Case Reports in Gastrointestinal Medicine The latest articles from Hindawi © 2017 , Hindawi Limited . 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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. Metastatic Cutaneous Melanoma of the Gallbladder Mon, 30 Jan 2017 00:00:00 +0000 Metastatic melanoma is an aggressive disease that can spread to many organs of the body. In rare cases, it can spread to the gallbladder causing secondary lesions, yet presenting with little to no symptoms. Therefore, most cases of metastatic melanoma lesions to the gallbladder go undiagnosed. Here, we present the case of a 41-year-old male with a four-month history of melanoma of the face, with a postresection status, who presented with right upper quadrant abdominal pain. Doppler ultrasound and computed tomography confirmed the presence of a mass on the gallbladder. Laparoscopic excision along with liver wedge resection was performed. Pathology staining revealed the presence of a malignant metastatic melanoma lesion of the gallbladder. Dhruvan Patel, Shazia Sohrawardy, Yub Raj Sedhai, Soney Basnyat, Anisha Daxini, Aparna Basu, Vivek R. Mehta, Aasim Mohammed, and Steven Lichtenstein Copyright © 2017 Dhruvan Patel et al. All rights reserved. Single-Operator Peroral Cholangioscopy for Extraction of Cystic Duct Stones in Postcholecystectomy Mirizzi Syndrome Sun, 22 Jan 2017 00:00:00 +0000 Mirizzi syndrome is an exceptionally rare diagnosis with an annual incidence of less than 1% in developed countries. In this disease process, stone burden in the cystic duct or gallbladder neck leads to common hepatic duct obstruction, either by mechanical compression or secondary inflammation. Mirizzi syndrome is classified into one of four types based on the presence and severity of cholecystobiliary fistulization. Treatment is primarily surgical in nature and largely dictated by the type of Mirizzi syndrome encountered. It is typically diagnosed in the preoperative or operative setting of cholecystectomy; however, there have been rare occurrences of postcholecystectomy diagnosis. Factors thought to predispose to postcholecystectomy disease include low insertion of the cystic duct and long remnant duct length. Few case reports exist describing this phenomenon and its management, which is made exceptionally difficult due to the presence of inflammation and surgical adhesion. We present the case of a young female with postcholecystectomy Mirizzi syndrome who underwent successful endoscopic management using peroral cholangioscopy and electrohydraulic lithotripsy. We also provide a brief overview of both Mirizzi syndrome and peroral cholangioscopy. Jason Deforest Jones and Rishi Pawa Copyright © 2017 Jason Deforest Jones and Rishi Pawa. All rights reserved. A Case of Acute Hepatitis E Infection in a Patient with Non-Hodgkin Lymphoma Treated Successfully with Ribavirin Sun, 15 Jan 2017 08:28:49 +0000 We present the case of a man who, following immunosuppressive treatment for non-Hodgkin lymphoma, became infected with viral hepatitis E. Acute hepatitis E virus infection should be considered in patients with deranged liver function on a background of haematological malignancies or immunosuppression, even without travel to endemic regions. Whilst clearance is usually spontaneous in immune-competent individuals, these at-risk groups may develop a more complicated and protracted disease course. Thus awareness is important as additional treatment with ribavirin or pegylated interferon may be required, as in this case, in order to help achieve eradication. Hasan N. Y. Haboubi, Rizwan Diyar, Ann Benton, and Chin Lye Ch’ng Copyright © 2017 Hasan N. Y. Haboubi et al. All rights reserved. A Time to Pause and Reflect: When a Patient with Autoimmune Hepatitis Stops Responding to Corticosteroids Sun, 25 Dec 2016 07:19:36 +0000 Drug-induced liver injury (DILI) with features of autoimmunity (AI) is a challenging diagnosis to make particularly due to its apparent corticosteroid responsiveness. We present the case of a 74-year-old woman who presented with a 2-week history of jaundice and fatigue. She was initially diagnosed with autoimmune hepatitis (AIH) based on biochemical and histological characteristics and prompt response with budesonide but a biochemical relapse occurred soon after inadvertent rechallenge with irbesartan, a drug that she had discontinued prior to her presentation but was not initially considered to be a cause of her symptoms. Lewis Tsang, Mitali Fadia, and Shivakumar Chitturi Copyright © 2016 Lewis Tsang et al. All rights reserved. Colonoscopic Splenic Injury: A Simplified Radiologic Approach Sun, 18 Dec 2016 12:18:46 +0000 Colonoscopy is a commonly performed procedure for diagnosis and