Colonic Metastasis in a Patient With Hereditary Diffuse Gastric Cancer: A Case Report.

Metastasis of gastric carcinoma to atypical locations can complicate management, often leading clinicians to rely heavily on chemotherapy. While instances of gastric carcinoma spreading to the liver, peritoneum, and lymphatics are well documented in the literature, there is limited evidence of its spread to intraintestinal organs, particularly the colon. This scarcity of reports complicates diagnosis, given the variations in histopathology. This case report highlights a 35-year-old patient diagnosed with colonic metastasis from hereditary diffuse gastric cancer (HDGC) while being evaluated for potential causes of iron deficiency anemia. A mutation in the E-cadherin (CDH1) tumor suppressor gene is associated with HDGC. Dysregulation of CDH1 leads to tumor proliferation, invasion, migration, and metastasis. Treatment options for gastric cancer include surgical resection with neoadjuvant or adjuvant chemotherapy or palliative care with chemotherapy in metastatic disease. Although colonic metastasis from gastric cancer is rare, documented incidents can offer valuable insights that avoid misdiagnosing primary tumors and help guide further management.

The Great Mimicker Gets Caught: A Rare Case of Syphilis in the Gastrointestinal Tract.

Syphilis is a sexually transmitted disease that impacts multiple organ systems and can mimic various diseases and is an extremely rare cause of proctitis in men who have sex with men and transgender females. We present a case of a 49-year-old transgender female with a medical history significant for diabetes mellitus and hyperlipidemia who presented to the emergency department with dull abdominal pain in the left upper and lower quadrants for two days. She had non-bloody, nonbilious emesis, 10-pound weight loss over 1 month, and constipation for 2 weeks. Laboratory results showed a cholestatic pattern. Computed tomography of the abdomen showed rectal wall thickening, multiple enlarged perirectal adenopathy, and mild inflammatory infiltration around the rectum suggesting superimposed proctitis. On colonoscopy, a possible rectal mass or severe proctitis with near complete obstruction was seen with initial pathology concerning for lymphoma or a rare type of colitis. The patient was empirically started on ceftriaxone and doxycycline leading to improvement in inflammation. Special stains requested were positive for Treponema pallidum confirming the diagnosis of syphilitic proctitis and highly suggestive syphilitic hepatitis. Few cases of syphilitic proctitis imitating rectal malignancy and syphilitic hepatitis have been reported. Syphilis requires exclusion as well as confirmation of spirochetes for high-risk populations with special staining. It is important to diagnose syphilis in special populations that are at high risk of contraction.

A Rare Case of a Neuroendocrine Tumor at the Duodenum.

Neuroendocrine tumors (NETs) are slow-growing cancers derived from neuroendocrine cells that typically affect the pancreas, lungs, and gastrointestinal tract. A rare form can develop in the duodenum and can be difficult to diagnose and treat. The case below describes a rare incidence of a well-differentiated duodenal bulb NET in a 77-year-old man who had early satiety and persistent dyspepsia. Endoscopy, biopsies, and immunohistochemistry staining were used to confirm the diagnosis. According to the features of the tumor, management techniques, including endoscopic, surgical, and medicinal procedures, are being implemented.

Incidental Discovery of Asymptomatic Stage IV Hiatal Hernia With Complete Gastric Thoracic Herniation: A Case Report.

Hiatal hernia is a gastrointestinal disorder characterized by abnormal displacement of a portion of the stomach into the thoracic cavity. It has multiple stages ranging from type I-IV according to severity. The more severe the hernia, the more likely it will produce symptoms, and it would be unlikely for it to be asymptomatic. In this case report, we describe a rare situation in which a 79-year-old woman's type IV hiatal hernia was incidentally found after she suffered a mechanical fall.

Investigating causal links between gastroesophageal reflux disease and essential hypertension.

Gastroesophageal reflux disease (GERD) is a prevalent global health concern with a rising incidence. Various risk factors, including obesity, hiatal hernia, and smoking, contribute to its development. Recent research suggests associations between GERD and metabolic syndrome, cardiac diseases, and hypertension (HTN). Mechanisms linking GERD to HTN involve autonomic dysfunction, inflammatory states, and endothelial dysfunction. Furthermore, GERD medications such as proton-pump inhibitors may impact blood pressure regulation. Conversely, antihypertensive medications like beta-blockers and calcium channel blockers can exacerbate GERD symptoms. While bidirectional causality exists between GERD and HTN, longitudinal studies are warranted to elucidate the precise relationship. Treatment of GERD, including anti-reflux surgery, may positively influence HTN control. However, the interplay of lifestyle factors, comorbidities, and medications necessitates further investigation to comprehensively understand this relationship. In this editorial, we comment on the article published by Wei et al in the recent issue of the World Journal of Clinical Cases. We evaluate their claims on the causal association between GERD and HTN.

