonoscopy revealed a 2.5 × 3 cm cecal tubulovillous adenoma with high-grade dysplasia suspicious for his origin of infection. Clinicians understand the link between Streptococcus gallolyticus subsp. gallolyticus (bovis type I) and malignancy, but the new speciation may be unfamiliar. There are no guidelines for managing S. gallolyticus subsp. pasteurianus bacteremia; therefore a colonoscopy should be considered when no source is identified. Gaurav Chand, Leonid Shamban, Adam Forman, and Prabhat Sinha Copyright © 2016 Gaurav Chand et al. All rights reserved. Campylobacter Pouchitis Mimicking the Appearance of Crohn’s Disease Sun, 31 Jul 2016 08:03:39 +0000 An unusual case of campylobacter pouchitis resembling the endoscopic appearance of Crohn’s disease is reported. Greg S. Cohen and Meena Prasad Copyright © 2016 Greg S. Cohen and Meena Prasad. All rights reserved. Sterile Seroma after Drainage of Purulent Muscle Abscess in Crohn’s Disease: Two Cases Wed, 27 Jul 2016 08:11:56 +0000 Purulent skeletal muscle abscesses can occur in Crohn’s disease. We report a case of a sterile seroma complicating percutaneous drainage of a purulent skeletal muscle abscess in Crohn’s ileitis. We compare and contrast this case with a similar case we published earlier. We emphasize the importance of recognition and differentiation from a septic purulent abscess. Natasha Shah, Lara Dakhoul, Adam Treitman, Muhammed Tabriz, and Charles Berkelhammer Copyright © 2016 Natasha Shah et al. All rights reserved. Lighter Ingestion as an Uncommon Cause of Severe Vomiting in a Schizophrenia Patient Thu, 21 Jul 2016 13:00:12 +0000 Background. Foreign bodies in the gastrointestinal tract are important morbid and mortal clinical conditions. Particularly, emergency treatment is required for cutting and drilling bodies. The majority of ingested foreign bodies (80–90%) leave gastrointestinal tract without creating problems. In 10–20% of cases, intervention is absolutely required. Less than 1% of cases need surgery. In this paper, we present a schizophrenia patient who swallowed multiple lighters. Case. A 21-year-old male schizophrenic patient who uses psychotic drugs presented to the emergency department with the complaints of abdominal pain, severe vomiting, and inability to swallow for a week. His physical examination revealed epigastric tenderness. A plain radiograph of the abdomen revealed multiple tiny metallic densities. Gastroscopy was performed. The lighters were not allowing the passage, and some of them had penetrated the gastric mucosa, and bezoars were observed. One lighter was extracted with the help of the polypectomy snare. Other lighters as a bezoar were removed by surgery. Conclusion. Excessive vomiting of swallowed foreign bodies in the etiology of psychotic patients should be kept in mind. Endoscopic therapy can be performed in the early stages in these patients, but in the late stage surgery is inevitable. Yahya Atayan, Yasir Furkan Cagin, Mehmet Ali Erdogan, Yılmaz Bilgic, Remzi Bestas, Murat Harputluoglu, and Yüksel Seckin Copyright © 2016 Yahya Atayan et al. All rights reserved. Endoscopic Observation of the Growth Process of a Right-Side Sessile Serrated Adenoma/Polyp with Cytological Dysplasia to an Invasive Submucosal Adenocarcinoma Wed, 29 Jun 2016 11:21:16 +0000 A sessile serrated adenoma/polyp (SSA/P) with cytological dysplasia in the right colon, which transformed to an invasive submucosal adenocarcinoma finally, was endoscopically observed in a 76-year-old woman. A whitish soft SSA/P (approximately 25 mm in diameter) was detected in the cecum. Biopsy samples were obtained from the small nodule, and the lesion was eventually diagnosed as an SSA/P with cytological dysplasia, considering endoscopic observations, among which the narrow-band imaging features suggested that the lesion was adenomatous, that is, a round-oval pattern, and hyperplastic, that is, comprising a circular pattern with dots and an invisible capillary vessel. After 11 months, an SSA/P had rapidly developed into a submucosal adenocarcinoma with lymphatic