Efficacy of topical clotrimazole vs. topical tolnaftate in the treatment of otomycosis. A randomized controlled clinical trial / Eficácia do clotrimazol tópico versus tolnaftato tópico no tratamento da otomicose: um ensaio clínico controlado randomizado

Abstract Introduction: Otomycosis, an infection of the ear canal by fungi, is prevalent in hot and humid weather. Nevertheless, there is not sufficient evidence for the effectiveness of different topical antifungal treatments. Tolnaftate, is a topical antifungal agent described to be effective in the treatment of otomycosis. Currently there are not sufficient studies that prove its efficacy. Objectives: To compare the efficacy of clotrimazole and tolnaftate administration in the treatment of otomycosis. Material and methods: A controlled, randomized and open clinical trial included patients diagnosed with fungal external otitis who were treated with topical antifungals, randomized into two treatment groups: (1) clotrimazole cream; (2) tolnaftate solution. They were microscopically evaluated at one and two weeks of treatment to determine resolution of disease. Recurrence and complications were recorded. Demographic and clinical variables were collected and analyzed. Follow-up and final outcomes (absence of infection) were compared between groups. Results: Forty eight patients were included, 28 in the clotrimazole group and 20 in the tolnaftate group. Spring was the weather most commonly associated with otomycosis, while otic manipulation was the risk factor more common in both groups. Predominant symptoms were itching and otic fullness. Aspergillus niger organism was isolated most frequently. Treatment with clotrimazole resulted in 75% resolution vs 45% resolution with treatment with tolnaftate at one week of treatment (p = 0.007). The Tolnaftate treatment group demonstrated higher recurrence rates and treatment failures, 20% and 15% respectively. Conclusions: Clotrimazole cream treatment is more effective than tolnaftate for uncomplicated otomycosis. More studies are needed to corroborate our results.

Resumo Introdução: Otomicose, uma infecção fúngica do canal auditivo externo, é prevalente em climas quentes e úmidos. No entanto, a literatura não apresenta evidências suficientes sobre os diferentes tratamentos antifúngicos tópicos. O tolnaftato é um antifúngico tópico descrito como eficaz no tratamento da otomicose; entretanto, sua eficácia não está suficientemente comprovada. Objetivo: Comparar a eficácia do uso de clotrimazol e tolnaftato no tratamento da otomicose. Material e método: Ensaio clínico controlado e randomizado; incluiu pacientes diagnosticados com otite externa fúngica tratados com antifúngicos tópicos, randomizados em dois grupos de tratamento: 1) clotrimazole (creme); 2) solução de tolnaftato. Eles foram avaliados microscopicamente uma e duas semanas após o início do tratamento para avaliar a resolução da doença. Recorrência e intercorrências foram registradas; além disso, as variáveis demográficas e clínicas foram coletadas e analisadas. Os dados do acompanhamento e desfechos finais (ausência de infecção) foram comparados entre os grupos. Resultados: O estudo incluiu 48 pacientes, 28 dos quais foram alocados ao grupo clotrimazole e 20 ao grupo tolnaftato. A primavera foi a estação mais comum; a manipulação foi o fator de risco mais comum em ambos os grupos. Os sintomas mais comuns foram coceira e plenitude auricular. Aspergillus niger foi o micro-organismo mais comumente isolado. Após uma semana, o tratamento com clotrimazol apresentou uma taxa de resolução de 75% vs. 45% com o tratamento com tolnaftato (p = 0,007). O tratamento com tolnaftato apresentou maiores taxas de recidiva e falhas: 20% e 15%, respectivamente. Conclusões: Em casos de otomicose não complicada, o uso de clotrimazol (creme) é mais eficaz do que o de tolnaftato. Mais estudos são necessários para corroborar os presentes resultados.

