Safety and Efficacy of Powered Non-Thermal Endoscopic Resection Device for Removal of Colonic Polyps: A Systematic Review and Meta-Analysis.

Background: Endoscopic mucosal resection is a frequently employed method for removing colonic polyps. Nonetheless, the recurrence of these polyps over a healed submucosal base can complicate the extraction of leftover lesions through standard procedures. EndoRotor®, a non-thermal device specifically designed for endoscopic mucosal resection, has recently been assessed for its utility in removing colonic polyps, non-dysplastic Barrett's esophagus, and pancreatic necrosis. We conducted a systematic review and meta-analysis to ascertain the safety and efficacy of EndoRotor® in resecting scared or recurrence colonic polyps. Methods: We conducted an exhaustive review of existing literature using databases such as Medline, Embase, Web of Science, and the Cochrane Library until January 2023. Our aim was to find all studies that assessed the safety of non-thermal endoscopic resection devices in removing colonic polyps. The primary outcome we focused on was the rate of technical success. Secondary outcomes that we considered included the frequency of remaining lesions and instances of adverse events. To analyze these data, we used comprehensive meta-analysis software. Results: Our analysis incorporated three studies comprising 54 patients who underwent resection of 60 lesions. The combined technical success rate was 93.9% (95% confidence interval (CI): 77.7-98.6%, I2 = 25.5%). In patients who had another endoscopic examination, 20 were found to have a residual lesion. After the initial session, the combined rate of remaining lesions was 39.8% (95% CI: 15.3-70.8%, I2 = 74.5%). There were eight occurrences of intraoperative bleeding and four instances of bleeding post-procedure. The combined rate of intraoperative bleeding was 13.2% (95% CI: 6.7-24.3%, I2 = 0%), and post-procedure bleeding stood at 8.5% (95% CI: 3.4-19.8%, I2 = 0%). Only one major bleeding event was recorded, and no cases of perforation were reported. Conclusion: Our research indicates that the EndoRotor® effectively removes scarred colonic polyps, though the rate of remaining lesions is significant, potentially necessitating several sessions for a thorough removal. There is a need for broader prospective studies, mainly randomized controlled trials, to further assess EndoRotor®'s efficiency and safety in eliminating colonic polyps.

Evaluating the diagnostic accuracy of magnetic resonance imaging in distinguishing strictures in Crohn's disease: a systematic review and meta-analysis.

PURPOSE: This systematic review and meta-analysis sought to assess the diagnostic accuracy of magnetic resonance imaging (MRI) in distinguishing fibrotic from inflammatory strictures in Crohn's disease (CD) patients. METHODS: A rigorous and systematic exploration of five key databases yielded studies that met predefined criteria. Data were extracted for a comprehensive meta-analysis using MetaDiSC and MetaDTA software, providing diagnostic accuracy measures. The Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) tool was utilized for evaluating the methodological quality and potential bias within the studies. RESULTS: The systematic review involved the evaluation of 7437 records, culminating in the inclusion of 22 studies. In detecting fibrotic strictures in CD patients, MRI exhibited a pooled sensitivity of 85.20% (95% CI: 76.10-91.20%) and specificity of 96.00% (95% CI: 87.80-98.70%). For differentiating fibrotic strictures from inflammatory stenosis, the sensitivity was 81.5% (95% CI: 70.2-89.20%), and the specificity was 97.2% (95% CI: 90.0-99.3%). In terms of assessing the severity of strictures, sensitivity stood at 90.4% (95% CI: 78.1-96.1%) and specificity at 89.4% (95% CI: 57.4-98.2%). The consistency of the diagnostic accuracy was observed across different geographical locations and the various reference tests applied in the studies. CONCLUSIONS: The results of this meta-analysis underscore the robust diagnostic accuracy of MRI in detecting fibrotic strictures, distinguishing between fibrotic and inflammatory strictures, and evaluating stricture severity in CD patients. These findings support the integration of MRI into standard diagnostic protocols for patients with CD. Further large-scale, multicenter trials are warranted to confirm these results and to identify any potential limitations associated with the application of MRI in this clinical setting.

