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Introduction: Dieulafoy lesion (DL) is a relatively rare and arguably under-recognized condition, accounting for 1-2% of acute GI bleeding. Most bleeding DLs occur in the stomach, followed by the small intestine, with less than 1% occurring in the jejunum. Bleeding DL on a jejunal diverticulum is even more rare, with a handful cases described in the literature. Here we present a rare case of a bleeding DL in a jejunal diverticulum with its endoscopic management. Case Description/Methods: A 65-year-old female with history of COVID-19 infection one month prior to presentation treated with steroids and therapeutic anticoagulation presented to the ED after having multiple episodes of coffee-ground emesis and two episodes of syncope at home. Last dose of Apixaban was 12 hours prior to admission. Physical exam revealed BP of 90/60 on Norepinephrine infusion, HR of 96, abdominal exam was soft and nontender, DRE revealed melena. Hemoglobin/hematocrit was significantly decreased at 3.6/12.8. Patient was appropriately resuscitated with blood products and fluids, and she was scheduled for an EGD. Initial EGD did not identify a clear source of her bleeding, and she was scheduled for colonoscopy. Colonoscopy with deep cannulation of the terminal ileum up to 40cm revealed significant amounts of fresh blood all throughout the colon and terminal ileum. Decision was made for push enteroscopy, which revealed a jejunal diverticulum containing a Dieulafoy lesion with an overlying clot (Image A). The lesion was first injected with epinephrine at 2 sites followed by a clot removal overlying the lesion using 13-0 circular snare. A clear stigma of recent bleeding was noticed from the lesion after clot removal (Image B), after which 2 metallic clips were placed over the lesion to achieve hemostasis (Image C). The patient had no further episodes of bleeding and was follow up in clinic eventually, recovering well. Discussion(s): Because of the life-threatening nature of Dieulafoy lesions, identification is of paramount importance for treatment purposes. Jejunal DLs are a rare entity but should be considered in cases with negative bidirectional endoscopies. In our case, push enteroscopy helped identify the bleeding lesion. DL in a diverticulum can pose a challenge to the endoscopist due to difficulty of access to the lesion. Epinephrine injection followed by mechanical clipping showed a positive outcome in our case which can be considered while approaching bleeding DLs in a diverticulum. (Figure Presented).
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Introduction: Endoscopic submucosal dissection (ESD) is a minimally invasive technique used for removal of superficial dysplastic or early cancerous colon and rectal lesions. For larger lesions ( .20mm) that are not amenable to endoscopic mucosal resection, superficial biopsies are typically taken prior to referral for ESD. The aim of this study was to evaluate the degree of concordance between superficial forceps biopsies and ESD pathology. Method(s): A retrospective medical record review was performed including consecutive patients who underwent ESD of colon and rectal lesions at a tertiary care center between 10/2018 and 11/2021. Pathology results from outside hospital and same institution pre-ESD superficial forceps biopsies were compared to ESD pathology results. The primary outcome was the number of patients found to have higher disease severity on ESD pathology compared with superficial forceps biopsies. Result(s): Of the 84 patients who underwent ESD of colon or rectal lesions, 72 had pre-ESD superficial forceps biopsies which were taken at an outside hospital (n=48) or at the same institution (n=36). The average length of time between outside hospital superficial forceps biopsies and ESD was 91 days compared to 75 days for those performed at the same institution. Delays between superficial forceps biopsies and ESD may be related to the COVID-19 pandemic prolonging time between procedures. Pathology findings after ESD differed from superficial forceps biopsies in 31/72 patients (43%) with 21 patients receiving upgraded disease severity and 6 patients receiving a new cancer diagnosis based on ESD pathology. Patients who received a new cancer diagnosis had more days between superficial forceps biopsies and ESD compared with the whole cohort (86 vs 75, respectively). Conclusion(s): While superficial forceps biopsies of colon and rectal lesions were typically concordant with ESD pathology, 29% of patients in this cohort received upgraded disease severity based on ESD pathology. This shows that while superficial forceps biopsies can aid in diagnosis, en bloc resection via ESD remains critical for accurate diagnosis of large colon and rectal lesions. These results also show that ESD is not only diagnostic but therapeutic given 75% of the patients in this cohort achieved R0 resection.