Removal of intrahepatic bile duct stone could reduce the risk of cholangiocarcinoma.

Hepatolithiasis (HL) poses a significant risk for cholangiocarcinoma (CCA) development, with reported incidences ranging from 5%-13%. Risk factors include older age, smoking, hepatitis B infection, and prolonged HL duration. Chronic inflammation and mechanical stress on the biliary epithelium contribute to CCA pathogenesis. Hepatectomy reduces CCA risk by removing stones and atrophic liver segments. However, residual stones and incomplete removal increase CCA risk. Kim et al identified carbohydrate antigen 19-9, carcinoembryonic antigen, and stone laterality as CCA risk factors, reaffirming the importance of complete stone removal. Nonetheless, challenges remain in preventing CCA recurrence post-surgery. Longer-term studies are needed to elucidate CCA risk factors further.

Role of second look endoscopy in endoscopic submucosal dissection and peptic ulcer bleeding: Meta-analysis of randomized controlled trials.

BACKGROUND: Second-look endoscopy (SLE) to prevent recurrent bleeding in patients with peptic ulcer disease (PUD) and those undergoing endoscopic submucosal dissection (ESD) is routinely being performed. Conflicting evidence exists regarding efficacy, risk, benefit, and cost-effectiveness. AIM: To identify the role and effectiveness of SLE in ESD and PUD, associated rebleeding and PUD-related outcomes like mortality, hospital length of stay, need for endoscopic or surgical intervention and blood transfusions. METHODS: A systematic review of literature databases PubMed, Cochrane, and Embase was conducted from inception to January 5, 2023. Randomized controlled trials that compared patients with SLE to those who did not have SLE or evaluated the role of prophylactic hemostasis during SLE compared to other conservative interventions were included. The study was conducted per PRISMA guidelines, and the protocol was registered in PROSPERO (ID CRD42023427555:). RevMan was used to perform meta-analysis, and Mantel-Haenszel Odds ratio (OR) were generated using random effect models. RESULTS: A total of twelve studies with 2687 patients were included in our systematic review and meta-analysis, of which 1074 patients underwent SLE after ESD and 1613 patients underwent SLE after PUD-related bleeding. In ESD, the rates of rebleeding were 7% in the SLE group compared to 4.4% in the non-SLE group with OR 1.65, 95% confidence intervals (CI) of 0.96 to 2.85; P = 0.07, whereas it was 11% in the SLE group compared to 13% in the non-SLE group with OR 0.8 95%CI: 0.50 to 1.29; P = 0.36. The mean difference in the blood transfusion rates in the SLE and no SLE group in PUD was OR 0.01, 95%CI: -0.22 to 0.25; P = 0.91. In SLE vs non-SLE groups with PUD, the OR for Endoscopic intervention was 0.29, 95%CI: 0.08 to 1.00; P = 0.05 while it was OR 2.03, 95%CI: 0.95 to 4.33; P = 0.07, for surgical intervention. The mean difference in the hospital length of stay was -3.57 d between the SLE and no SLE groups in PUD with 95%CI: -7.84 to 0.69; P = 0.10, denoting an average of approximately 3 fewer days of hospital stay among patients with PUD who underwent SLE. For mortality between SLE and non-SLE groups in PUD, the OR was 0.88, 95%CI: 0.45 to 1.72; P = 0.70. CONCLUSION: SLE does not confer any benefit in preventing ESD and PUD-associated rebleeding. SLE also does not provide any significant improvement in mortality, need for interventions, or blood transfusions in PUD patients. SLE decreases the hospital length of stay on average by 3.5 d in PUD patients.

Baker's Yeast Might not always be Good for Everyone - A Case of Percutaneous Gastrostomy Tube Induced Saccharomyces Cerevisiae Peritonitis in an Immunocompromised Patient.

Peritonitis, the inflammation of the protective membrane surrounding parts of the abdominal organs, is a common clinical pathology with multifactorial aetiologies. While bacterial infections are well-recognised as a cause of peritonitis, fungal infections remain relatively uncommon especially Saccharomyces cerevisiae, which is commonly used for breadmaking and as a nutritional supplement. This fungus has been reported to induce peritonitis in patients on peritoneal dialysis. However, it has never been reported as secondary to percutaneous endoscopic gastrostomy (PEG) tube insertion in immunocompromised patients. We present a 64-year-old female with a history of human immunodeficiency virus (HIV) who developed S. cerevisiae peritonitis following PEG tube insertion. The case highlights the importance of considering rare organisms when treating immunocompromised patients with peritonitis, especially after gastrointestinal tract penetration or peritoneal membrane disruption. LEARNING POINTS: Fungal infection can be a cause of peritonitis especially in an immunocompromised patient.Saccharomyces cerevisiae can be a pathological organism and induce serious infections.Early recognition of the cause of peritonitis and controlling the source is critical to prevent complications.