A Case of a Visual Field Defect with Optical Coherence Tomography Changes after Sildenafil Citrate Overdose

PURPOSE: A case of a transient visual field defect and a change in spectral-domain optical coherence tomography (SD-OCT) after an overdose of sildenafil citrate is described. CASE SUMMARY: A 67-year-old male with no previous medical history presented with a bluish tinge and visual field defect in both eyes. He had consumed eight tablets of sildenafil citrate (800 mg) 3 days before the visit. His best-corrected visual acuity was 14/20 in the right eye and 20/20 in the left eye. No specific finding was noted on slit-lamp examination. Fundus examination and fundus photography revealed focal foveal hypopigmentation in both eyes. He underwent SD-OCT imaging with the Cirrus HD-OCT (Carl Zeiss Meditec, Oberkochen, Germany), and thickening of the ellipsoid zone and choroid was revealed by SD-OCT scans. He was advised not to take any more sildenafil citrate and was followed for 1 week after the first visit. Central scotomas of both eyes were revealed by a visual field test, and thickening of the ellipsoid zone and choroid remained. His eyes were re-evaluated 1 and 3 months after the first visit, and although the symptoms nearly disappeared, abnormalities in the visual field test and on SD-OCT remained, albeit with some degree of improvement. He revisited us 4 months after the first visit, at which time the visual field test and SD-OCT scans showed results within normal ranges. CONCLUSIONS: Sildenafil citrate overdose can result in a color anomaly (bluish tinge), visual field defects, and thickening of the ellipsoid zone and choroid on SD-OCT scans.

A Case of Cement Hardening Agent Intoxication with Acute Kidney Injury

Chronic silica nephropathy has been associated with tubulointerstitial disease, immune-mediated multisystem disease, chronic kidney disease, and end-stage renal disease. On the other hand, acute intentional exposure is extremely rare. The authors' experienced a 44-year-old man who took rapid cement hardener (sodium silicate) in a suicide attempt whilst in a drunken state. He visited the emergency department approximately 1 hour after ingestion. Information on the material was obtained after 3 L gastric lavage. The patient complained of a sore throat, epigastric pain, and swollen to blood tinged vomitus. Proton pump inhibitors, hemostats, steroid, and fluids were administered. Nine hours after ingestion, he was administered 200 mL hematochezia. Immediately after, a gastroenterologist performed an endoscopic procedure that revealed diffuse hyperemic mucosa with a color change and variable sized ulceration in the esophagus, whole stomach, and duodenal 2(nd) portion. Approximately 35 hours later, persistent oligouria and progressive worsening of the renal function parameters (BUN/Cr from 12.2/1.2 to 67.5/6.6 mg/dL) occurred requiring hemodialysis. The patient underwent 8 sessions of hemodialysis for 1 month and the BUN/Cr level increased to 143.2/11.2 mg/dL and decreased to 7.6/1.5 mg/dL. He was discharged safely from the hospital. Follow up endoscopy revealed a severe esophageal stricture and he underwent endoscopic bougie dilatation. Acute cement hardener (sodium silicate) intoxication can cause renal failure and strong caustic mucosal injury. Therefore, it is important to consider early hemodialysis and treatment to prevent gastrointestinal injury and remote esophageal stricture.

Rhino-Orbito-Cerebral Mucormycosis Complicated as Facial Paralysis and Ophthalmoplegia without Rhinologic Manifestation / 대한이비인후과학회지

Rhinocerebral mucormycosis is a type of opportunistic infections, which can often be lethal in immunocompromised patients. The infection usually occurs in the nose and can spread to adjacent structures. The most typical symptom is facial pain, followed by headache, fever and bloody tinged rhinorrhea. We experienced three cases of rhino-orbito-cerebral mucormycosis, which showed atypical initial presentations. In our cases, patients visited hospital for unilateral ophthlamoplegia and facial palsy without having any nasal symptoms. After evaluating neurologic and ophthalmic problems, they were referred to the Otolaryngology Head and Neck Surgery Department for confirming nasal invasions. Despite using early a parenteral antifungal agent with immediate surgical debridement, patients died due to a residual cerebral lesions and multiple organ failure. In this article, we present the prognosis and management of rhinocerebral mucormycosis patients with atypical symptoms, as well as a review of the published literatures.

