Case Reports in Gastrointestinal Medicine https://www.hindawi.com The latest articles from Hindawi © 2017 , Hindawi Limited . 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 http://www.hindawi.com/journals/crigm/2017/3212056/ 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. Foreign Body Moves Retrograde through Ileocecal Valve during Colonoscopy Wed, 17 May 2017 00:00:00 +0000 http://www.hindawi.com/journals/crigm/2017/8707959/ 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. Recurrent Enterolithiasis Small Bowel Obstruction: A Case Seldom Described Sun, 14 May 2017 09:32:44 +0000 http://www.hindawi.com/journals/crigm/2017/4684182/ 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 http://www.hindawi.com/journals/crigm/2017/9615359/ 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 http://www.hindawi.com/journals/crigm/2017/3602910/ 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 http://www.hindawi.com/journals/crigm/2017/8628206/ 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 http://www.hindawi.com/journals/crigm/2017/2416901/ 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 http://www.hindawi.com/journals/crigm/2017/7294896/ 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 http://www.hindawi.com/journals/crigm/2017/7916976/ 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. Nodular Esophageal Xanthoma: A Case Report and Review of the Literature Mon, 10 Apr 2017 06:39:24 +0000 http://www.hindawi.com/journals/crigm/2017/1503967/ Xanthomas are localized nonneoplastic lesions within tissues that may manifest as papules, plaques, or nodules. These lesions can be found anywhere along the gastrointestinal tract, commonly in the stomach and colon, and rarely in the small intestine and esophagus. Esophagogastroduodenoscopy (EGD) with biopsy is the gold standard tool for diagnosis. Here, we report a rare case of a lower solitary nodular esophageal xanthoma in an elderly black female. Correspondingly, all cases of esophageal xanthomas reported in the English medical literature were reviewed and presented with the reported case. Ahmed Dirweesh, Muhammad Khan, Sumera Bukhari, Cheryl Rimmer, and Robert Shmuts Copyright © 2017 Ahmed Dirweesh et al. All rights reserved. Delayed Awareness of the History of Barium Examination: Perforated Barium Appendicitis Sun, 09 Apr 2017 08:23:58 +0000 http://www.hindawi.com/journals/crigm/2017/6316175/ A 41-year-old man presented to our hospital with lower abdominal pain and a high-grade fever. Physical examination revealed rebound tenderness and guarding in the lower abdomen. Abdominal X-ray examination showed a radiopaque object in the right lower quadrant of the abdomen. Abdominal computed tomography (CT) demonstrated that the object had a strong artifact with over 10,000 Hounsfield units, as well as ascites around the terminal ileum. We diagnosed acute peritonitis with a suspicion of the perforation due to unknown foreign body and performed an emergency laparotomy. Operative findings showed a contained perforation of a phlegmonous appendicitis, and appendectomy was performed. The resected specimen demonstrated that the appendix contained a fecalith, and histopathological examination showed the crystal structure of barium sulfate in the lumen of the appendix. Unfortunately, we did not obtain the history of screening for gastric cancer using a barium examination one month prior to our appendectomy. Our experience demonstrates the importance of establishing a history of barium examinations of the gastrointestinal tract in a patient with a radiopaque object in the right lower quadrant of the abdomen for early diagnosis of barium appendicitis. Additionally, early diagnosis of barium appendicitis may affect the selection of surgical procedures. Susumu Saigusa, Masaki Ohi, Satoshi Oki, Takashi Ichikawa, Minako Kobayashi, Yasuhiro Inoue, and Chikao Miki Copyright © 2017 Susumu Saigusa et al. All rights reserved. Hematochezia: An Uncommon Presentation of Colonic Tuberculosis Mon, 03 Apr 2017 07:40:15 +0000 http://www.hindawi.com/journals/crigm/2017/7831907/ Abdominal tuberculosis (TB) is an uncommon entity in the United States. Colonic TB is reported in 2-3% of patients with abdominal TB. It is frequently misdiagnosed as Crohn’s disease or carcinoma of the colon due to their shared clinical, radiographic, and endoscopic presentations. We present a case of a 72-year-old male with colonic tuberculosis presenting as hematochezia. Our patient presented with