Continuous vs. intermittent terlipressin infusion for portal hypertension: a systematic review and meta-analysis.

Background: Portal hypertension, a major complication of chronic liver disease, often leads to life-threatening variceal bleeding, managed effectively with vasoactive drugs like terlipressin. However, the most optimal method of terlipressin administration, continuous versus intermittent infusion, remains a subject of debate, necessitating this systematic review and meta-analysis for evidence-based decision-making in managing this critical condition. Methods: This systematic review and meta-analysis adhered to the PRISMA standards and explored multiple databases until 6 April 2023, such as MEDLINE through PubMed, Scopus, Web of Science, and CENTRAL. Independent reviewers selected randomized controlled trials (RCTs) that met specific inclusion criteria. After assessing study quality and extracting necessary data, statistical analysis was performed using Review Manager (RevMan), with results presented as risk ratios (RR) or mean differences. Results: Five RCTs (n=395 patients) were included. The continuous terlipressin group had a significantly lower risk of rebleeding (RR=0.43, P=0.0004) and treatment failure (RR=0.22, P=0.02) and fewer total adverse effects (RR=0.52, P<0.00001) compared to the intermittent group. However, there were no significant differences between the two groups in mean arterial pressure (P=0.26), length of hospital stays (P=0.78), and mortality rates (P=0.65). Conclusion: This study provides robust evidence suggesting that continuous terlipressin infusion may be superior to intermittent infusions in reducing the risk of rebleeding, treatment failure, and adverse effects in patients with portal hypertension. However, further large-scale, high-quality RCTs are required to confirm these findings and to investigate the potential benefits of continuous terlipressin infusion on mortality and hospital stays.

Protein Induced by Vitamin K Absence or Antagonist-II Versus Alpha-Fetoprotein in the Diagnosis of Hepatocellular Carcinoma: A Systematic Review With Meta-Analysis.

Background: Protein induced by vitamin K absence or antagonist-II (PIVKA-II) and α-fetoprotein (AFP) are promising tumor markers for the diagnosis of hepatocellular carcinoma (HCC). Yet, their diagnostic performance differs throughout HCC investigations. The aim of this meta-analysis was to assess the effectiveness of PIVKA-II and AFP in the diagnosis of HCC. Methods: A systematic literature search was performed to identify relevant studies from eight databases, which were published up to February 2023, in order to compare the diagnostic performance of PIVKA-II and AFP for HCC. Pooled sensitivity and specificity were calculated. Summary receiver operating characteristic (SROC) curve was performed to assess the diagnostic accuracy of each biomarker. Results: Fifty-three studies were identified. The pooled sensitivity (95% confidence interval (CI)) of PIVKA-II and AFP was 0.71 (0.70 - 0.72) and 0.64 (0.63 - 0.65), respectively in diagnosis of HCC, and the corresponding pooled specificity (95% CI) was 0.90 (0.89 - 0.90) and 0.87 (0.87 - 0.88), respectively. The area under the ROC curve (AUC) of PIVKA-II and AFP was 0.89 (0.88 - 0.90) and 0.78 (0.77 - 0.79), respectively. Subgroup analysis demonstrated that PIVKA-II presented higher AUC values compared to AFP in terms of ethnic group (African, European, Asian, and American patients), etiology (mixed-type HCC, hepatitis C virus (HCV)-related, and hepatitis B virus (HBV)-related) and sample size of cases (≤ 100 and > 100). Conclusion: This study reveals that PIVKA-II is a promising biomarker for identifying and tracking HCC, exhibiting greater accuracy than AFP. Our findings indicate that PIVKA-II outperforms AFP in detecting HCC across diverse racial groups and sample sizes, as well as in cases of HBV-related, HCV-related, or mixed-etiology HCC.

Inappropriate Multi-Target Stool DNA Use for Colorectal Cancer Screening: Risks, Compliance, and Outcomes.