treatment of large bowel diseases. Recognized complications include bleeding and perforation. Splenic injury during colonoscopy is a rare complication. We report a case of a 73-year-old woman who presented with left-sided abdominal pain after colonoscopy with finding of splenic injury on CT scan. She was managed conservatively. We discuss the diagnostic and therapeutic approach to colonoscopic splenic injury. Tara Chen, Qiu Tong, and Alexander Kurchin Copyright © 2016 Tara Chen et al. All rights reserved. Severe Erosive Pill Esophagitis Induced by Crizotinib Therapy: A Case Report and Literature Review Thu, 08 Dec 2016 13:44:08 +0000 Previous case reports have described esophagitis thought to be secondary to crizotinib, an oral tyrosine-kinase inhibitor used in the treatment of anaplastic lymphoma kinase- (ALK-) positive non-small cell lung cancer (NSCLC). In those reports, the interval development of esophagitis was between two days and three months after initiating or reinitiating crizotinib therapy. We present a woman who developed ulcerative esophagitis ten months after beginning crizotinib therapy, which is highly unusual. We believe the provoking factor was a change in her medication administration routine, done to accommodate religious practices during the period of Ramadan. This case illustrates the mechanism of pill esophagitis and reinforces the importance of patient education when it comes to medication administration. Clinicians may consider early imaging or investigations in patients with concerning symptomatology in the context of crizotinib therapy or other offending medications. Future research may help to uncover additional risk factors for this exceedingly rare diagnosis in this patient population. Most importantly, this case highlights nonpharmacologic ways to improve tolerability and decrease adverse effects of a highly effective chemotherapeutic agent. Patrick Jung, Kyle J. Fortinsky, Zane R. Gallinger, and Piero Tartaro Copyright © 2016 Patrick Jung et al. All rights reserved. Polypoid Dysplasia in Barrett’s Esophagus: Diagnosis, Management, and Very Different Outcomes in Two Consecutive Cases Wed, 23 Nov 2016 09:06:20 +0000 Background. Barrett’s esophagus is associated with an increased risk of adenocarcinoma. Dysplasia in Barrett’s esophagus is a precursor to adenocarcinoma. Rarely, dysplastic polypoid lesions are superimposed on Barrett’s esophagus. Most reported cases of polypoid dysplasia in Barrett’s esophagus have been advanced on presentation and treated with esophagectomy. We describe two cases of polypoid changes in Barrett’s esophagus and treatment with polypectomy followed by radiofrequency ablation. Cases. A 75 yo male presented with esophageal polyps, which on biopsy showed gastric cardia/foveolar mucosa with focal intestinal metaplasia without dysplasia. Biopsy of intervening flat mucosa was consistent with nondysplastic Barrett’s esophagus. Extensive hot snare polypectomies were performed followed by RFA. One year later, repeat EGD revealed no evidence of Barrett’s esophagus. A 61 yo male presented with esophageal polyps, which on biopsy showed gastric cardia/foveolar mucosa with intestinal metaplasia and foci of low-grade dysplasia. Extensive hot snare polypectomies were performed followed by RFA. At repeat EGD, four months later, an esophageal mass was found. Biopsy of the mass showed invasive adenocarcinoma. The patient was referred for esophagectomy. Conclusion. This case series shows two outcomes, one with successful eradication of dysplasia and the other with disease progression to invasive adenocarcinoma requiring esophagectomy. Megan Murphy, Christina Tofani, Kunjal Gandhi, and Anthony Infantolino Copyright © 2016 Megan Murphy et al. All rights reserved. Cholecystocolonic Fistulas from Diverticulosis: A Potentially Missable Cause of Liver Abscesses Tue, 22 Nov 2016 09:10:15 +0000 Cholecystocolonic fistulas (CCF) due to colonic diverticulosis are a rare cause of liver abscesses. It is even rarer to simultaneously have choledocholithiasis, another cause for liver abscesses. In this case report, we found both pathologies and emphasise the need to study cholangiograms carefully so as not to miss alternative diagnoses. Ben Warner, Terry Wong, and Philip Berry Copyright © 2016 Ben Warner et al. All rights reserved. Cannabinoid Hyperemesis Syndrome: A Case Report of Cyclic Severe Hyperemesis and Abdominal Pain with Long-Term Cannabis Use Thu, 17 Nov 2016 08:20:02 +0000 Introduction. Cannabinoid Hyperemesis Syndrome (CHS) is a rare condition that includes cyclic severe vomiting in subjects who have been consuming large doses of cannabis for several years. One of the major diagnostic criteria is the alleviation of symptoms