The Role of Transnasal Esophagoscopy in ENT Office: A Prospective, Multicenter Study in Korea

OBJECTIVES: The purpose of study was to report the current role of transnasal esophagoscopy (TNE) in Korea. METHODS: One hundred thirty-seven patients who underwent TNE at Soonchunhyang University Bucheon Hospital (n=69) and Korea University Anam Hospital (n=68) from July 2007 to February 2009 were prospectively analyzed. Laryngopharyngeal reflux disease (LPRD) patients without any response to proton-pump inhibitor (n=102), and patients with complaints that require esophagoscopy as part of their evaluation (n=35) were included in this study; investigation of metachronous lesions or routine follow-up screening of head and neck cancer patients, n=17; dysphagia, n=9; blood tinged saliva, n=4; to determine the cause of vocal fold paralysis as screening tool, n=4; suspicious esophageal foreign body, n=1. RESULTS: Fifty-three patients (38.7%) had positive findings on TNE. Positive finding ratio was highest in group of dysphagia (7 among 9 patients, 78%). Forty-two patients (41.1%) were found to have pathology (esophagitis, n=41; esophageal diverticulum, n=1) during the screening examination for LPRD. There were no significant complications in any of the patients. CONCLUSION: TNE is a high-yield diagnostic and therapeutic modality available to otolaryngologists for use on awake patients in the office setting.

Successful Sirolimus Treatment of Kaposi's Sarcoma in Multiple Pulmonary Nodules after Kidney Transplantation / 대한이식학회지

Kaposi's sarcoma is one of the most serious complications associated with immune suppression treatment after kidney transplantation. Because it usually manifestations as skin lesions or lymphadenopathies, its clinical suspicion and tissue diagnosis is relatively easy. However, Kaposi's sarcoma presented as multiple pulmonary nodules without skin manifestations is not easily detected early and usually has a deadly prognosis. We present the case of a 36-year-old male who underwent kidney transplantation 13 months ago and has been on tacrolimus and mycophenolate mofetil (MMF)-based immune suppression presented dry cough, blood tinged sputum, and multiple pulmonary nodules without any skin lesions. Both bronchoscopic washing cytology and fine needle aspiration cytology of peripheral lung tissues were performed but failed due to low cellular yields. A video-assisted thoracoscopic biopsy subsequently revealed Kaposi's sarcoma. Following the diagnosis, we changed the immune suppression from a tacrolimus and MMF-based regimen to a sirolimus-based regimen. Respiratory symptoms gradually disappeared and we found complete remission on follow-up radiologic evaluations. Thus sirolimus may be the preferred method of treatment for patients with immune suppression after kidney transplantation.

Pulmonary Carcinoma with beta-Human Chorionic Gonadotropin Expression: Further Understanding and Suggestions for This Entity from Six Cases Experience in a Single Institution

PURPOSE: beta-human chorionic gonadotropin (beta-hCG) expressing pulmonary carcinoma is very rare, and little is known about this entity. The aim of this study was to find the characteristic clinicopathologic features of beta-hCG expressing pulmonary carcinoma. MATERIALS AND METHODS: Of all 2790 lobectomy specimens of lung excised between January 2006 and December 2010, only six cases of beta-hCG expressing pulmonary carcinoma were identified retrospectively. The cases were classified according to the WHO classification, and clinicopathologic features were investigated. RESULTS: The patients consisted of 4 males and 2 females, and the median age was 64 years. Half of the patients presented with blood tinged sputum or hemoptysis. The median tumor diameter was 4.2 cm. All but one case showed prominent area of hemorrhage and necrosis. All six cases were pleomorphic carcinoma, composed of various types of non-small cell carcinomatous component and giant cell component. All cases showed significant area of beta-hCG positivity, and beta-hCG was usually expressed in the pleomorphic giant cells. CONCLUSION: In pulmonary carcinoma with pleomorphic giant cells, is necessary to check immunohistochemical stain for beta-hCG and to follow up the serum beta-hCG levels, to further establish the concept of beta-hCG expressing pulmonary carcinoma.

Feeding Introlerance Due to Allergic Enterocolitis in Very Low Birth Weight Infants