Background Inappropriate or "off-label" use of multi-target stool DNA (mt-sDNA) tests refers to their use in patients for whom colonoscopy or no testing at all is warranted. Examples include a positive family history of colorectal cancer, a history of inflammatory bowel disease, or medical issues necessitating diagnostic colonoscopy, among others. Current understanding of off-label mt-sDNA use for colorectal cancer screening, its associated risks, and outcomes is lacking. We examined off-label mt-sDNA prescription and compliance with testing in an outpatient setting in southeast Michigan. Aims The primary aims of the study were determining the extent of off-label mt-sDNA testing and compliance, and results of all testing, as well as demographic factors associated with off-label prescriptions. The secondary aims were to examine explanations for incomplete testing and factors contributing to successful completion. Methods Using a retrospective design, we identified mt-sDNA orders from outpatient internal medicine clinics between January 1, 2018, to July 31, 2019, to evaluate the proportion of off-label mt-sDNA, results of testing, and follow-up colonoscopies up to one year after order placement. Patients were categorized as "off-label" if any inappropriate criteria were met. Statistical analysis was performed for primary and secondary outcomes. Results From 679 mt-sDNA orders within the study period, 81 (12.1%) had at least one off-label criterion for testing. In total, 404/679 (59.5%) patients completed testing. Lack of follow-up comprised the majority of incompletions (216/275; 78.6%). Only 52 (70.3%) out of 74 positive results were followed by diagnostic colonoscopy. Retired employment status (OR = 1.87; 95%CI, 1.17-2.98; P = 0.008) and age of 76 years or older (OR = 2.28; 95%CI, 0.99-5.21; P = 0.044) were significantly associated with increased risk of off-label mt-sDNA prescription. Increasing age range was associated with higher test completion (χ2 (5) = 12.085, p = 0.034). Multinomial logistic regression revealed an increasing age range (OR = 1.29; 95% CI, 1.09-1.54; P = 0.004), predictive of a positive mt-sDNA result for both groups. There was no significant difference between off-label or on-label groups in the mean number of resected polyps or pathology scores on follow-up colonoscopy. Conclusions Off-label mt-sDNA use remains a concern in the outpatient setting. Compliance for test completion and follow-up colonoscopy for positive results require further improvement. Our findings shed new light on the factors associated with off-label testing while reiterating its burden. We also describe common reasons for incomplete tests in an attempt to augment future colorectal cancer (CRC) screening initiatives.

Low versus high dose anticoagulation in patients with Coronavirus 2019 pneumonia at the time of admission to critical care units: A multicenter retrospective cohort study in the Beaumont healthcare system.

PURPOSE: Coagulopathy is common in patients with COVID-19. The ideal approach to anticoagulation remains under debate. There is a significant variability in existing protocols for anticoagulation, and these are mostly based on sporadic reports, small studies, and expert opinion. MATERIALS AND METHODS: This multicenter retrospective cohort study evaluated the association between anticoagulation dose and inpatient mortality among critically ill COVID-19 patients admitted to the intensive care units (ICUs) or step-down units (SDUs) of eight Beaumont Healthcare hospitals in Michigan, USA from March 10th to April 15th, 2020. RESULTS: Included were 578 patients with a median age of 64 years; among whom, 57.8% were males. Most patients (n = 447, 77.3%) received high dose and one in four (n = 131, 22.7%) received low dose anticoagulation. Overall mortality rate was 41.9% (n = 242). After adjusting for potential confounders (age, sex, race, BMI, ferritin level at hospital admission, intubation, comorbidities, mSOFA, and Padua score), administration of high anticoagulation doses at the time of ICU/SDU admission was associated with decreased inpatient mortality (OR 0.564, 95% CI 0.333-0.953, p = 0.032) compared to low dose. CONCLUSION: Treatment with high dose anticoagulation at the time of ICU/SDU admission was associated with decreased adjusted mortality among critically ill adult patients with COVID-19.

Arterial Dissection in Antiphospholipid Syndrome Patients: Two Case Reports and a Literature Review.