shortness of breath and weight loss. Chest X-ray demonstrated ill-defined bilateral parenchymal opacities in the perihilar, mid, and lower lung zones. The patient was diagnosed and treated for community acquired pneumonia, with no improvement. Hematochezia complicated by symptomatic hypotension developed later in the course of admission. Colonoscopy revealed multiple ulcers at the anus and transverse and ascending colon as well as the cecum with stigmata of bleeding. Biopsy of a sigmoid ulcer was consistent with colonic tuberculosis. Antitubercular therapy was initiated, but the patient passed away secondary to multiorgan failure 29 days into admission. Fares Ayoub, Vikas Khullar, Harry Powers, Angela Pham, Shehla Islam, and Amitabh Suman Copyright © 2017 Fares Ayoub et al. All rights reserved. Post-ERCP Emphysematous Cholecystitis in a Young Woman: A Rare and Potentially Fatal Complication Tue, 21 Mar 2017 07:24:45 +0000 http://www.hindawi.com/journals/crigm/2017/1971457/ A 45-year-old woman with suspected Functional Biliary Sphincter Disorder (FBSD) developed Clostridium perfringens related emphysematous cholecystitis after ERCP. A low index of suspicion for emphysematous cholecystitis in this young, otherwise healthy woman led to a significant delay in making the correct diagnosis, and air in the gallbladder was wrongly attributed to a possible gallbladder perforation. ERCP is associated with significant risks, particularly in patients with FBSD, where diagnostic uncertainty renders the balance of risk versus benefit even more critical. Post-ERCP emphysematous cholecystitis secondary to Clostridium perfringens is a rare but potentially fatal complication. Roisin Stack, Joseph McLoughlin, Amy Gillis, and Barbara M. Ryan Copyright © 2017 Roisin Stack et al. All rights reserved. An Uncommon Cause of a Small-Bowel Obstruction Sun, 12 Mar 2017 08:11:53 +0000 http://www.hindawi.com/journals/crigm/2017/1628215/ Sarcoidosis is a systemic granulomatous disease of unknown etiology, characterized by the formation of noncaseating granulomas. Gastrointestinal (GI) system involvement that is clinically recognizable occurs in less than 0.9% of patients with sarcoidosis, with data revealing small intestine involvement in 0.03% of the cases. A high index of suspension is required in patients presenting with small-bowel obstruction and previous history of sarcoidosis. Establishing a definitive diagnosis of GI sarcoidosis depends on biopsy evidence of noncaseating granulomas, exclusion of other causes of granulomatous disease, and evidence of sarcoidosis in at least one other organ system. Treatment of GI sarcoidosis depends on symptomatology and disease activity. Herein, we are presenting a case of 67-year-old female patient who had acute small-bowel obstruction at the level of jejunum with postoperative histopathologic evidence of noncaseating granulomatous inflammation with multinucleated giant cells, consistent with sarcoidosis. Ali Zakaria, Bayan Al Share, Issam Turk, Samira Ahsan, and Waseem Farra Copyright © 2017 Ali Zakaria et al. All rights reserved. Postural Syncope and Constipation: An Unusual Presentation of a Duodenal Dieulafoy’s Lesion Tue, 07 Mar 2017 00:00:00 +0000 http://www.hindawi.com/journals/crigm/2017/6983434/ Dieulafoy lesions are a rare etiology of gastrointestinal bleeding from a large caliber-persistent tortuous submucosal artery. They account for 1-2% of all causes of acute gastrointestinal hemorrhage with 80%–95% of these lesions located in the stomach along the lesser curvature. One-third of these lesions present at an extragastric location, with the proximal duodenum accounting for 15% of them. We present a 21-year-old male with no significant past medical history or risk factors, who presented with repeated syncopal episodes followed by hematemesis, found to have a Dieulafoy lesion located at the duodenal bulb. This lesion was diagnosed and successfully treated via upper endoscopy with epinephrine injection and the application of 2 endoscopic clips. Ahmed Dirweesh, Alvarez Chikezie, Muhammad Yasir Khan, Sana Zia, and Muhammad Tahir Copyright © 2017 Ahmed Dirweesh et al. All rights reserved. “Black Esophagus” or Gurvits Syndrome: A Rare Complication of Diabetic Ketoacidosis Sun, 05 Mar 2017 10:09:59 +0000 http://www.hindawi.com/journals/crigm/2017/4815752/ Acute esophageal necrosis (AEN) also known as “black esophagus” or necrotizing esophagitis is a rare syndrome characterized by a striking diffuse patchy