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Introduction: IgM Multiple Myeloma (MM) is a rare subtype of MM consisting of <1% cases of MM. It is distinguished from Waldenstrom Macroglobinemia, which also produces IgM, by the absence of somatic mutation MYD88. We present a patient with a chief complaint of diarrhea which unknowingly led to his hematological diagnosis Case Description/Methods: A 64 year old male with RA-SLE overlap syndrome on steroids, and recent COVID19 pneumonia, had presented with 5 episodes of watery diarrhea every day and 40 Ib weight loss within 2 months. CT revealed small bowel enteritis and stool studies, including C. diff, cultures, ova and parasites were negative. Diarrhea persisted despite antibiotics, therefore an EGD and Colonoscopy were performed which showed duodenal lymphangiectasia and a normal colon. Duodenal biopsy revealed eosinophilic deposits in the villous lamina propria which stained for IgM and stained negative under congo red ruling out amyloidosis. SPEP and a bone marrow biopsy revealed monoclonal IgMspikes and plasma cells in the bone marrow suggesting MMalong with a co-existing population of CLL. Next-generation sequencing was negative forMYD88, supporting IgM MM instead of Waldenstrom. He developed a protein-losing enteropathy with dramatic hypoalbuminemia (albumin 0.9) and lower extremity edema and DVTs. He was started on chemotherapy and frequent albumin infusions. His diarrhea completely resolved, however not in time, as his other medical comorbidities lagged behind and he developed anasarca and continued to deteriorate. Discussion(s): Plasma cell dyscrasias such as IgM MM or more commonly Waldenstrom have rarely been reported to cause GI symptoms. GI involvement can include direct GI infiltration of plasma cells, IgM deposition, or the finding of a plasmacytoma. It has been speculated that IgM deposits can lead to interstitial viscosity and obstructive lymphangiectasia leading to diarrhea and a protein-losing enteropathy as in our patient. Protein loss has led him to have hypoalbuminemia and possibly loss of antithrombotic proteins that have caused DVTs. Few case reports have suggested that treating the underlying cause with chemotherapy stops diarrhea entirely. Although our patient's diarrhea ceased, we believe that it was not in time for him to entirely recover from the later complications of the disease. We hope that this case can help clinicians to attempt prompt treatment of patients when they find GI specimens showing IgM deposits and they suspect a plasma cell dyscrasia.
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Introduction: Biliary fistulas are a rare complication of gallstones. Fistula formation can occur in a number of adjacent sites;even more rare complication is the formation of a cholecystocolonic fistula. Case Description/Methods: A 74-year-old man who had recently undergone an extensive hospitalization secondary to inflammatory demyelinating polyneuropathy (IDP) and COVID-19 infection. During his hospitalization, he required ICU admission and mechanical ventilation with subsequent PEG tube placement. He was discharged to an inpatient rehabilitation facility when he developed worsening respiratory distress. Laboratory examinations were pertinent for ALT of 252, AST of 140 and ALP of 401 without hyperbilirubinemia. Blood cultures revealed Escherichia coli bacteremia. Given transaminitis and bacteremia, an MRCP was performed which demonstrated evidence absent space between gallbladder and hepatic flexure of the colon suggesting a CCF (Figure A). An ERCP with sphincterotomy was performed which showed extravasation of contrast from the gallbladder into the colon at the hepatic flexure (Figure B). He underwent cholecystectomy and fistula repair without any complications and gradual improvement in liver function test. He was discharged to a rehabilitation facility. Discussion(s): Complications of gallstones are well established, which include the common bile duct obstruction, but also include the rare occurrences of acute cholangitis, malignancy, and fistula formation. CCF is a rare complication of gallstones which can occur in the stomach, duodenum, or colon with a variable clinical presentation. Complications from an undiagnosed fistula can be life threatening including colon perforation and fecal peritonitis. This case highlights the diagnostic challenge and the high degree of clinical suspicion involved in establishing the diagnosis of CCF in patient without abdominal symptoms suggestive of gallbladder disease. We hypothesize that stone formation resulting in the development of the fistula may be secondary to the underlying history of IDP and subsequent immobility. Although rare, CCF should be considered in patients presenting with unexplained pneumobilia and bacteremia. A timely diagnosis should be made to proceed with immediate treatment including cholecystectomy and fistula closure to prevent fatal complications.