Antiphospholipid syndrome (APS) is a multisystemic autoimmune disease which presents with thromboembolic disease, pregnancy complications and the presence of antiphospholipid antibodies. There are some reports of arterial dissections in different sites of the body associated with APS. We describe two patients with APS who developed ischaemic stroke as a result of vertebral artery dissection in the absence of acquired and genetic risk factors for arterial dissection. We also conducted a systematic review of the literature for cases of arterial dissection associated with APS. We suspect that APS may be a potential cause of vasculopathy and arterial dissection. Further research is needed to explore this possible association. LEARNING POINTS: Antiphospholipid syndrome (APS) is a major risk factor for stroke in young patients.APS may be associated with vasculopathy and arterial dissection.Patients should meet both clinical and laboratory criteria for a diagnosis of APS.

Phenobarbital Versus Lorazepam for Management of Alcohol Withdrawal Syndrome: A Retrospective Cohort Study.

Introduction  Annually, 500,000 episodes of alcohol withdrawal syndrome (AWS) are severe enough to require clinical attention. A symptom-triggered lorazepam regimen remains the standard of care for the management of hospitalized AWS patients. However, phenobarbital has also been shown to be an effective adjunctive therapy for severe AWS, reducing benzodiazepine use in the emergency department (ED) and the intensive care unit (ICU). The purpose of this study is to compare hospital length of stay (LOS) for AWS patients using phenobarbital-based versus lorazepam-based treatment protocols as monotherapy for management of AWS on general medical units. Methods This is a retrospective cohort study over a two-year period (March, 2016 to March, 2018), conducted at three hospitals within the St. Joseph Mercy Health System. We included 606 patients with a primary diagnosis of AWS or alcohol intoxication who met our inclusion criteria (543 in the lorazepam cohort and 63 in the phenobarbital cohort). Adjusted comparisons were done using propensity scoring methods. Hospital LOS was set as the primary outcome. Secondary outcomes included all-cause 30-day readmission, alcohol-related 30-day readmission, 30-day ED visits after discharge, and need for ICU transfer during hospital stay. Results Patients who received phenobarbital had a statistically significant shorter hospital LOS as compared to patients who received lorazepam (2.8 versus 3.6 days, P < 0.001). Furthermore, the phenobarbital treatment group had statistically significant lower rates of all-cause 30-day readmission (11.11% versus 14.18%, P = 0.020) and 30-day ED visits after discharge (11.11% versus 18.6%, P = 0.015). No statistical significance was detected for alcohol-related 30-day readmission and the need for ICU transfer between the treatment groups. Conclusion This study suggests that phenobarbital may be a reasonable alternative to lorazepam in the management of AWS patients admitted to general medical units. Larger scale, well-executed, and adequately powered prospective studies and randomized controlled trials are needed to corroborate these findings.

Liquid Presenting as Solid: A Rare Presentation of Acute Myeloid Leukaemia as a Solid Epidural Mass.

Myeloid sarcoma (MS) is a very rare malignant tumour composed of myeloblasts. It most commonly involves soft tissue, bone, periosteum and lymph nodes, but unusual presentation sites have also been reported. Typically, MS evolves concurrently with active leukaemia or following remission, when it is known as secondary MS. But rarely MS can occur de novo without evidence of concomitant haematological disease. Herein, we report an unusual case of central nervous system-MS in a patient without evidence of concomitant haematological disease. In this case, progressive thoracic and lumbar pain with paraplegia ultimately led to the diagnosis of acute myeloid leukaemia. We also conducted a PubMed search for case reports, case series and reviews of past literature regarding central nervous system-MS and report our findings. LEARNING POINTS: Myeloid sarcoma (MS) can present de novo in the absence of antecedent leukaemia.Clinical manifestations of neural MS can be variable, including rare ones like spinal cord compression.Timely recognition of MS is paramount, as it is potentially curable.

Emphysematous Gastritis in the Setting of Chronic Abdominal Pain.

