Case Reports in Gastrointestinal Medicine The latest articles from Hindawi Publishing Corporation © 2016 , Hindawi Publishing Corporation . All rights reserved. Hemorrhage from Extra-Antral Gastric Antral Vascular Ectasia in a Patient with Duodenal Heterotopic Gastric Mucosa Tue, 18 Oct 2016 06:41:51 +0000 Gastric antral vascular ectasias (GAVE) have been increasingly recognized as an uncommon cause of chronic gastrointestinal bleeding and anemia, although their underlying pathogenesis is not completely well understood. Heterotopic gastric mucosa (HGM) has been reported to occur at various sites along the gastrointestinal tract and although relatively common, it is often asymptomatic. We report a case of a 60-year-old woman with a prior history of GAVE who developed melena and symptomatic anemia during her hospitalization following cardiac catheterization. Initial EGD demonstrated nonbleeding antral GAVE and a newly discovered duodenal mass. Duodenal mass biopsies were ultimately notable for HGM along with histologic features of extra-antral GAVE. The patient required blood transfusions and consequently had a small bowel endoscopy notable for fresh blood in the proximal small bowel. The patient underwent a small bowel push enteroscopy which demonstrated active bleeding of the duodenal mass and overlying oozing GAVE, which was cauterized with Argon-Plasma Coagulation with adequate hemostasis. We present for the first time a novel association between GAVE and HGM. Our case illustrates that extra-antral GAVE may occur with HGM in the duodenum. We explore potential mechanisms by which HGM may be involved in the pathogenesis of GAVE. John Gubatan, Nathan Raines, Hasan Khosravi, Tracy L. Challies, and Tyler M. Berzin Copyright © 2016 John Gubatan et al. All rights reserved. Primary Histoplasma capsulatum Enterocolitis Mimicking Peptic and Inflammatory Bowel Disease Wed, 12 Oct 2016 13:07:01 +0000 In immunocompromised patients, histoplasmosis may present as disseminated disease. We present a 52-year-old Caucasian male with symptoms of dyspepsia, postprandial epigastric pain, nausea, and nonbloody diarrhea. Upper and lower gastrointestinal endoscopies were suspicious for inflammatory bowel disease (IBD); however, biopsies were consistent with histoplasmosis, specifically in the duodenum. Rahman Nakshabendi, Andrew C. Berry, Daisy Torres-Miranda, Francis Daniel LaBarbera, Ozdemir Kanar, Ahmad Nakshabandi, and Imad Nakshabendi Copyright © 2016 Rahman Nakshabendi et al. All rights reserved. Periesophageal Pseudoaneurysms: Rare Cause of Refractory Bleeding Treated with Transarterial Embolization Wed, 12 Oct 2016 07:14:01 +0000 A 43-year-old female with history of systemic lupus erythematosus, prior cytomegalovirus esophagitis treated with ganciclovir, and long segment Barrett’s esophagus (Prague class C8 M9) with high grade dysplasia treated with radiofrequency ablation presented to the hospital with hematemesis. An upper gastrointestinal endoscopy showed multiple esophageal ulcers with active arterial spurting which could not be controlled with endoscopic interventions including placement of hemostatic clips. An emergent angiogram demonstrated actively bleeding saccular dilations (pseudoaneurysms) in the esophageal branches of the lower thoracic aorta as well as left gastric artery for which gelfoam and coil embolization was initially successful. Due to recurrence of massive bleeding, she subsequently underwent emergent esophagectomy and bipolar exclusion. Pathology demonstrated submucosal hemorrhage, esophagitis with dysplastic Barrett’s mucosa, and an ulcer containing cytomegaloviral inclusions. We report the first case of arterial bleeding from periesophageal pseudoaneurysms as well as use of angiographic embolization for arterial bleeding in the esophagus. Divyanshoo R. Kohli, Rachit D. Shah, Daniel J. Komorowski, and George B. Smallfield Copyright © 2016 Divyanshoo R. Kohli et al. All rights reserved. Use of Aldosterone Antagonist to Treat Diarrhea and Hypokalemia of Ogilvie’s Syndrome Wed, 12 Oct 2016 06:30:58 +0000 Ogilvie’s syndrome (OS) is a functional obstruction of the bowel due to an autonomic imbalance. It often presents with diarrhea and is associated with hypokalemia. We present a case of a 70-year-old male