or circumferential black appearance of the esophageal mucosa that preferentially affects the distal esophagus and terminates at the gastroesophageal junction. Only 88 patients over a span of 40 years have received this diagnosis, and the prevalence of this disease ranges from 0.001 to 0.2% of cases in literature. It more commonly affects men (4 : 1 ratio) in the sixth decade of life. It is associated with a high mortality rate, approaching 32%. We report a case of AEN presenting in the setting of diabetic ketoacidosis (DKA), affecting both the proximal and distal esophagus. Vivek Choksi, Kairavee Dave, Rulz Cantave, Sameer Shaharyar, Jeevan Joseph, Uday Shankar, Steven Kaplan, and Hamid Feiz Copyright © 2017 Vivek Choksi et al. All rights reserved. A Case of Hepatic Portal Venous Gas: Hypothesis of a Transient Direct Communication between a Penetrating Antral Gastric Ulcer and Mesenteric Varices Sun, 26 Feb 2017 00:00:00 +0000 http://www.hindawi.com/journals/crigm/2017/8185132/ Hepatic portal venous gas (HPVG) is a rare radiological sign that usually signifies an acute intra-abdominal process, most commonly bowel ischemia and sepsis. Few reports described an association with underlying gastric pathologies. We report a 60-year-old patient who presented with melena and chills and was discovered to have a gastric ulcer that appeared to have penetrated into a mesenteric varix. This, in turn, likely caused development of HPVG associated with fungemia. Treatment with a proton pump inhibitor and bowel rest was sufficient to resolve symptoms and the HPVG. Hassan M. Ghoz, Shamlan M. Sheikh, Kanika Khandelwal, Joseph Fiore, Nicholas James, and Joel Weinstock Copyright © 2017 Hassan M. Ghoz et al. All rights reserved. Chronic Hepatitis with Liver Granulomas in a Patient with Granuloma Annulare: A Case Report and Review of the Literature Thu, 23 Feb 2017 09:07:24 +0000 http://www.hindawi.com/journals/crigm/2017/8768529/ Granuloma annulare (GA) is a benign granulomatous skin disorder of unknown etiology. GA is rarely associated with liver diseases. We report a unique case of chronic hepatitis with liver granulomas in a patient with GA. Despite an extensive workup, no clear etiology for the hepatitis was found. Based on the possible immune pathophysiology of GA and the presence of liver granulomas, the patient was treated with prednisone and azathioprine which resulted in complete normalization of the liver enzymes and concurrent improvement of GA. The association between liver diseases and GA is reviewed. Majid Alsahafi, Mohammed I. AlJasser, Sunil Kalia, H. M. Yang, and Alnoor Ramji Copyright © 2017 Majid Alsahafi et al. All rights reserved. Shigella sonnei Bacteremia Presenting with Profound Hepatic Dysfunction Thu, 23 Feb 2017 00:00:00 +0000 http://www.hindawi.com/journals/crigm/2017/7293281/ Worldwide, Shigellosis is a significant public health issue, associated with nearly one million deaths annually. About half a million cases of Shigella infection are reported annually in the United States. Shigella bacteremia is uncommon and generally seen in children and immunocompromised adults. We present a case of a Shigella sonnei bacteremia with marked hepatic derangement in a 27-year-old previously healthy homosexual male with history of Roux-en-Y gastric bypass, who presented to the emergency room with a 4-day history of loose watery stool, abdominal cramps, nausea and vomiting, and yellow skin of 2-day duration. He reports similar diarrhea illness in two close contacts in preceding days. On examination, he was fully oriented but dehydrated, icteric, and febrile. Laboratory data revealed WBC of 2200/μL, elevated AST and ALT (201 IU/L, 73 IU/L resp.), normal alkaline phosphatase, elevated total and direct bilirubin of 8.2 mg/dL and 4.4 mg/dL, albumin of 3.2 g/dL, INR of 2.9, prothrombin time of 31.7, and platelet of 96,000/μL. Workup for infectious, autoimmune and medication-induced hepatitis, Wilson’s disease, and hemochromatosis was negative. Abdominal ultrasound and computed tomography of the abdomen showed hepatic steatosis and right-sided colitis. Stool and blood cultures were positive for Shigella sonnei. He was treated with ciprofloxacin with improvement in liver function. Follow-up blood test 4 months later was within normal limits. Oluwaseun Shogbesan, Andrew Rettew, Bilal Shaikh, Abdullateef Abdulkareem, and Anthony Donato Copyright © 2017 Oluwaseun Shogbesan et al. All rights reserved. Association of Chronic Pancreatitis