infiltrations, and the most aggressive deep invasion was observed in the central depression. This case suggests that right-side SSA/Ps with cytological dysplasia should be removed immediately, considering the potential for rapid progression to a larger size and eventually to deep and extensive cancer. Kaoru Omori, Kanako Yoshida, Sadafumi Tamiya, Tsutomu Daa, and Masahiro Kan Copyright © 2016 Kaoru Omori et al. All rights reserved. Spontaneous Perforation of Common Bile Duct: A Rare Presentation of Gall Stones Disease Tue, 28 Jun 2016 11:17:19 +0000 Background. Spontaneous perforation of the extrahepatic biliary system is a rare presentation of gall stones. Very few cases of bile duct perforation have been reported in adults. It is rarely suspected or correctly diagnosed preoperatively. Case Presentation. A 66-year-old female presented at the surgical emergency with 3 days’ history of severe upper abdominal pain with distension and repeated episodes of vomiting, as she had evidence of generalized peritonitis and underwent an exploratory laparotomy. A single 0.5 cm 0.5 cm free perforation was present on the anterolateral surface of the common bile duct at the junction of cystic duct. A cholecystectomy and the CBD exploration were performed. Conclusion. Spontaneous perforation of the extrahepatic bile duct is a rare but important presentation of gall stones in adults. Therefore, awareness of the clinical presentation, expert ultrasound examination, and surgery are important aspects in the management. Duminda Subasinghe, Edippuli Arachchige Don Udayakumara, Upul Somathilaka, and Milinda Huruggamuwa Copyright © 2016 Duminda Subasinghe et al. All rights reserved. Organizing Pneumonia in a Patient with Quiescent Crohn’s Disease Mon, 20 Jun 2016 14:16:00 +0000 A 64-year-old man with Crohn’s disease (CD) was admitted to our hospital due to moderate risk of pneumonia while receiving scheduled adalimumab maintenance therapy. Symptoms remained virtually unchanged following administration of antibiotics. A final diagnosis of organizing pneumonia (OP) was made based on findings of intra-alveolar buds of granulation tissue and fibrous thickening of the alveolar walls on pathological examination and patchy consolidations and ground glass opacities on computed tomography. Immediate administration of prednisolone provided rapid, sustained improvement. Although a rare complication, OP is a pulmonary manifestation that requires attention in CD patients. Satoshi Tanida, Masaya Takemura, Tsutomu Mizoshita, Keiji Ozeki, Takahito Katano, Takaya Shimura, Yoshinori Mori, Eiji Kubota, Hiromi Kataoka, Takeshi Kamiya, and Takashi Joh Copyright © 2016 Satoshi Tanida et al. All rights reserved. Gastrointestinal Pyogenic Granuloma (Lobular Capillary Hemangioma): An Underrecognized Entity Causing Iron Deficiency Anemia Wed, 15 Jun 2016 11:10:03 +0000 Pyogenic granuloma (PG), more accurately known as lobular capillary hemangioma, is a benign vascular tumor that usually occurs in the skin or oral mucosa. This lesion is rarely reported in the gastrointestinal tract but is known to bleed if not resected. We herein describe a case series with the clinical, endoscopic, and histologic findings of four cases of gastrointestinal PG at our institution. In addition, we provide a review of the literature and summation of all reported cases of PG specific to the gastrointestinal tract. Based on our experience, we suggest that the actual incidence of gastrointestinal PG may in fact be higher than reported because PG can be unrecognized or improperly diagnosed. It is important for the clinician to properly recognize this lesion as a source of anemia and its propensity to bleed during biopsy or resection. Marshall W. Meeks, Umar M. Kamal, Muhammad B. Hammami, Jason R. Taylor, M. Louay Omran, Yongxin Chen, and Jin-Ping Lai Copyright © 2016 Marshall W. Meeks et al. All rights reserved. Common Hepatic Duct Mixed Adenoneuroendocrine Carcinoma Masquerading as Cholangiocarcinoma Tue, 07 Jun 2016 06:26:14 +0000 Bile duct mixed adenoneuroendocrine carcinoma (MANEC) is a rare entity. It is defined as having mixed elements of both neuroendocrine tumors (NET) and an adenocarcinoma element, the lesser component forming at least 30% of the tumor. It is a subtype of neuroendocrine carcinoma (NEC) showing both gland-forming epithelial tumor cells and neuroendocrine cells. It is generally misdiagnosed as cholangiocarcinoma on imaging studies. The preoperative pathological workup from the endoscopic retrograde cholangiography brush cytology usually misses the NET/NEC component since it often lies deeper in the tumor. However, it is reported that it is the NEC component that defines the prognosis of the tumor; hence, it is vital to identify the NEC component. We present a rare case of common hepatic duct (CHD) MANEC that was preoperatively misdiagnosed as cholangiocarcinoma. Sali Priyanka Akhilesh, Yadav Kamal Sunder, Tampi Chandralekha, Parikh Samir, and Wagle Prasad Kashinath Copyright © 2016 Sali Priyanka Akhilesh et al. All rights reserved. Esophageal Microperforation due to Calcified Mediastinal Lymph Node Leading to Tracheoesophageal Fistula Mon, 06 Jun 2016 08:41:42 +0000 A 42-year-old male presented with worsening gastroesophageal reflux disease symptoms and cough. The clinical symptoms during the early course of illness were striking for aspiration pneumonia. He was given a prescription of proton pump inhibitors and antibiotics. Rapid decline in the clinical condition with worsening respiratory status was noted. Worsening symptoms of fever, cough, and chest pain prompted further diagnostic work-up suggesting esophageal microperforation. Esophagogram was found to be suggestive of tracheoesophageal fistula. The tracheoesophageal fistula was due to subcarinal lymph node of nontuberculous origin. Sankalp Dwivedi, E. Brooke Schrickel, Fayez Siddiqui, John O’Brien, and James Kruer Copyright © 2016 Sankalp Dwivedi et al. All rights reserved. Isolated Retropancreatic Tuberculous Lymphadenitis Mimicking Carcinoma: A Diagnostic Challenge Mon, 30 May 2016 09:43:55 +0000 Tuberculosis as a cause of obstructive jaundice is a rare entity with only a few cases reported in the literature. Patients with this condition usually present with a protracted illness, jaundice, and weight loss, which may be confused with malignancies. We are reporting unusual case of isolated enlarged tuberculous lymph node compressing the common bile duct in the retropancreatic region and causing obstructive jaundice in an immunocompetent patient which to the best of our knowledge is the first case of isolated retropancreatic tuberculous lymphadenitis in Saudi Arabia. H. Kuriry, R. Alenezi, A. Alghamdi, and A. M. Swied Copyright © 2016 H. Kuriry et al. All rights reserved. Herpes Simplex Virus-2 Esophagitis in a Young Immunocompetent Adult Tue, 19 Apr 2016 11:02:44 +0000 Herpes simplex esophagitis (HSE) is commonly identified in immunosuppressed patients. It is rare among immunocompetent patients and almost all of the reported cases are due to HSV-1 infection. HSV-2 esophagitis is extremely rare. We report the case of a young immunocompetent male who presented with dysphagia, odynophagia, and epigastric pain. Endoscopy showed multitudes of white nummular lesions in the distal esophagus initially suspected to be candida esophagitis. However, classic histopathological findings of multinucleated giant cells with eosinophilic intranuclear inclusions and positive HSV-2 IgM confirmed the diagnosis of HSV-2 esophagitis. The patient rapidly responded to acyclovir treatment. Although HSV-2 is predominantly associated with genital herpes, it can cause infections in other parts of the body previously attributed to only HSV-1 infection. Deepak K. Kadayakkara, Angela Candelaria, Ye Eun Kwak, and Caroline Loeser Copyright © 2016 Deepak K. Kadayakkara et al. All rights reserved. Urticarial Vasculitis-Associated Intestinal Ischemia Sun, 17 Apr 2016 13:56:11 +0000 Urticarial vasculitis (UV) is a rare small vessel vasculitis. UV is often idiopathic but can also present in the context of autoimmune disorders such as