who developed severe abdominal distension, watery diarrhea, and persistent hypokalemia status after left hip arthroplasty after suffering from a femoral neck fracture due to a fall and was diagnosed with OS. The persistent hypokalemia was slow to improve despite aggressive repletion because of the high potassium losses in the stool. This is most likely mediated through the increased expression of BK channels in the colonic mucosa. Aldosterone is theorized to have a role in the regulation of BK channels. Spironolactone was subsequently given and resulted in marked improvement of the diarrhea and hypokalemia. Thus, this case suggests a novel therapeutic approach for the treatment of Ogilvie’s syndrome-associated diarrhea and hypokalemia. Pradhum Ram, Abhinav Goyal, Marvin Lu, Joshua Sloan, and William McElhaugh Copyright © 2016 Pradhum Ram et al. All rights reserved. Seronegative Intestinal Villous Atrophy: A Diagnostic Challenge Mon, 10 Oct 2016 08:31:11 +0000 Celiac disease is the most important cause of intestinal villous atrophy. Seronegative intestinal villous atrophy, including those that are nonresponsive to a gluten-free diet, is a diagnostic challenge. In these cases, before establishing the diagnosis of seronegative celiac disease, alternative etiologies of atrophic enteropathy should be considered. Recently, a new clinical entity responsible for seronegative villous atrophy was described—olmesartan-induced sprue-like enteropathy. Herein, we report two uncommon cases of atrophic enteropathy in patients with arterial hypertension under olmesartan, who presented with severe chronic diarrhea and significant involuntary weight loss. Further investigation revealed intestinal villous atrophy and intraepithelial lymphocytosis. Celiac disease and other causes of villous atrophy were ruled out. Drug-induced enteropathy was suspected and clinical improvement and histologic recovery were verified after olmesartan withdrawal. These cases highlight the importance for clinicians to maintain a high index of suspicion for olmesartan as a precipitant of sprue-like enteropathy. Cláudio Martins, Cristina Teixeira, Suzane Ribeiro, Daniel Trabulo, Cláudia Cardoso, João Mangualde, Ricardo Freire, Ana Luísa Alves, Élia Gamito, Isabelle Cremers, and Ana Paula Oliveira Copyright © 2016 Cláudio Martins et al. All rights reserved. An Unusual Case of Gastrointestinal Bleeding from Isolated Gallbladder Varices in a Patient with Pancreatic Cancer Complicated by Portal Biliopathy Wed, 05 Oct 2016 13:06:41 +0000 Portal biliopathy is the complex of abnormalities of extrahepatic and intrahepatic bile ducts, cystic duct, and gallbladder, arising as a result of extrahepatic portal vein obstruction and noncirrhotic portal fibrosis, which can be caused by coagulopathies, tumors, inflammation, postoperative complications, dehydration, and neonatal umbilical vein catheterization. We report a case of a 55-year-old male patient with the history of pancreatic cancer and cholecystoenteric anastomosis presenting with gastrointestinal bleeding from gallbladder varices via the anastomosis. Mahir Gachabayov, Kubach Kubachev, Elbrus Abdullaev, Nonna Zarkua, Abakar Abdullaev, and Artur Fokin Copyright © 2016 Mahir Gachabayov et al. All rights reserved. Giant Inflammatory Fibroid Polyp of the Hepatic Flexure of Colon Presenting with an Acute Abdomen Mon, 03 Oct 2016 14:21:16 +0000 Background. Inflammatory Fibroid Polyp (IFP) of the colon is an exceedingly rare condition. Since 1952 till now only 32 cases have been reported worldwide of which only 5 were giant (>4 cm) polyps mostly found in the caecum (15 cases) with only 3 in the descending colon. Case Presentation. A 36-year-old female with no previous illness presented to the emergency unit with an acute onset pain over the right hypochondrium for 3 days associated with intermittent fever and anorexia. As she had evidence of localized peritonitis she underwent a diagnostic laparoscopy and subsequently an exploratory laparotomy. A mass measuring 8 × 7 × 5 cm arising from the hepatic flexure of colon was noted. Right hemicolectomy with ileotransverse anastomosis was performed. The mass was subsequently reported to be IFP. Conclusion. IFP is a very rare condition with clinical presentation depending