and Malignant Main Duct IPMN: A Rare but Difficult Clinical Problem Wed, 22 Feb 2017 08:19:52 +0000 http://www.hindawi.com/journals/crigm/2017/8705195/ We report the case of a 70-year-old woman who consulted for recurrent short episodes of mild-to-moderate abdominal pain. Dilated main pancreatic duct was seen on CAT scan and magnetic resonance, with multiple calcifications and intraductal stones, typical in CP. However, for a more pronounced cystic dilatation in the pancreatic head, we could not exclude the coexistence of a main duct IPMN. ERCP was performed, with pancreatic sphincterotomy and extraction of pancreatic stones, but, at the same time, mucin extrusion was seen from the dilated duct through the papilla. Pancreatoduodenectomy was performed. Surgery and histology confirmed malignant IPMN with the typical image of chronic pancreatitis and intraductal stones in the vicinity. The patient is doing well 4 years after the surgery, without recurrence of the malignant disease, with changes of chronic pancreatitis in the pancreatic remnant. This paper discusses the possible relationships between the two entities and emphasizes the need of differential diagnosis. Zoltán Berger, Hernán De La Fuente, Manuel Meneses, Fernanda Matamala, Makarena Sepúlveda, and Claudia Rojas Copyright © 2017 Zoltán Berger et al. All rights reserved. A Patency Capsule Remained Intact in the Colon over 210 Hours Wed, 22 Feb 2017 00:00:00 +0000 http://www.hindawi.com/journals/crigm/2017/1201404/ We present an unusual case of a 35-year-old male patient whom a patency capsule stayed in his gut without breaking. He has a history of Peutz-Jeghers syndrome and multiple abdominal surgeries. Prestudy was performed for abdominal searching, but a patency capsule remained in the colon over 9 days. He displayed neither abdominal nor obstructive symptoms in that period. We collected the patency capsule using colonoscopy after dilating a postoperative stricture at an anastomotic site of the rectum. Clinicians should bear in mind that patency capsules may become retained as distally as the colon in patients with a surgical history of the large intestine. Yu Hihara, Satoru Joshita, Toshiharu Takahashi, Shinji Okaniwa, Yoshiki Mizukami, and Yoshiyuki Nakamura Copyright © 2017 Yu Hihara et al. All rights reserved. A Perplexing Case of Abdominal Pain That Led to the Diagnosis of Zollinger-Ellison Syndrome Tue, 21 Feb 2017 00:00:00 +0000 http://www.hindawi.com/journals/crigm/2017/7636952/ Zollinger-Ellison syndrome (ZES) is a rare clinical disorder, characterized by hypersecretion of gastric acid and multiple ulcers distal to the duodenal bulb. This occurs via the release of gastrin by neuroendocrine tumors known as gastrinomas. Patients with ZES present with nonspecific GI symptoms, which often leads to a delay in diagnosis. Our patient is a 55-year-old female with chronic abdominal pain, nausea, and diarrhea. She underwent EGD, EUS, MRCP, CT scans, and cholecystectomy, which did not reveal the cause of her symptoms. Repeat EGD showed a cratered ulcer in the second portion of the duodenum, suspicious for ZES. Serum gastrin was initially only moderately elevated while on PPI therapy, but chromogranin A was also elevated. Repeat gastrin level after stopping PPI therapy was 1639 pg/mL. Somatostatin receptor scintigraphy was obtained, which showed two small lesions in the gastrinoma triangle. She subsequently underwent a Whipple pancreaticoduodenectomy and pathology was positive for four microscopic foci of a neuroendocrine tumor. She reported improvement in her symptoms after surgery. This case highlights the need for increased awareness of ZES in patients with unexplained GI complaints and emphasizes the use of multiple modalities in the diagnosis of ZES. Adrienne Lenhart, Mona Hassan, Alireza Meighani, Omar Sadiq, and Yousuf Siddiqui Copyright © 2017 Adrienne Lenhart et al. All rights reserved. Hemorrhagic Shock as Complication of Intramural Intestinal Bleeding Sun, 12 Feb 2017 09:39:34 +0000 http://www.hindawi.com/journals/crigm/2017/5424631/ Introduction. Mural intestinal hematoma (MIH) is an uncommon complication of anticoagulant therapy. Hemorrhagic shock has been rarely reported as a revealing modality. Results. We report two cases of shock induced by mural intestinal hematoma in patients under oral anticoagulant for aortic prosthetic valve and atrial fibrillation. Patients were admitted to the ICU for gastrointestinal tract bleeding associated with hemodynamic