systemic lupus erythematosus, drug reactions, infections, or a paraneoplastic syndrome. Extracutaneous complications include intestinal ischemic injuries, in UV patients with nonspecific gastrointestinal symptoms such as abdominal pain and nausea. Prompt recognition and treatment can minimize morbidity and mortality. This paper describes a case of urticarial vasculitis-associated intestinal ischemia. Uni Wong, Harris Yfantis, and Guofeng Xie Copyright © 2016 Uni Wong et al. All rights reserved. CMV Colitis in Immunocompetent Patients: 2 Cases of a Diagnostic Challenge Tue, 12 Apr 2016 11:25:35 +0000 CMV infections are generally thought to be opportunistic by immunosuppression. Many literature cases though indicate that CMV infections can be also observed in immunocompetent patients. We present an unusual case of an extensive concentric benign stenosis due to CMV colitis and a case of coexistence with Crohn’s Disease, both observed in nonimmunosuppressed individuals. The right diagnosis was set after implementation of multiple unsuccessful treatment strategies. Our purpose is therefore to familiarize clinicians involved with the diagnosis and treatment of gastroenterological diseases with this entity. Maria Paparoupa, Viola Schmidt, Helgard Weckauf, Huy Ho, and Frank Schuppert Copyright © 2016 Maria Paparoupa et al. All rights reserved. The Role of PCR in Diagnosis of a Rare Appendicular Tuberculosis and Mini Literature Review Thu, 31 Mar 2016 18:03:14 +0000 Tuberculosis is a prevalent public health problem especially in the poor developing countries and results in significant mortality. Albeit tuberculosis almost always affects any organ or system of the body, abdominal tuberculosis is less frequent; moreover, tuberculous appendicitis is very rare with an incidence estimated at about 0.1–0.6% of all gastrointestinal tuberculosis. The purpose of this report was to present an unusual case of primary tuberculous appendicitis and the approach used for accurate diagnosis as well as a current update on the disease. We are reporting a 30-year-old male who presented with acute abdominal pain, fever, and vomiting and was admitted with the clinical diagnosis of acute appendicitis. Patient was investigated thoroughly and histopathologic examination was strongly suggestive of tuberculous appendicitis; however, Ziehl-Neelsen (ZN) was negative in tissue section. To confirm the diagnosis, molecular biology [polymerase chain reaction (PCR)] study was performed from the formalin fixed paraffin embedded (FFPE) appendicular tissue and revealed presence of Mycobacterium tuberculosis. As there are numerous differential diagnoses in granulomatous lesions of appendix and due to the fact that appendicular tuberculosis is a rare phenomenon; verification etiologic agent is crucial for appropriate management of the disease. Asmerom Tesfamariam Sengal, Ahmed Abdalla Mohamedani, Hanan Hasaan Hussein, and Alaa Kamal Copyright © 2016 Asmerom Tesfamariam Sengal et al. All rights reserved. Multiple Giant Splenic Artery Aneurysms Causing Sinistral (Left-Sided) Portal Hypertension Sun, 27 Mar 2016 13:40:34 +0000 Background. Splenic artery aneurysm is the most common type of visceral aneurysms. They are usually asymptomatic and have a potential for rupture and therefore life-threatening hemorrhage. It is rare for them to cause sinistral portal hypertension. Case Report. A 23-year-old female patient presented to our clinic with gastric varices, splenomegaly, pancytopenia, and normal liver functions. She was thus diagnosed with left-sided portal hypertension. Radiologic evaluation showed splenomegaly, splenic vein obstruction, and multiple aneurysms along the splenic artery ranging from 2.5 cm to 7 cm. Splenic artery aneurysm was thought to be the cause of portal hypertension and hypersplenism. We decided splenectomy is the best course of treatment. Pancytopenia could not be corrected preoperatively despite the transfusion treatment. Surgical exploration revealed multiple aneurysms deeply embedded in pancreas. Thrombocyte and erythrocyte transfusion