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Introduction: Mucosa-associated lymphoid tissue (MALT) lymphomas are extra-nodal marginal zone B-cell lymphomas, most commonly found in the stomach, associated with Helicobacter pylori infections, and generally not linked with inflammatory bowel disease. Rectal MALT lymphoma is very uncommon and often associated with painful defecation, change in bowel habits, or rectal pressure/prolapse. Here, we present a rare case of an asymptomatic female with ulcerative colitis (UC) found to have benign-appearing rectal polyps during a routine screening colonoscopy. Case Description/Methods: The patient is a 56-year-old female with a history of left-sided UC, diagnosed in 1993, with one flare after receiving the 2nd dose of the Moderna COVID-19 vaccine, taking oral Olsalazine 500 mg twice daily, low-dose Prednisone, and mesalamine suppositories as needed presenting for screening colonoscopy. The patient was asymptomatic, citing regular non-bloody bowel movements and normal stool consistency. Colonoscopy revealed two 7 mm sessile, non-bleeding rectal polyps, surrounded by congested, erythematous, friable, and ulcerated mucosa in the rectosigmoid colon. Cold forceps biopsies were taken. Hematopathology evaluation of the routine colon biopsy samples revealed chronic nonspecific colitis while pathology of the rectal polyps showed marked lymphoplasmacytic infiltrate and extra-nodal marginal zone lymphoma of MALT. Ancillary studies, immunohistochemistry, and molecular studies for B-cell gene rearrangement confirmed extra-nodal marginal zone lymphoma of MALT with prominent plasmacytic differentiation. The patient was informed and close follow-up in Gastroenterology clinic was arranged. (Figure) Discussion: Rectal MALT lymphoma is rare with unclear management options. Treatments of UC include watchful waiting, surgical resection, endoscopic mucosal resection, radiation, and/or chemotherapy. Helicobacter pylori infections, though strongly linked with gastric MALT lymphoma, have not been shown to be strongly correlated with rectal MALT lymphoma. Given that patients with UC have chronic UCassociated colonic inflammation, lymphoma is often difficult to distinguish visually during colonoscopy, frequently masked by ulcerations and pseudo-polyps. In cases like these, more definitive treatments such as surgical resection could therefore be warranted. Long-term follow-up data is sparse and definitive management remains a clinical conundrum, thus these patients require reliable long-term multidisciplinary close follow-up. (Figure Presented).
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The review is dedicated the interconnection between neurodegenerative diseases, chronic pain and gut microbiota's structure and function. The gut microbiota's role in gut-brain axis, neuroimmune interaction is considered. The modern data about gut dysbiosis in Alzheimer disease, Parkinson disease, osteoarthrosis, neuropathic pain in COVID infection, muscular-skeletal pain in fibromyalgia, irritable bowel syndrome et cetera are provided. The gut microbiota's modification by means of pre and probiotics in combination with medicines and diet modification can be used for the treatment of chronic pain and dementia.Copyright © T.M. MANEVICH.