Emphysematous gastritis is a rare but fatal variant of gastritis. It is caused by gastric wall invasion by gas-forming organisms. It follows disruption of gastric mucosal integrity by a variety of factors, most commonly caustic ingestion and alcohol abuse. Patients typically present with abdominal symptoms with features of septic shock. Emphysematous gastritis carries a high mortality rate warranting early intervention with supportive measures and broad-spectrum antibiotics. It is essential to consider this rare entity in the differential diagnosis of a patient presenting with abdominal pain as timely intervention is crucial for survival. LEARNING POINTS: Emphysematous gastritis is rare but important to keep in mind when evaluating patients with acute abdominal pain.Emphysematous gastritis is a serious condition which has a high mortality rate if not diagnosed early.

Endoscopic Management of a Tubulovillous Adenoma Within a Diverticulum: Report of a Case and Review of Literature.

Adenomas or adenocarcinomas located within a colonic diverticulum are considered a rare phenomenon that has been described in the literature. These lesions are technically difficult to manage endoscopically and usually require surgical intervention for removal. There is also an increased risk of perforation upon endoscopic resection owing to the lack of a muscular layer within the diverticulum. We report a case and include a literature review to evaluate different endoscopic techniques and propose the most effective for management of adenomas within a diverticulum. This technique is potentially comprised of employing a combined approach using a suction banding device, an over-the-scope clip (OTSC; Ovesco Endoscopy AG, Tübingen, Germany) , and hyperthemic snare to successfully remove the polyp, ensure tissue retrieval, and reduce risk of iatrogenic colonic perforation.

A Case of Late Recurrence of Colon Cancer After Curative Treatment.

Colorectal cancer (CRC) is the most common tumor type in both sexes combined in Western countries. Although screening programs, including the implementation of fecal occult blood test and colonoscopy, might reduce mortality by removing precursor lesions and making the diagnosis at an earlier stage. Unfortunately, ~25% to 40% will develop a tumor recurrence despite a curative operation. It is well-known that most recurrences occur within five years. There are a lot of solid guidelines for recurrence surveillance. We present a case of colon adenocarcinoma that underwent surgical resection of the descending colon with close recurrence surveillance follow-ups that showed normal carcinoembryonic antigen (CEA) for 12 years and then presented again with blood in stool and was found to have recurrent colon adenocarcinoma.

Metastatic Osteoarticular Infective Endocarditis by Methicillin-sensitive Staphylococcus Aureus.

Infective endocarditis (IE) is a well-known complication of bacteremia with high-risk microorganisms such as Staphylococcus and Streptococcus. Skin and soft tissue infections with Staphylococcus remain a significant cause of bacteremia and IE, even with proper prompt management of the source of infection and the absence of risk factors. Although methicillin-resistant Staphylococcus aureus is a well-known etiology for osteoarticular septic emboli in IE, healthcare providers should be aware of the hidden virulence of methicillin-sensitive Staphylococcus aureus for metastatic osteoarticular infection. We report a case of IE with septic vertebral embolic lesion complicating a properly managed acute paronychia.

Postcolonoscopy Appendicitis: A Delayed Complication.

Colonoscopy is a procedure that enables a physician (usually a gastroenterologist) to directly image and examine the entire colon. It has both diagnostic and therapeutic benefits with a relatively low morbidity rate. Complications have been well described in the literature. Nevertheless, it is necessary for operators to be aware of the rare complications of colonoscopy. Acute appendicitis is an unusually rare occurrence following a colonoscopy, and it can be easily confused with other complications of the procedure. Prompt recognition of this complication can lead to early, effective treatment, and delayed diagnosis can lead to serious results. We present a case of a 33-year-old man who underwent a routine colonoscopy with no intraoperative complication who presented with appendicitis two weeks later as a rare delayed side effect; such a delayed presentation has not been described in the literature previously. This case highlights that appendicitis should be considered in the differential diagnosis of right-sided lower abdominal pain following a colonoscopy.

Capsule Endoscopy Transit Time to Duodenum: Relation to Patient Demographics.