instability. After resuscitation, an abdominal CT scan has confirmed the diagnosis showing an extensive hematoma. Medical treatment was sufficient and there was no need for surgery. Conclusion. Gastrointestinal bleeding associated with shock in patients treated by oral anticoagulant should alert physicians to research a probable MIH. Urgent diagnosis and appropriate medical treatment can avoid surgical interventions. Asma Ben Ali, Mohamed Ali Cherif, Walid Mhajba, Hamdi Hamdène Doghri, Malek Hassouna, Youssef Zied El Hechmi, Zouheir Jerbi, Ines Ben Hassen, and Mohamed Habib Daghfous Copyright © 2017 Asma Ben Ali et al. All rights reserved. Endoscopic Appearance of Oropharyngeal and Upper GI Kaposi’s Sarcoma in an Immunocompromised Patient Sun, 05 Feb 2017 10:07:33 +0000 http://www.hindawi.com/journals/crigm/2017/3742684/ Introduction. Kaposi’s sarcoma (KS) usually manifests as a cutaneous disease but GI manifestation is often rare. It is associated with human herpes virus-8 (HHV-8) and seen in immunocompromised patients. In the USA, use of highly active antiretroviral therapy (HAART) has drastically reduced incidence of KS in HIV patients. Case Presentation. A 65-year-old male with human immunodeficiency virus (HIV) was admitted to the intensive care unit (ICU) with cardiopulmonary arrest secondary to hyperkalemia of 7.5 meq/L. Following placement of orogastric and endotracheal tube (ETT), a significant amount of blood was noticed in the ETT. Hemoglobin trended down from 9.6 mg/dL to 6.7 mg/dL over five days. Stool guaiac was positive. Esophagogastroduodenoscopy (EGD) was performed and revealed multiple large hypervascularized violaceous submucosal nodular lesions with stigmata of bleeding seen on the soft palate and pharynx and within the cricopharyngeal area close to the vocal cords. Biopsy of the soft palate lesions showed proliferation of neoplastic spindle shaped cells arranged in bundles with slit-like capillary spaces containing erythrocytes consistent with Kaposi’s sarcoma. Biopsy was positive for HHV-8. Colonoscopy was unremarkable. There were no cutaneous manifestations of the disease. Conclusion. GI involvement of Kaposi’s sarcoma must be considered in immunocompromised patients and can be confirmed by endoscopic methods. Umar Darr, Anas Renno, Zubair Khan, Turki Alkully, Maitham A. Moslim, Sehrish Kamal, and Ali Nawras Copyright © 2017 Umar Darr et al. All rights reserved. Granular Cell Tumor of Rectum: A Very Rare Entity Tue, 31 Jan 2017 09:58:10 +0000 http://www.hindawi.com/journals/crigm/2017/3795482/ Granular cell tumors are predominantly benign, occurring more commonly in women, with about 10% developing in the gastrointestinal tract. Rectal location of this tumor is very rare. We herein report one such case of a 61-year-old man with granular cell tumor in the rectum who underwent endoscopic curative resection. Tagore Sunkara, Savitha V. Nagaraj, and Vinaya Gaduputi Copyright © 2017 Tagore Sunkara et al. All rights reserved. A Rare Cause of Primary Aortoenteric Fistula: Streptococcus parasanguinis Aortitis Tue, 31 Jan 2017 09:39:51 +0000 http://www.hindawi.com/journals/crigm/2017/9087308/ Primary aortoenteric fistula is a rare cause of upper gastrointestinal bleed but can lead to significant mortality if the diagnosis is delayed. Aortitis, characterized by inflammation of the aortic wall, is a rare cause of aortoenteric fistula. We present a case report of a 72-year-old male patient with infectious aortoenteric fistula secondary to Streptococcus parasanguinis, along with a review of the literature. This case demonstrates the importance of early diagnosis and aggressive surgical treatment of aortoenteric fistulae and recognizing infectious aortitis as a potential etiology. Fredy Nehme, Kyle Rowe, Cyrus Munguti, and Imad Nassif Copyright © 2017 Fredy Nehme et al. All rights reserved. Solid Pseudopapillary Neoplasm of the Pancreas in Young Male Patients: Three Case Reports Tue, 31 Jan 2017 00:00:00 +0000 http://www.hindawi.com/journals/crigm/2017/9071678/ A preoperative diagnosis of solid pseudopapillary neoplasms (SPNs) in young male patients is difficult to achieve using radiological images. We herein present three cases of young male patients with relatively small SPNs. Endoscopic ultrasound (EUS) showed well-encapsulated, smooth-surfaced, heterogeneous solid lesions in all patients, and all preoperative diagnoses were achieved by EUS-guided fine needle aspiration (EUS-FNA). The final pathological