upon its size and location. Definitive diagnosis is possible with histopathological examination of tissue aided by immunohistochemical studies. Surgical resection has been the most common method of treatment especially for large and giant colonic IFPs owing to challenges in terms of diagnosis and technical difficulties associated with endoscopic methods. Ashish Lal Shrestha and Pradita Shrestha Copyright © 2016 Ashish Lal Shrestha and Pradita Shrestha. All rights reserved. Barrett’s Oesophagus in an Achalasia Patient: Immunological Analysis and Comparison with a Group of Achalasia Patients Mon, 26 Sep 2016 12:40:02 +0000 The aim of the study was to characterize the presence of diverse CD4 and CD8 T cell subsets and regulatory cells in peripheral blood and lower oesophageal sphincter (LES) from a young patient with BE/achalasia without treatment versus achalasia group. In order to characterize the circulating cells in this patient, a cytometric analysis was performed. LES tissue was evaluated by double-immunostaining procedure. Five healthy blood donors, 5 type achalasia patients, and 5 oesophagus tissue samples (gastrooesophageal junction) from transplant donors were included as control groups. A conspicuous systemic inflammation was determined in BE/achalasia patient and achalasia versus healthy volunteer group. Nonetheless, a predominance of Th22, Th2, IFN-α-producing T cells, Tregs, Bregs, and pDCregs was observed in BE/achalasia patient versus achalasia group. A low percentage of Th1 subset in BE/achalasia versus achalasia group was determined. A noticeable increase in tissue of Th22, Th17, Th2, Tregs, Bregs, and pDCregs was observed in BE/achalasia versus achalasia group. Th1 subset was lower in the BE/achalasia patient versus achalasia group. This study suggests that inflammation is a possible factor in the pathogenesis of BE/achalasia. Further research needs to be performed to understand the specific cause of the correlation between BE and achalasia. Samuel Torres-Landa, Janette Furuzawa-Carballeda, Enrique Coss-Adame, Miguel A. Valdovinos, Edgar Alejandro-Medrano, Bárbara Ramos-Ávalos, Braulio Martínez-Benítez, and Gonzalo Torres-Villalobos Copyright © 2016 Samuel Torres-Landa et al. All rights reserved. Laparoscopic Resection of Pancreatic Tail Solid Pseudopapillary Tumour in a Young Male Sun, 25 Sep 2016 07:36:02 +0000 Background. Solid Pseudopapillary Tumours of the pancreas are a rare entity and more commonly seen in women than in men. These tumours have typically reached large sizes when clinically detected. Case Description. A 21-year-old male was found to have a left hypochondrial mass on physical examination following a trivial soft tissue injury. Contrast-enhanced computed topography (CT) of the abdomen showed a 10.3 × 7.6 × 10.3 cm size arising from the body and the tail of the pancreas. He underwent laparoscopic resection of distal pancreatic tumour en bloc with spleen. Large tumour was noted originating from the body and tail of the pancreas with dilated veins surrounding the tumour. Histology revealed a clear cell variant of solid pseudopapillary neoplasm with steatotic pattern. Resection margin was free of tumour. Discussion. Several studies have shown significant short term advantages using laparoscopic approach compared to open surgery, in terms of lower blood loss, resumption of oral intake, and hospital stay. This case and few other case reports published in world literature have shown that laparoscopic approach is safe and oncologically adequate. W. G. P. Kanchana, R. A. A. Shaminda, K. B. Galketiya, V. Pinto, D. Walisinghe, S. Wijetunge, and R. Heendeniya Copyright © 2016 W. G. P. Kanchana et al. All rights reserved. Magnifying Endoscopic Features of Follicular Lymphoma Involving the Stomach: A Report of Two Cases Thu, 22 Sep 2016 06:56:40 +0000 A 70-year-old woman presented with follicular lymphoma involving the stomach, duodenum, jejunum, bone, and lymph nodes. Esophagogastroduodenoscopy revealed multiple depressed lesions in the stomach. Examination with magnifying endoscopy showed branched abnormal vessels along with gastric pits, which were irregularly shaped but were preserved. The second case was a 45-year-old man diagnosed with stage II1 follicular lymphoma with duodenal, ileal, and