Background Anesthesia guidelines recommend fasting for at least two hours to minimize aspiration risk related to endoscopic procedures, and the American Society for Gastrointestinal Endoscopy (ASGE) states that the final oral preparation liquid can be administered three to eight hours before the procedure. We have observed the cancellation of endoscopy procedures if liquids were consumed within four, six, or eight hours of the start time. Objectively, documenting gastric transit time via a review of pill endoscopy data could address clinician concerns, prevent delays in patient care, and improve the rate at which our clinicians practice within national guidelines. The objective was to utilize capsule endoscopy data from our center to report the relationship between patient factors that could affect gastric transit time (GTT) and small bowel transit time (SBTT) such as chronic kidney disease (CKD), diabetes mellitus (DM), nutritional status, and obesity. Methods This retrospective review obtained data on adult pill endoscopy (PillCam™ SB 3) (Medtronic, Minneapolis MN) studies on in- and outpatients. Past medical history and laboratory data were abstracted from electronic medical records. Mean GTT and SBTT are reported in minutes + standard deviation (SD) and times were compared accounting for conditions that could prolong transit, such as diabetes mellitus or chronic kidney disease (CKD). Results One hundred and sixty-three records reviewed. Four patients were excluded as the pill did not pass out of the stomach. The mean age was 66 years, 57% were female, and 26% were evaluated for gastrointestinal (GI) bleeding. The mean GTT for all patients (n = 159) was 35 + 49 with a median of 19 minutes. There were no statistically significant differences in GTT between the following subgroups: CKD0 (n = 100) 40 + 58 versus CKD5 (n = 11) 35 + 39, albumin > 3.0 (n = 123) 37 + 53 versus albumin < 3.0 (n = 36) 27 + 30, diabetes mellitus (DM) (n = 40) 51 + 71 vs. non-DM (n = 119) 42 + 79, body mass index (BMI) > 30, or aspirin use. The SBTT results in all patients (n = 124) was 238 + 88 minutes. Similarly, there was no relation between SBTT and albumin, any CKD, CKD0 versus CKD5, DM status, or BMI. The patients with the capsule stuck in the stomach did not have any other clinical history to explain this occurrence. Conclusions This analysis of objective data regarding pill endoscopy found that the mean GTT was 44 minutes, and it was < 60 minutes for 85% of the cohort. Patient factors were not associated with longer transit times, and this is the first report to document PillCam times in relation to CKD. These data support recommendations that endoscopic procedures, in accordance with anesthesia and ASGE guidelines, can be safely conducted in the majority of patients within 60 minutes of ingesting liquids.

Concomitant Acute Hepatic Failure and Renal Failure Induced by Intravenous Amiodarone: A Case Report and Literature Review.

Hepatotoxicity caused by chronic oral amiodarone is well documented with around 15-20% incidence rate. However, acute liver failure due to intravenous (IV) amiodarone is rare clinical presentation with 3% incidence rate. Incidence of concomitant renal failure is even rarer. There is no full explanation for the underlying mechanism. Herein, we are presenting a rare case of concomitant acute hepatic failure and acute-on-chronic renal injury induced by use of IV amiodarone. A 67-year-old man with past medical history of coronary artery disease s/p coronary artery bypass graft (CABG), history of alcoholism, and chronic kidney disease stage 3 presented with chest pain for 1 week. In the emergency department (ED), he was found to have atrial flutter. Due to unresponsiveness to IV ß-blocker and diltiazem, the patient was loaded with IV amiodarone and continued IV amiodarone drip. His liver function tests (LFTs) and renal functions at the time of administration of IV amiodarone were aspartate transaminase (AST) 176 (10 - 42 IU/L) and alanine transaminase (ALT) 208 (10 - 60 IU/L), international normalized ratio (INR) 1.39 (reference value 2 - 3), blood urea nitrogen (BUN) 37 (5 - 25 mg/dL), and creatinine 1.85. Sixteen hours later patient developed acute hepatic failure with AST 4,250 (reference value 10 - 42 IU/L), ALT 2,422 (10 - 60 IU/L), INR 2.28, and acute renal failure with creatinine of 3.2 mg/dL (0.44 - 1.0 mg/dL), and BUN of 44 mg/d (5 - 25 mg/dL). Patient was intubated due to acute hepatic encephalopathy and sent to intensive care unit (ICU). IV amiodarone was stopped immediately. All workup for other causes of acute hepatic failure came back negative. He was started on IV N-acetylcysteine and required hemodialysis for acute-on-chronic renal failure. LFTs peaked 72 h after discontinuation of amiodarone. Kidney functions started to improve 5 days after discontinuation of amiodarone and patient came off hemodialysis. Acute hepatic failure as result of IV amiodarone is a rare presentation; however, it has a high mortality. Risk factors include low ejection fraction, hepatic congestion and pre-existing hepatic dysfunction. No obvious underlying mechanism to this presentation has been fully explained. Acute renal failure can be associated with this presentation which is even rarer. Stopping IV amiodarone, administering N-acetylcysteine and good supportive care can lead to favorable outcome.