A Rare Presentation of Synchronous Colorectal Adenocarcinoma.

Synchronous carcinoma is defined as multiple malignant lesions presented in a single patient at initial diagnosis. Synchronous colorectal adenocarcinoma is a rare entity that has been increasingly recognized, likely due to the significant improvement in imaging and diagnostic tools. Making the appropriate diagnosis of synchronous colorectal cancer has a major role in the management's determination and treatment plans. Herein, we are reporting a case of a 73-year-old gentleman who was diagnosed with synchronous colorectal adenocarcinoma with two masses in the left colon and was treated initially surgically followed by chemotherapy.

Beyond the Expectation: Pembrolizumab-Associated Tumor Lysis Syndrome in Metastatic Gastric Adenocarcinoma.

Tumor lysis syndrome (TLS) emerges as a critical oncological emergency, a consequence of the body's struggle to manage the intense cellular turnover and release of cytotoxins induced by treatments such as chemotherapy, radiation, targeted immune therapy, or hormonal therapy. While commonly associated with hematological malignancies, the heightened risk also extends to advanced-stage solid tumors and instances of liver metastasis. Although TLS is a rare occurrence in gastric adenocarcinoma, reported cases are usually linked to the initiation of chemotherapy. Remarkably, the incidence of TLS following the commencement of pembrolizumab in gastric adenocarcinoma remains undocumented in the existing literature. In this context, we present a compelling case involving a 73-year-old gentleman diagnosed with advanced-stage metastatic gastric adenocarcinoma. Strikingly, the patient developed TLS subsequent to the initiation of pembrolizumab (Keytruda®). This unique scenario not only accentuates the atypical manifestation of TLS in the context of gastric adenocarcinoma but also underscores the need for heightened awareness and exploration of potential complications associated with immunotherapeutic agents in solid tumor settings. The detailed analysis of this case contributes valuable insights that may prove instrumental in refining our understanding of the intricate interplay between immunotherapy and tumor lysis syndrome in the specific landscape of gastric adenocarcinoma.

Association of Non-Alcoholic Fatty Liver Disease and Metabolic-Associated Fatty Liver Disease with COVID-19-Related Intensive Care Unit Outcomes: A Systematic Review and Meta-Analysis.

Background and Objective: The association of non-alcoholic fatty liver disease (NAFLD) and metabolic-associated fatty liver disease (MAFLD) with intensive care unit (ICU) admissions and the need for mechanical ventilation and disease severity in COVID-19 patients. Material and Methods: A systematic literature review was conducted on the databases: Cochrane, Embase, PubMed, ScienceDirect, and the Web of Science from January 2019 to June 2022. Studies evaluating MAFLD using laboratory methods, non-invasive imaging, or liver biopsy were included. The study protocol was registered in PROSPERO (ID CRD42022313259), and PRISMA guidelines were followed. The NIH quality assessment tool was used for quality assessment. RevMan version 5.3 software was used for pooled analysis. A sensitivity analysis was performed to assess the result's stability. Results: A total of 37,974 patients from 17 studies were assessed for the association between MAFLD and ICU admission. A total of 3396 COVID-19 patients required ICU admission: 1236 (20.41%) in the MAFLD group and 2160 (6.77%) in the non-MAFLD group. The odds ratio was 1.86 for ICU admission, p = 0.007, and a (95% CI) of [1.18-2.91]. A total of 37,166 patients from 13 studies were included in the need for invasive mechanical ventilation analysis. A total of 1676 patients required mechanical ventilation: 805 in the MAFLD group (14.20% of all MAFLD patients) and 871 patients in the non-MAFLD group (2.76% of all non-MAFLD patients). The odds ratio was 2.05, p = 0.02, and a (95% CI) of [1.12-3.74]. A total of 5286 patients from 14 studies were included in the COVID-19 disease severity analysis. Severe COVID-19 was seen in 1623 patients, with 33.17% (901/2716) of MAFLD patients and 28.09% (722/2570) of non-MAFLD patients having severe disease. The odds ratio was 1.59 for disease severity, p = 0.010, and a (95% CI) of [1.12-2.26]. Conclusions: Our meta-analysis suggests that there are significantly increased odds of ICU admissions, a need for invasive mechanical ventilation, and disease severity in MAFLD patients who acquire COVID-19.

Association of non-alcoholic fatty liver and metabolic-associated fatty liver with COVID-19 outcomes: A systematic review and meta-analysis.