by hot showers. The syndrome was first described in 2004 and is so far neither completely understood nor well known. The latter leads to continued morbidity in concerned subjects and unnecessary expenses for futile investigations. Standard treatments of vomiting as 5-HT3 or D2-receptor antagonists have been shown to be ineffective in alleviating the symptoms. The only long-term satisfying treatment option is the complete abstinence from cannabis consumption. Case Summary. In this case report we describe a 26-year-old male Caucasian long-term cannabis consumer who repeatedly presented in our emergency room with cyclic severe nausea and vomiting ceased by hot showers and resistant to all other treatments. The final diagnosis was not established until his third visit to the ER. Conclusion. CHS is an important differential diagnosis in patients who present with cyclic vomiting and abdominal pain with a history of long-term cannabis use. Recognition of this syndrome is important in order to avoid unnecessary clinical testing and to help the patients break the cycle of drug use. Julia Hermes-Laufer, Lola Del Puppo, Ihsan Inan, François-Xavier Troillet, and Omar Kherad Copyright © 2016 Julia Hermes-Laufer et al. All rights reserved. Diagnostic Colonoscopy Leading to Perforated Appendicitis: A Case Report and Systematic Literature Review Thu, 17 Nov 2016 07:11:14 +0000 Introduction. Intestinal perforation is a known complication after colonoscopy. However, appendiceal involvement with inflammation and perforation is extremely rare and only 37 cases of postcolonoscopy appendicitis have been reported so far. We describe a case of perforated appendicitis 24 hours after colonoscopy that was treated successfully in our Department. Case Report. A 60-year-old female patient underwent a colonoscopy during the investigation of nontypical abdominal pain without pathologic findings. 24 hours after the examination she presented gradually increased right lower quadrant abdominal pain and a CT scan was performed, showing an inflammation of the appendiceal area with free peritoneal air. Through laparotomy, perforated appendicitis was diagnosed and an appendectomy was performed. The patient was discharged on the tenth postoperative day in good health condition. Discussion. The characteristics of all cases reported in the literature are described, including our case. Perforated appendicitis soon after a colonoscopy is a rare, but serious complication; therefore, it is crucial to be included in the differential diagnosis of postcolonoscopy acute abdominal pain. Daniel Paramythiotis, Konstantinia Kofina, Vasileios Papadopoulos, and Antonios Michalopoulos Copyright © 2016 Daniel Paramythiotis et al. All rights reserved. Atypical Aortoesophageal Fistula with Atypical and Delayed Presentation and Negative Imaging Studies Mon, 14 Nov 2016 13:54:10 +0000 A 59-year-old man with past medical history of thoracic aortic aneurysm treated with thoracic endovascular aortic repair presented with melena for 2 weeks. Initial EGD did not reveal the source of bleeding and showed normal esophagus; abdominal arteriogram did not reveal a fistulous communication and initial CTA showed normal position of the aortic graft stent without endoleak. The sixth EGD revealed a submucosal tumor-like projection in the upper esophagus and stigmata of recent bleeding. Another thoracic endovascular aortic repair with stent was placed over the old graft for presumed aortoesophageal fistula. Poststent upper gastrointestinal series with contrast showed extravasation of the contrast from the esophagus and CTA showed fistulous tract between aorta and esophagus. The patient refused definitive surgical repair despite having infected aortic graft; jejunostomy tube was placed and life-long suppressive antibiotic treatment was given and the patient is doing well at 2-year follow-up. Seifeldin Hakim, Mihajlo Gjeorgjievski, Lohit Garg, Molly Orosey, and Tusar Desai Copyright © 2016 Seifeldin Hakim et al. All rights reserved. Pneumomediastinum Secondary to Barotrauma after Recreational Nitrous Oxide Inhalation Sun, 13 Nov 2016 11:38:30 +0000 We present a case of a seventeen-year-old patient, admitted in the care of the surgical team following inhalation of nitrous oxide at high pressure, leading to extensive pneumomediastinum and surgical emphysema. We discuss the subsequent investigations and management for this patient. In the absence of history of airway injury and respiratory problems including asthma and with no oesophageal perforation on investigations, the diagnostic and management challenges encountered have been discussed which will help in future management of similar cases. H. Jeddy, Farhan Rashid, H. Bhutta, B. Lorenzi, and