was performed after splenic artery ligation to correct pancytopenia before further intervention. Splenic artery, spleen, and distal pancreas were resected en bloc. Patient’s blood parameters became normal within first postoperative day. Patient had an uneventful postoperative course and was discharged without incident. Conclusion. Splenic artery aneurysms are rare but potentially life-threatening incidents. Therefore, it is important to know the unusual presentations and prepare accordingly. Kemal Beksac and Derya Karakoc Copyright © 2016 Kemal Beksac and Derya Karakoc. All rights reserved. Peculiar Presentation of Ulcerative Colitis Sun, 06 Mar 2016 09:22:13 +0000 Ulcerative colitis (UC) is a chronic inflammatory and recurrent disorder that is characterized by bowel inflammation. Among the extraintestinal manifestations (EIMs) that associate UC are the joints and renal manifestations. Joint affection in the form of arthritis can precede the intestinal manifestations of UC. However, renal affection with amyloidosis does not precede the UC diagnosis. Herein, we report a case of 26-year-old male diagnosed with UC after having peripheral arthritis for long time in addition to spondylitis and kidney amyloidosis. Hamdy M. A. Ahmed, Amany Diab, Ayman Ahmed, Samar Abohamad, and Hala Elgendy Copyright © 2016 Hamdy M. A. Ahmed et al. All rights reserved. A Case of Advanced Descending Colon Cancer in an Adult Patient with Intestinal Malrotation Thu, 03 Mar 2016 07:59:37 +0000 This report presents an operative case of advanced descending colon cancer in an adult patient with intestinal malrotation. A 63-year-old Japanese male was suffering from left side abdominal pain, abdominal distension, and constipation. An endoscopic examination revealed an advanced tumor in the descending colon. Computed tomography (CT) of the abdomen revealed the thickening of the descending colon wall and superior mesenteric vein rotation. An opaque enema detected severe stenosis of the descending colon. An abdominal X-ray examination revealed the dilation of the colon and small intestine with niveau. At the insertion of an ileus tube, the C-loop of the duodenum was observed to be absent and the small intestine was located on the right side of the abdomen. After the decompression of the bowel contents, laparotomy was performed. Descending colon cancer was observed to have directly invaded the left side of the transverse colon. Left hemicolectomy, lymph node dissection, and appendectomy were performed. The patient had an uneventful recovery and was discharged from the hospital on the 16th day after surgery. This report presents a rare operative case of descending colon cancer in an adult patient with intestinal malrotation. Yoshifumi Nakayama, Masaki Akiyama, Yusuke Sawatsubashi, Noritaka Minagawa, Takayuki Torigoe, and Keiji Hirata Copyright © 2016 Yoshifumi Nakayama et al. All rights reserved. Gastric and Duodenal Pseudomelanosis: An Extended Unusual Finding in a Patient with End Stage Kidney Disease Wed, 02 Mar 2016 06:35:33 +0000 Gastric and duodenal pseudomelanosis is a rare endoscopic mucosal finding, characterized by the accumulation of iron in macrophages of the lamina propria of the stomach and duodenum. The clinical significance and long term sequelae have not been clarified yet. However, this benign condition is associated with a variety of clinical conditions, such as essential hypertension, chronic renal failure, diabetes mellitus, long term intake of iron supplements, and furosemide. Duodenal pseudomelanosis appears to be more common than gastric pseudomelanosis given the fact that a few cases of gastric pseudomelanosis have been reported in the literature so far. We report a case of 88-year-old lady with ESRD who is maintained on hemodialysis and presented with abdominal pain. An upper GI endoscopy showed discoloration of the antrum of the stomach and most portion of her duodenum. Histopathology report confirmed the presence of iron laden macrophages in the lamina propria of both stomach and duodenum. Noor Ul Ain Qureshi, Muhammad