PURPOSE: Feeding intolerance is common in very low birth weight infants(VLBWI); however, research on the etiology is limited. We investigated the incidence of allergic enterocolitis (AEC) as a cause of feeding intolerance and present the clinical characteristics of VLBWIs. METHODS: The medical records of VLBWIs admitted to the neonatal intensive care unit of Samsung Medical Center between January 2009 and July 2010 were retrospectively analyzed. AEC was defined as patients who had feeding intolerance with eosinophila and who responded to hypoallergenic feeding intervention. Feeding intolerance symptoms included blood tinged stools, abdominal distension, residual feeding and regurgitation. Eosinophilia was defined as an eosinophil count > or =700 cells/mm3. Patients with feeding intolerance were divided into the AEC or non-AEC group. RESULTS: Of the 181 patients, 161 (88.9%) had a feeding intolerance, and 119 (65.7%) had eosinophilia. Seventeen infants were diagnosed with AEC. No difference in mean gestational age, birth weight, antibiotics duration, TPN duration, hospitalization, or symptom onset day was observed between patients with AEC and non-AEC patients. The percentage of eosinophilia was significantly higher in patients with AEC than in non-AEC patients. Two patients (12%) improved with restricted breast milk, 10 patients (59%) with extensively hydrolyzed formula and five patients (29%) with free amino acid-based formula. CONCLUSION: Our results suggest that AEC should be considered in VLBWIs who have clinical features of feeding intolerance and eosinophilia. An aggressive increase in feeding would be possible through feeding intervention in VLBWIs with feeding intolerance.

A Case of Novel Influenza A (H1N1) Virus Pneumonia Complicated Pnemomediastinum and Subcutenous Emphysema / 결핵및호흡기질환

Recently, a novel influenza A (H1N1) has been recognized as the cause of a worldwide respiratory infection outbreak. Although the symptoms of a novel influenza A (H1N1) are usually mild, the disease can cause severe illness and death. A complication of novel influenza A (H1N1) is pneumomediastinum, a rarely reported condition. We report a case of influenza A (H1N1) complicating pneumomediastinum with subcutaneous emphysema, which had initially presented with blood tinged sputum and chest pain. In addition, we demonstrate bronchoalveolar lavage in influenza A (H1N1).

Pulmonary Cryptococcosis Presenting Solitary Pulmonary Nodule in an Immunocompetence: A Case Report and Review of the Korean Literatures

In immunocompetent individuals, pulmonary cryptococcosis is a rarely diagnosed fungal infection. It's common radiological findings are multiple pulmonary nodules. We report a case of pulmonary cryptococcosis in a 67-year-old woman who presented with solitary pulmonary nodule (SPN) on chest computed tomography (CT). She complained of intermittent blood tinged sputum for 10 days. She was a non-smoker and had no clinical evidence of immonosuppression. Pathological examination of the lung tissue core via percutaneous fine needle biopsy revealed chronic granulomatous inflammation compatible with cryptococcosis on the special stain. She received 6 months of antifungal therapy with fluconazole and the SPN was disappeared on the CT after antifungal therapy. We also reviewed that the features of pulmonary cryptococcosis presenting SPN in immnocompetent patients reported in the Korean literatures.

A Case of Pulmonary Alveolar Proteinosis / 영남의대학술지

Pulmonary alveolar proteinosis (PAP) is a rare disorder that's characterized by accumulation of surfactant components in the alveolar space. Idiopathic PAP is recognized as an autoimmune disease that's due to impaired alveolar macrophage function and this caused by autoantibodies against granulocyte-macrophage colony-stimulating factor (GM-CSF). We report here a case of pulmonary alveolar proteinosis that was deemed interstitial lung disease at the initial diagnosis. A 61-year-old man presented with intermittent blood tinged sputum and dyspnea on exertion. The man was a painter for 30 years and he had a 10 pack-years smoking history. Chest computerized tomography (CT) revealed multifocal ground-glass opacity with interstitial thickening at both lungs. His pulmonary function tests and methacholine test revealed non specific results. He was diagnosed with interstitial lung disease on the basis of the chest CT finding and occupational history. However, seven months later, his symptoms progressed. Follow-up chest CT was performed. Wedge resection via video-assisted thoracoscopic surgery (the anterior basal segment of the left lower lobe) was done. Microscopic examination showed large groups of alveoli with excessive amounts of surfactant and a complex mixture of protein and lipid (fat) molecules. Finally, he was diagnosed as having pulmonary alveolar proteinosis.