A. Charalabopoulos Copyright © 2016 H. Jeddy et al. All rights reserved. A Case of Chronic Calcific Nonalcoholic Pancreatitis Thu, 10 Nov 2016 12:58:25 +0000 Tropical Calcific Pancreatitis (TCP) is a type of chronic calcific nonalcoholic pancreatitis. Similar to nonalcoholic chronic pancreatitis, it presents in the second and third decades of life; however this type is reported mostly in the developing tropical and subtropical countries. It is associated with the formation of pancreatic calculi and a high probability of developing insulin-dependent diabetes mellitus. Epidemiologic studies have shown that these patients have an increased risk of developing pancreatic carcinoma. The etiology of TCP remains uncertain, with the current consensus suggesting genetics as well as possible toxicity from consuming large amounts of cassava, a tuber. Definite diagnosis of TCP requires younger age of onset, history of malnutrition, and presence of diabetes mellitus along with extensive pancreatic calcification and ductal calculi. When patients meet most but not all of these conditions the term Idiopathic Chronic Pancreatitis (ICP) is used. This is a case of a 44-year-old man who presented with most features seen in TCP, and however, was diagnosed with ICP. Aaron Kangas-Dick, Umair Khan, Oluwafunbi Awoniyi, Shanza Waqar, Nu Nwe Tun, Karthikeyan Viswanathan, and Cynthia Wong Copyright © 2016 Aaron Kangas-Dick et al. All rights reserved. Breast Cancer Metastasis to the Stomach That Was Diagnosed after Endoscopic Submucosal Dissection Wed, 09 Nov 2016 11:04:26 +0000 A 52-year-old woman presented with stage IIB primary breast cancer (cT2N1M0), which was treated using neoadjuvant chemotherapy (epirubicin, cyclophosphamide, and paclitaxel). However, the tumor persisted in patchy areas; therefore, we performed modified radical mastectomy and axillary lymph node dissection. Routine endoscopy at 8 months revealed a depressed lesion on the gastric angle’s greater curvature, and histology revealed signet ring cell proliferation. We performed endoscopic submucosal dissection for gastric cancer, although immunohistochemistry revealed that the tumor was positive for estrogen receptor, mammaglobin, and gross cystic disease fluid protein-15 (E-cadherin-negative). Therefore, we revised the diagnosis to gastric metastasis from the breast cancer. Masahide Kita, Masashi Furukawa, Masaya Iwamuro, Keisuke Hori, Yoshiro Kawahara, Naruto Taira, Tomohiro Nogami, Tadahiko Shien, Takehiro Tanaka, Hiroyoshi Doihara, and Hiroyuki Okada Copyright © 2016 Masahide Kita et al. All rights reserved. A Unique Case of Pancreatic Mass due to Pancreatic Elastofibromatosis Sun, 06 Nov 2016 13:42:31 +0000 Elastofibroma is a benign tumor of the musculoskeletal system characterized by the abnormal accumulation of elastinophilic fibers. It has been classically described for subscapular region but has been reported in several musculoskeletal sites over the years and rarely even in the GI tract but never in pancreas. We therefore present the case of a 45-year-old female who presented with intermittent abdominal pain. CT of abdomen revealed 1.4 cm pancreatic neck lesion without peripancreatic lymphadenopathy. Endoscopic ultrasound (EUS) guided FNA was nondiagnostic. Surgical resection was performed with central pancreatectomy. Histopathology revealed well demarcated nodules of hypocellular collagen with abundant elastic fibers, characteristic of pancreatic elastofibroma. Treatment is not needed unless symptomatic and surgical resection is the preferred therapeutic option when indicated. This case adds another entity to the differential diagnosis of pancreatic mass lesions. Abhinav Goyal, Deepanshu Jain, Ishfaq Bhat, and Shailender Singh Copyright © 2016 Abhinav Goyal et al. All rights reserved. A Silent and Chronic Complication of Percutaneous Endoscopic Gastrostomy Tube: Small Bowel Enterocutaneous Fistula Sun, 06 Nov 2016 13:03:47 +0000 Percutaneous endoscopic gastrostomy (PEG) has gradually gained the popularity since its invention and become the most preferred method for gastrostomy insertion in recent years. PEG is associated with lower morbidity and mortality and has the advantages of being minimally invasive and more convenient over the conventional open gastrostomy. However, significant rates of major complication still occur. Enterocutaneous fistula is one of the key complications that can be easily neglected due to its asymptomatic nature. We present a case of small bowel enterocutaneous fistula which was only found 8 years after the PEG insertion, being diagnosed after the longest duration of delay in diagnosis reported in literature. Sai Wah Cheung Copyright © 2016 Sai Wah Cheung. All rights reserved.