colorectal involvement, as well as lymphadenopathy of the mesenteric lymph nodes. Esophagogastroduodenoscopy performed six years after the diagnosis revealed multiple erosions in the gastric body and angle. Magnifying endoscopic observation with narrow-band imaging showed that the gastric pits were only partially preserved and were destroyed in most of the stomach. Branched abnormal vessels were also seen. Pathological features were consistent with follicular lymphoma in both cases. The structural differences reported between the two cases appear to reflect distinct pathologies. Disappearance of gastric pits in the latter case seems to result from loss of epithelial cells, probably due to chronic inflammation. In both cases, branched abnormal vasculature was observed. These two cases suggest that magnified observations of abnormal branched microvasculature may facilitate endoscopic detection and recognition of the extent of gastric involvement in patients with follicular lymphoma. Masaya Iwamuro, Katsuyoshi Takata, Seiji Kawano, Nobuharu Fujii, Yoshiro Kawahara, Tadashi Yoshino, and Hiroyuki Okada Copyright © 2016 Masaya Iwamuro et al. All rights reserved. Pancreatic Neuroendocrine Tumor in the Setting of Dorsal Agenesis of the Pancreas Wed, 21 Sep 2016 12:18:29 +0000 Dorsal agenesis of the pancreas (DAP) is an uncommon embryological abnormality where there is absence of the distal pancreas. DAP is mostly asymptomatic, but common presenting symptoms include diabetes mellitus, abdominal pain, pancreatitis, enlarged pancreatic head, and, in a few cases, polysplenia. MRCP and ERCP are the gold standard imaging techniques to demonstrate the absence of the dorsal pancreatic duct. The literature on the association of pancreatic neoplasia and DAP is limited. We present the case of a pancreatic neuroendocrine tumor in a patient with dorsal agenesis of the pancreas, with a review of the related literature. Samih Nassif, Cecilia Ponchiardi, and Teviah Sachs Copyright © 2016 Samih Nassif et al. All rights reserved. An Atypical Presentation of Sporadic Jejunal Burkitt’s Lymphoma Thu, 08 Sep 2016 14:36:27 +0000 Burkitt’s lymphoma is a very aggressive type of B-cell NHL with replication approaching 100%. Primary gastrointestinal lymphoma is rare. In our case, a 24-year-old male initially presented with symptomatic anemia. He was initially evaluated with colonoscopy and EGD, both of which were unremarkable. A capsule endoscopy was then performed to further evaluate his significant anemia which revealed friable inflamed ulcerated mass in the jejunum. A push enteroscopy was then performed to obtain tissue from the jejunal mass. Biopsy results and immunohistochemical stains were consistent with Burkitt’s lymphoma. PET/CT scan revealed only jejunal involvement. Treatment consisted of bowel resection prior to chemotherapy due to concern for perforation with chemotherapy. Patient achieved complete remission after the treatment. Pratik Naik, James Wang, Michael J. Brazeau, and Domingo Rosario Copyright © 2016 Pratik Naik et al. All rights reserved. A Unique Case of Mycophenolate Induced Colitis after 10 Years of Use Wed, 07 Sep 2016 08:54:14 +0000 A 31-year-old female with a history of lupus nephritis on Hydroxychloroquine, Prednisone, and Mycophenolate Mofetil (MMF) for 10 years presented to the hospital for ankle swelling. On day four, she started to have severe, nonbloody, watery diarrhea with abdominal distension and tenderness. Stool PCR was negative for C. difficile. CT abdomen/pelvis showed gaseous distension of the colon without any obstruction. Flexible sigmoidoscopy revealed a normal looking mucosa. Histopathology showed crypt atrophy and increased crypt apoptosis, consistent with MMF colitis. The diarrhea resolved three days after stopping MMF. Although generally well tolerated, diarrhea is a common side effect of MMF. Most cases occur in the first six months of starting MMF. This case is unique because it describes MMF colitis in lupus after more than 10 years. Thus, MMF colitis should be considered as a differential in patients taking it, regardless of the duration of use. Abhinav Goyal, Moiz Salahuddin, and Yogesh Govil Copyright © 2016 Abhinav Goyal et al. 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.