Living Donor Liver Transplantation (LDLT) using Monosegment Graft for a Small Infant / 대한이식학회지

A 1.5-month-old girl, weighing 4.7 Kg, presented with vomiting, blood tinged stool and jaundice. We performed living donor liver transplantation(LDLT) for the management of fulminant hepatic failure with worsening encephalopathy. The donor was her father, 30 years old, weighing 51 kg. During the pre-operative donor evaluation, a computed tomography volumetry was 170 mL for left lateral section of the liver, which was 3.61% of the graft-recipient weight ratio(GRWR). In donor operation, the reduction of the left lateral section was made just after parenchyma resection of left lateral section was completed, and before clamping of the vessels. The segment II was resected from the left lateral section in situ. The transection plane between segment II and III was identified with the use of intraoperative ultrasonography and clamping of Glisson of segment II. The segment III graft weighed 135 g, which was 2.87 % GRWR. The operation time was 6 hours 15 minutes and transfusion was not needed. Recipient operation was performed in conventional manner of pediatric LDLT using left lateral section with primary closure of abdominal wall without tension. The operation time was 7 hours 35 minutes and cold ischemic time was 1 hour 33 minutes. She recovered well without any significant complications. She discharged on the post operative 24th day. Total bilirubin, aspartic acid transaminase and alanine aminotransferase was 0.6 mg/dL, 26 IU/L and 37 IU/L respectively at the point of discharge. LDLT with monosegment seems to be a feasible option for neonates and small infants requiring liver transplantation.

A Case of Perilla Allergy in a 2-Year-old Boy / 소아알레르기및호흡기학회지

Even though perilla is one of the most commonly consumed grain in Asia including Korea, perilla allergy is rare. A 2 year-old boy had erythematous popular urticaria on his whole body, as well as vomiting and diarrhea after ingestion of boiled perilla. On the second day of admission, old blood clots in the vomitus and blood tinged stool were shown. He underwent an esophago gastro duodenoscopy which showed a large duonenal ulcer. After treatment, his general condition improved. We report a case of perilla allergy with brief review of related literature.

A Case of Isolated Congenital Absence of Right Pulmonary Artery / 결핵및호흡기질환

Unilateral absence of the pulmonary artery (UAPA) is a rare congenital anomaly that occurs in association with other cardiovascular anomalies, such as tetralogy of Fallot or ventricular septal defects. On the other hand, it is less commonly found as an isolated finding without accompanying diseases. Isolated UAPA is a rare cause of hemoptysis, and massive hemoptysis has been reported to occur in approximately 18~20% of UAPA patients during their clinical course. Even if a lung resection is considered a treatment option to control life-threatening hemoptysis, the procedure is more difficult than an ordinary lung resection because of the excessive collateral vessels from the systemic circulation. We encountered an isolated UAPA occurring in a young male patient suffering from intermittent blood tinged sputum. To our knowledge, only a few cases of isolated UAPA have been reported in Korea. This case is expected to be a good example to help clinicians better understand isolated UAPA as an unusual cause of hemoptysis.

Effects of Eating Behaviors on Health-related Parameters in the Elderly Living in Seongnam City(Korean Longitudinal Study on Health and Aging study)

BACKGROUND: With global trends in population aging, healthy aging has become a most important matter. Thus, many researchers are developing and implementing healthy aging methods to promote quality of life in the elderly. METHODS: This cross-sectional study was designed to assess health-related factors associated with nutritio- nal risks in the older population. 880 subjects(411males, 469females) living in Seongnam City, all over 65 yrs, were interviewed about their eating behaviors by well-trained nurses. Tests included anthropometric measurements, biochemistry, and visceral and subcutaneous fat measurements from abdominal CT scans. RESULTS: Mean BMI was 23.7+/-3.2kg/m2 in men and 24.2+/-3.4kg/m2 in women. The prevalence of diabetes mellitus and hypertension was 36.0% and 67.6%, respectively, for males and 31.3% and 72.7%, respectively, for females. Seen in this study, several aspects of human eating behavior may be relevant in identifying effective measures to prevent or treat metabolic risks. Increased subcutaneous fat was associated with overea- ting and irregular meals. Increased visceral fat was associated with overeating and having hurried meals (less than 20 minutes). BMI was influenced by frequent eating out, rapid food ingestion, and favoring spicy foods. CONCLUSION: Factors such as food choice and eating behavior affect the risk of obesity and cardiovascular accidents. Clinicians should recognize the importance between nutrition and health in the elderly. Our data suggest that good eating behavior reduces metabolic risks in the older population.