Symptomatic congenital Morgagni hernia presenting as a chest pain: a case report.

BACKGROUND: Morgagni hernia is a rare form of congenital diaphragmatic hernia with a prevalence of 2-3%. It occurs due to a defect on the anterior part of the diaphragm, which allows abdominal organs to penetrate into the thoracic cavity. This condition can be detected during fetal life by routine ultrasonography or late during adult life. Late diagnosis of this condition in adults is extremely rare. According to our literature search, only a few cases of symptomatic hernia in adults have been reported so far. Surgery provides definitive treatment for patients with Morgagni hernia; it is always recommended for symptomatic and asymptomatic adult patients to avoid future complications such as volvulus, small bowel obstruction, incarceration, or strangulation. We report a case of a patient who presented with chest pain due to newly diagnosed congenital diaphragmatic hernia. CASE PRESENTATION: A 29-year-old unemployed white man with no significant past medical history or family history of coronary artery disease, who was a current smoker with a 1-pack-per-day history, presented to our hospital with a 1-month history of intermittent chest pain. His chest pain was localized to the right side with a pressure-like quality, moderate intensity 4-6/10, nonradiating, and relieved by standing up and worsened by lying flat. His pain was not associated with increase or decrease in activity level. The pain had progressively worsened, which prompted the patient to come to the emergency room. The patient was admitted for further evaluation. A chest x-ray showed a suspected loop of bowel on the right side of the chest. Subsequently, the patient underwent computed tomography of the chest, which revealed a 7-cm defect in the right hemidiaphragm with a large amount of intra-abdominal fat and a loop of the proximal transverse colon within the hernial sac. The patient was evaluated by a surgeon and eventually underwent laparoscopic repair of the diaphragmatic hernia with mesh repair. In follow-up, the patient's symptoms resolved. CONCLUSION: Morgagni hernia is a rare form of congenital diaphragmatic hernia. It is commonly found either in the first few hours of life or in the antenatal period. It is less common in adults and is usually diagnosed accidentally in asymptomatic patients. Symptomatic adult cases are extremely rare. Respiratory symptoms are the most common presenting symptoms. The primary management for both symptomatic and incidentally discovered asymptomatic cases of Morgagni hernia is surgical correction. Various thoracic and abdominal surgical approaches have been described without a clear consensus on preference for operative repair technique.

A Rare Case of Signet Cell Carcinoma of Transverse Colon in a Young Patient With Ulcerative Colitis.