Faraz Younus, Kourosh Alavi, and Muhammad Yasin Sheikh Copyright © 2016 Noor Ul Ain Qureshi et al. All rights reserved. Small Intestinal and Mesenteric Multiple Gastrointestinal Stromal Tumors Causing Occult Bleeding Tue, 16 Feb 2016 16:21:57 +0000 Gastrointestinal stromal tumors are the meseancymal neoplasms which may involve any part of gastrointestinal tract. C-Kit and platelet derived factor receptor alpha polypeptide are believed to be responsible for the genetic basis. This case presentation aimed to discuss the diagnostic and therapeutic modality of multiple small intestinal, omental, and mesenteric GISTs with different sizes which caused occult bleeding in a 43-year-old male patient. Tolga Dinc, Selami Ilgaz Kayilioglu, Ahmet Erdogan, Erdinc Cetinkaya, Ozgur Akgul, and Faruk Coskun Copyright © 2016 Tolga Dinc et al. All rights reserved. Mixed Adenoneuroendocrine Carcinoma Is a Rare but Important Tumour Found in the Oesophagus Wed, 03 Feb 2016 09:53:24 +0000 Mixed adenoneuroendocrine carcinoma (MANEC) is a rare tumour of the gastrointestinal tract that consists of a dual adenocarcinomatous and neuroendocrine differentiation, each component representing at least 30% of the tumour. We report a case of a 68-year-old man who presented with two-month history of postprandial pain and vomiting. Gastric endoscopy revealed a polypoid mass in the lower part of the oesophagus. In contrast to the majority of these tumours, this biopsy was immunohistochemically positive for chromogranin A, and synaptophysin and Ki-67 index was 50% and the tumour was diagnosed as poorly differentiated neuroendocrine carcinoma of the oesophagus. The patient underwent surgery and lower oesophagus resection was performed. Based on the histopathology and immunohistochemistry of the tumour in the oesophagogastrectomy specimen, a mixed adenoneuroendocrine carcinoma (MANEC) was diagnosed. The objective of this case report is to advocate for the focus on the MANEC diagnosis as such patients need to be referred to a centre of excellence with expertise in NET tumours, to have the correct diagnostic work-up, treatment, and secondary diagnostic procedures performed at progression, as this will have paramount influence of the choice of treatment. Mohammad Murad Kasim Kadhim, Marie Louise Jespersen, Hans Kristian Pilegaard, Marianne Nordsmark, and Gerda Elisabeth Villadsen Copyright © 2016 Mohammad Murad Kasim Kadhim et al. All rights reserved. Agenesis of the Gallbladder in Monozygotic Twin Sisters Tue, 26 Jan 2016 12:57:10 +0000 Agenesis of the gallbladder, a rare anomaly, is generally regarded as an organogenic failure. Several reports suggest that this congenital defect is inherited but that supposition remains controversial. We described agenesis of the gallbladder in identical twins. A 21-year-old female presented with a history of acute pain in the epigastrium and right hypochondrium. Various imaging modalities showed “gallbladder agenesis.” Moreover, her older identical twin sister had also no visualized gallbladder in imaging modalities. This case report strongly suggested that agenesis of the gallbladder would be caused by a genetic abnormality. Koki Hoshi, Atsushi Irisawa, Goro Shibukawa, Akane Yamabe, Mariko Fujisawa, Ryo Igarashi, Ai Sato, and Takumi Maki Copyright © 2016 Koki Hoshi et al. All rights reserved. A Timely Intervention: Endoscopic Retrieval of a Swallowed Magnetized Activity Watch Tue, 19 Jan 2016 12:47:05 +0000 The accidental ingestion of a foreign object often presents a difficult scenario for the clinician. This includes not only the decision to retrieve the material but also the appropriate technique to use. We present the case of a young asymptomatic girl who swallowed a magnetic activity watch, which was then successfully retrieved with an endoscopic snare. To our knowledge, this is the first documented case of salvaging an operational watch from the stomach using an endoscopic technique. Jason S. Radowsky, Joseph S. Lee, and Andrew T. Schlussel Copyright © 2016 Jason S. Radowsky et al. All rights reserved.