diagnosis after surgery was an SPN with a Ki-67 labeling index of <2%. SPNs should be considered even in young male patients. EUS with EUS-FNA could be a useful diagnostic modality for SPNs even in young male patients. Akira Aso, Eikichi Ihara, Kazuhiko Nakamura, Irina Sudovykh, Tetsuhide Ito, Masafumi Nakamura, Tetsuo Ikeda, Nobuyoshi Takizawa, Yoshinao Oda, and Shuji Shimizu Copyright © 2017 Akira Aso et al. All rights reserved. Undigested Pills in Stool Mimicking Parasitic Infection Tue, 31 Jan 2017 00:00:00 +0000 http://www.hindawi.com/journals/crigm/2017/3718954/ Background. Orally ingested medications now come in both immediate release and controlled release preparations. Controlled release preparations were developed by pharmaceutical companies to improve compliance and decrease frequency of pill ingestion. Case Report. A 67-year-old obese male patient presented to our clinic with focal abdominal pain that had been present 3 inches below umbilicus for the last three years. This pain was not associated with any trauma or recent heavy lifting. Upon presentation, the patient reported that for the last two months he started to notice pearly oval structures in his stool accompanying his chronic abdominal pain. This had coincided with initiation of his nifedipine pills for his hypertension. He reported seeing these undigested pills daily in his stool. Conclusion. The undigested pills may pose a cause of concern for both patients and physicians alike, as demonstrated in this case report, because they can mimic a parasitic infection. This can result in unnecessary extensive work-up. It is important to review the medication list for extended release formulations and note that the outer shell can be excreted whole in the stool. Fazia Mir, Ilyas Achakzai, Jamal A. Ibdah, and Veysel Tahan Copyright © 2017 Fazia Mir et al. All rights reserved. A Case of Eosinophilic Esophagitis Accompanying Familial Mediterranean Fever Tue, 31 Jan 2017 00:00:00 +0000 http://www.hindawi.com/journals/crigm/2017/6863921/ Background. Eosinophilic esophagitis is an inflammatory condition where there is a dense infiltration of eosinophils typically exceeding fifteen cells per high power field. Familial Mediterranean fever is an autosomal recessive disorder characterized by brief, acute, and self-limited episodes of fever and polyserositis that recur at irregular intervals. Case Presentation. A three-year-and-nine-month-old Iranian girl was admitted to our center. The patient’s parents complained of a history of abdominal pain, poor appetite, and poor weight gain from 1.5 years ago and episodes of food impaction after starting solid foods. Eosinophilic esophagitis was diagnosed based on histology. Because of continuing abdominal pain after treatment of eosinophilic esophagitis, the episodic nature of disease, and the presence of fever with pain, screening for familial Mediterranean fever mutation was performed and the patient was found to be heterozygote for Mediterranean fever. Conclusion. We have reported a case of eosinophilic esophagitis coexisting with familial Mediterranean fever which has not been described previously. Pejman Rohani, Mehri Najafi Sani, Mitra Ahmadi, and Vahid Ziaee Copyright © 2017 Pejman Rohani et al. All rights reserved. A Rare Case of Rivaroxaban Causing Delayed Symptomatic Hepatocellular Injury and Hyperbilirubinemia Mon, 30 Jan 2017 05:59:07 +0000 http://www.hindawi.com/journals/crigm/2017/5678187/ Importance. As Rivaroxaban has increased in popularity, it has been accompanied with a growing body of evidence displaying its ability to cause drug induced liver injury (DILI). Observation. A 74-year-old Caucasian female developed Rivaroxaban DILI two weeks after finishing a 14-day course. The patient was symptomatic and jaundiced with elevated transaminases and hyperbilirubinemia with normal lab values two months priorly. Liver biopsies showed mixed inflammatory infiltrate of lymphocytes, neutrophils and eosinophils, rare necrotic hepatocytes, and canalicular and intrahepatocellular cholestasis, all of which are consistent with DILI. Conclusion and Relevance. We present this case to add to the growing evidence that Rivaroxaban can be associated with severe, symptomatic liver injury and to ensure physicians are aware of these possible side effects of novel anticoagulants with their increasing use. Keith Glenn, Patrick Chen, Mustafa Musleh, Rao Pallivi, and Melissa Grilliot Copyright © 2017 Keith Glenn et al. All rights reserved.