Signet ring cell carcinoma (SRCC) represents an extremely rare histological type for colon cancer, accounting for less than 1% of all colon neoplasms. SRCC is usually aggressive and it is associated with poor prognosis. It can be divided into mucinous adenocarcinoma (MAC) with signet cells and signet cell of more than 50% of the tumor area. Main differential diagnosis is metastatic gastric signet cell carcinoma. A 27-year-old African American man with past medical history of ulcerative colitis on mesalamine presented to emergency department with complaints of diarrhea abdominal pain and shortness of breath for 3 weeks. Physical exam was remarkable for tachycardia with a heart rate (HR) of 106 and pallor otherwise normal. Laboratory data showed potassium 2.8 mmol/L, creatinine 1.11 mg/dL, lactic acid 8 mmol/dL, hemoglobin 2 g/dL and white blood cell count 21 × 106/µL. Computed tomography (CT) scan of the abdomen with intravenous (IV) contrast showed distention of the colon, air-fluid levels and loss of haustra. Clostridium difficile stool PCR was positive. A clinical diagnosis of toxic megacolon due to C. difficile infection was made. Packed red blood cells (PRBCs) were transfused, and oral vancomycin and IV fluids were started. Symptoms and labs initially improved. However, on the third day, abdominal pain recurred with lactic acidosis. Diagnosis of refractory ulcerative colitis was made. Surgery was performed. Subtotal colectomy and ileostomy were done. Pathology revealed stage IV invasive signet ring cell adenocarcinoma, in the transverse colon poorly differentiated, with background of marked ulcerative colitis. Patient was started on adjuvant chemotherapy oxaliplatin, leucovorin and 5-flurouracil as an outpatient. Patient is undergoing 12 rounds of chemotherapy; he is currently in round 8 without complications. Patient is scheduled for screening colonoscopy and reversal of colostomy after completion of chemotherapy. SRCC of the colorectum is very rare, comprising less than 1% of colorectal cancer cases. It occurs mainly on the right colon and presents at later stages. Despite the rarity of this tumor, it is associated with ulcerative colitis. The main differential diagnosis is a metastasis from gastric signet cell carcinoma. It is associated with a poor prognosis.

A Rare Case of Helicobacter pylori Infection Complicated by Henoch-Schonlein Purpura in an Adult Patient.

Henoch-Schonlein purpura (HSP) is known as a leukocytoclastic vasculitis of small vessels, resulting in skin, joint, gastrointestinal (GI) and renal involvement. It is the most common acute vasculitis in children but is relatively uncommon in adults. The pathogenesis of HSP remains unclear, but a wide variety of conditions such as bacterial or viral infections, vaccinations, drugs and other environmental exposures may be responsible for the onset. A few previous case reports have described an association between gastric Helicobacter pylori (HP) infection and HSP. A 30-year-old Indian man who migrated to the USA from India 3 years prior to this presentation with a past medical history of psoriasis on remission, not on any medications presented to the emergency department with sudden onset constant abdominal pain for 5 days. The pain was in the right upper quadrant, spasmodic in nature. The abdominal examination was normal. The patient was evaluated with complete blood count, comprehensive metabolic panel, urinalysis, computed tomography scan of abdomen and pelvis, and right upper quadrant ultrasound, all of which were negative except for leukocytosis. He was discharged on pantoprazole and tramadol. Pain continued despite treatment. Patient was readmitted 2 days later, when he noticed a new maculopapular rash on both legs. Upper GI endoscopy was done showing non-bleeding small gastric ulcer with multiple duodenal erosions. Gastric biopsy came back positive for HP and he was started on clarithromycin, amoxicillin and lansoprazole. Pain persisted after finishing antibiotic course. Rash continued to spread to involve the thighs, flanks, around the umbilicus and extensor surfaces of arms. Immunological workup was negative. A skin biopsy of the skin rash came back positive for leukocytoclastic vasculitis. HSP diagnosis was made by exclusion. Patient was started on prednisone 40 mg daily and improved drastically on the following day. He was continued steroids taper for 8 weeks. Rash as well as abdominal pain resolved completely. In conclusion, HSP involves the skin, GI tract, joints and kidneys. It is a pediatric disease and rarely occurs in adults. It can be associated with underlying malignancy in adults. HP infection can trigger HSP in pediatric and adult patients. Detection of the carrier state is crucial in HSP patients in areas where HP is endemic. Eradication of HP infection is usually associated with the resolution of HSP. In resistant cases with GI and renal involvement, corticosteroids use results in resolution of symptoms and reduction of the duration of mild nephritis.