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Introduction: Lactulose is a non-absorbable disaccharide which acts in the large bowel, and is commonly used in the treatment of hepatic encephalopathy. We present an interesting case of altered mental status due to hepatic encephalopathy successfully managed with lactulose in a patient with history of total colectomy. Case Description/Methods: A 67-year-old male with non-alcoholic cirrhosis and inflammatory bowel disease (IBD) post total proctocolectomy with a continent ileostomy known as a Kock-pouch (K-pouch) presented to the hospital with flu like symptoms and altered mental status. He was subsequently found to be positive for COVID-19. At the time of initial evaluation, the patient was obtunded with an elevated ammonia level of 91 umol/L. Colorectal surgery was consulted as the patient was not able to empty his K-pouch. Recently, he complained of inability to catheterize and with bleeding from the stoma. Initial catheterization with a Water's tube yielded 400 cc of effluent. Nasogastric tube was placed through which he was receiving lactulose 30 mg q8 hours. The patient's mental status improved within 24 hours. The patient ultimately underwent flexible pouchoscopy with endoscopic dilation and placement of a 22 French mushroom catheter for decompression of the K-pouch. Discussion(s): Lactulose is a non-absorbable disaccharide composed of galactose and fructose. The small intestine does not have the enzymes required to breakdown lactulose so it reaches the large bowel in its original form. In the large bowel, it is metabolized by colonic bacteria into monosaccharides and then to volatile fatty acids, hydrogen and methane. Lactulose decreases both the production and absorption of ammonia mainly through the presence of gut bacteria. The question arises as to how lactulose decreased ammonia levels in this patient without a large bowel. One proposed mechanism is the translocation of bacteria normally found in the large bowel to the small intestine. Small Intestinal Bacterial Overgrowth (SIBO), is a condition causing an increased number of bacteria in the small intestine. Patients with IBD and structural abnormalities are at increased risk of developing SIBO. Lactulose is commonly used in the diagnosis through the administration of lactulose and subsequent measurements of hydrogen and methane gas in expired air. This condition, in our patient with history of ulcerative colitis and colectomy, is a proposed mechanism of the efficacy of lactulose in the treatment of hepatic encephalopathy.
ABSTRACT
Introduction: In a subset of Covid19-convalescent patients, a multitude of long-term sequelae are increasingly being reported. We report 4 cases with varying neuro-GI and motility manifestations after recent COVID-19 infection. Case Description/Methods: Case 1: A 23-year-old man contracted COVID-19 and had a protracted course of respiratory illness. Despite resolution of respiratory symptoms and dysgeusia, he continued to experience early satiety, postprandial nausea, vomiting and unintentional weight loss. Gastric Emptying Scan (GES) revealed gastroparesis (Figure A). Dietary modification and metoclopramide led to symptomatic improvement. Case 2: A 39-year-old woman with migraines, suffered from Covid-19 infection where anosmia and respiratory symptoms lasted for 2 weeks. Despite resolution of initial symptoms, she started experiencing nausea and vomiting, and reported stereotypical symptoms with complete absence of vomiting between episodes. Endoscopic examination, CT head and GES were normal. Urine tox screen was negative for cannabinoids. She responded favorably to amitriptyline and ondansetron. Case 3: A 47-year-old man started experiencing severe constipation associated with abdominal pain and bloating soon after being diagnosed with COVID-19. Three months after resolution of respiratory symptoms, in addition to constipation, he began reporting postprandial fullness, early satiation and epigastric pain. GES showed gastroparesis ( figure B) and a Sitzmarks Study revealed delayed colonic transit (Figure C). Prucalopride was started, leading to improvement in symptoms. Case 4: A 74-year-old woman with obesity and diabetes, was hospitalized and intubated for severe respiratory distress due to COVID-19. After discharge, she had persistent symptoms of brain fog, fatigue, dyspnea as well as diarrhea and abdominal cramping, persisting despite loperamide and dicyclomine. C. difficile toxin, random colonic biopsies and H2 breath test were unremarkable. Her symptoms eventually improved with rifaximin. Discussion(s): We report 4 cases with post-COVID gastroparesis, cyclical vomiting syndrome, pan-gut dysmotility, and post-infectious IBS phenotypes.The pathophysiology of post-infectious-gut-brain disorders is still obscure. The current conceptual framework implicates acquired neuropathy, altered motility, intestinal barrier disruption and persistent intestinal inflammation. Similar pathophysiology may be involved in COVID-19 infection leading to sustained neurogastroenterological dysfunction and gut dysmotility.