Right Pulmonary Artery Agenesis: A case report / 대한흉부외과학회지

Unilateral pulmonary artery agenesis is a rare congenital malformation usually associated with other cardiovascular anomaly such as Tetralogy of Fallot. Isolated pulmonary artery agenesis is very rare, and usually asymptomatic. It is usually highly suspected by routine chest X-ray, and associated symptoms are hemoptysis, blood tinged sputum, repeated pulmonary infection, and dyspnea on exertion. We have recently experienced the right pulmonary artery agenesis in 27 year-old male patient, complaining of minimal hemoptysis and sustained blood tinged sputum. He was successfully treated by right pneumonectomy, so we report this case with the review of associated literature.

Iliopsoas Bursitis following Total Hip Replacement Arthroplasty: A Case Report / 대한정형외과학회잡지

PURPOSE: To report the clinical, radiological and surgical findings of iliopsoas bursitis, and to suggest an indication for diagnosis and treatment. MATERIALS AND METHODS: We report two patients with iliopsoas bursitis who underwent THA in between June 1998 to June 2003. All presented with late onset hip joint discomfort, and their diagnosis were confirmed after interdepartmental consultations and with the help of investigations such as interventional angiography and MRI. Their signs, symptoms, investigations and surgical findings were reviewed retrospectively. RESULTS: Iliopsoas bursitis presented with hip pain, leg edema, palpable inguinal mass and ecchymosis, femoral nerve irritation and flexion contracture of hip. The radiographs provided no diagnostic clues but the MRI revealed a well marginated cystic lesion filled with fluid signals. Ultrasonography revealed the anatomic location that enabled guided aspiration and even ruled out vascular compromise. Two patients were treated with USG guided aspiration. One aspirate was serosanguinous and the other was old blood tinged fluid. One patient underwent surgical debridement of the cyst. Surgery revealed an intrapelvic hemorrhagic bursa with an ill-defined cystic wall and intramuscular extension into the iliacus. CONCLUSION: It is important for surgeons to rule out iliopsoas bursitis when a patient presents with vague hip pain after total hip arthroplasty without any evidence of infection or loosening. A diagnosis of iliopsoas bursitis can be made from the clinical features and ultrasonography.

Delayed Detection of a Penetrating Tracheal Foreign Body / 대한흉부외과학회지

The finding of a tracheal penetrating injury that's caused by a foreign body is rare in adulthood. A 42-year-old man had experienced penetrating trauma due to a glass fragment 10 years ago. He presented with blood tinged sputum and dyspnea on exertion, and this had developed 1 year previously. Chest CT scan and bronchoscopy revealed a foreign body crossing the tracheal lumen and the object arose from outside of the trachea; this was all associated with airway edema. We removed the foreign body, which was a 5cm length of glass fragment, and we repaired the tracheal defect using a simple primary suture. The postoperative course of the patient was uneventful and he is now being followed up at the outpatient department; he has had no additional symptoms.

A Case of Lung Cancer Obscured by Endobronchial Aspergilloma / 결핵및호흡기질환

A 70-year-old man was referred to the department of pulmonology due to blood tinged sputum and an abnormal chest X-ray. The chest X-ray and CT scans revealed a lobulated contour mass-like lesion in the left upper lung field. The bronchoscopic examination showed a whitish and polypoid mass occluding the left upper lobe bronchus. A biopsy specimen from the lesion revealed many aspergillus hyphae. Intravenous and oral itraconozole were administered over a 4 weeks period. Several months later, the size of the mass on chest X-ray increased and a percutaneous lung biopsy revealed a sarcomatoid carcinoma. We reported a case of lung cancer that was obscured by an endobronchial aspergilloma with a review of the relevant literature.

Basaloid Squamous Cell Carcinoma of the Rectum Manifesting as Multiple Submucosal Lesions / 대한소화기내시경학회지

Basaloid squamous carcinoma is a rare, pooly differentiated variant of squamous cell carcinoma. It occurs in various sites, including the upper digestive tract, the esophagus, lung, anus, cervix and thymus. It has been postulated that basaloid carcinoma may arise from outside of the anal canal, such as at where the cloacogenic embryologic cells rest, the squamous metaplastic epithelium, or the totipotential basal cells. This tumor is a distinct entity that should be carefully distinguished from basal cell carcinomas of the anal canal, which is a condition that has a very good prognosis, and anal or perianal squamous cell carcinomas, which have a different path of spread and they vary considerably in their behavior. We report here on a patient with basaloid squamous carcinoma in the distal rectum that manifested as multiple submucosal lesions, and the patient presented with abdominal pain and blood tinged stool.