BACKGROUND: Non-alcoholic fatty liver disease (NAFLD) and metabolic-associated fatty liver disease (MAFLD) are on the rise like any other liver disease, and tend to affect 25% of the United States population. The impact of NAFLD and MAFLD on patients with coronavirus disease 2019 (COVID-19) remains unclear. AIM: To identify the association of NAFLD and MAFLD with mortality, hospitalization, hospital length of stay, and supplemental oxygen utilization in COVID-19 patients. METHODS: A systematic review of literature on Cochrane, Embase, PubMed, ScienceDirect, and Web of Science databases was conducted from January 2019 to July 2022. Studies that evaluated NAFLD/MAFLD using laboratory methods, noninvasive imaging, or liver biopsy were included. The study protocol was registered in PROSPERO (ID CRD42022313259) and PRISMA guidelines were followed. The National Institutes of Health quality assessment tool was used to assess the quality of the studies. Pooled analysis was conducted using software Rev Man version 5.3. The stability of the results was assessed using sensitivity analysis. RESULTS: Thirty-two studies with 43388 patients were included in the meta-analysis of whom 8538 (20%) patients were observed to have NAFLD. There were 42254 patients from 28 studies included in the mortality analysis. A total of 2008 patients died from COVID-19; 837 (10.52%) in the NAFLD group and 1171 (3.41%) in the non-NAFLD group. The odds ratio (OR) was 1.38 for mortality with a 95% confidence interval (95%CI) = 0.97-1.95 and P = 0.07. A total of 5043 patients from eight studies were included in the hospital length of stay analysis. There were 1318 patients in the NAFLD group and 3725 patients in the non-NAFLD group. A qualitative synthesis showed that the mean difference in hospital length of stay was about 2 d between the NAFLD and non-NAFLD groups with a 95%CI = 0.71-3.27 and P = 0.002. For hospitalization rates, the OR was 3.25 with a 95%CI of 1.73-6.10 and P = 0.0002. For supplemental oxygen utilization, the OR was 2.04 with a 95%CI of 1.17-3.53 and P = 0.01. CONCLUSION: Our meta-analysis suggests that there are increased odds of hospitalization, longer hospital length of stay, and increased use of supplemental oxygen in NAFLD/MAFLD patients.

Lemmel's Syndrome: A Rare Complication of Periampullary Diverticula.

Periampullary diverticula are outpouches in the mucosa in the duodenum surrounding the ampulla of Vater. Most cases of periampullary diverticuli are asymptomatic, but complications can arise, increasing a patient's mortality. Diagnosis of periampullary diverticuli is often incidental during endoscopy or imaging studies for abdominal pain. When a patient with periampullary diverticuli is symptomatic, imaging modalities such as CT scan and MRI can help make the diagnosis, but a side-viewing endoscope provides direct visualization of the diverticuli and also allows for the potential treatment of the disease. Lemmel's syndrome is a complication of periampullary diverticuli where the diverticuli causes mechanical obstruction of the bile duct leading to obstructive jaundice without choledocholithiasis. These patients are at risk for further complications such as sepsis and perforation. Early diagnosis and treatment of these patients can help to prevent further complications from arising. We are presenting a case of Lemmel's syndrome with obstructive jaundice from a periampullary diverticuli, further complicated by cholangitis without dilation of the biliary tree.

Post-paracentesis scrotal edema: A case report.

Abdominal paracentesis is a common and safe procedure used to remove ascitic fluid from the body. It is performed in both the inpatient and outpatient setting and can be used for both diagnostic and therapeutic purposes. The most common complications of this procedure include a persistent fluid leak, an infection from the puncture site and an abdominal wall hematoma. The finding of sudden-onset massive genital swelling is a rare, and only occasionally reported, complication of a paracentesis. This article will discuss the case of a 58-year-old male with decompensated liver cirrhosis who presented with sudden-onset scrotal and penile swelling within 12 h after a paracentesis. After ruling out other causes of scrotal swelling, it was concluded that this is likely a complication of the recent paracentesis. The scrotal swelling was treated with conservative management including oral diuretic therapy and scrotal elevation, and the patient showed significant improvement in symptoms in 2 days. The cause of post-paracentesis scrotal edema is not widely studied; however, it is hypothesized to be caused by a fistula tract that forms between the peritoneal cavity and the Camper's and Scarpa's fascia which causes fluid to collect in the scrotum.

A Rare Case of Polymerase Chain Reaction-Negative Severe Clostridioides difficile Infection.

Accurately diagnosing Clostridioides difficile infection (CDI) is crucial for effective patient management. A misdiagnosis poses risks to patients, leads to treatment delays, and contributes to infection transmission in healthcare settings. While using polymerase chain reaction (PCR) to amplify the toxin B gene is a sensitive method for detecting toxigenic C. difficile, there is still a risk of false-negative results. These inaccuracies could have significant consequences for diagnosing and treating CDI, emphasizing the need for careful consideration and other diagnostic approaches. This case report highlights a patient with severe CDI who had negative PCR and toxin and a biopsy showing pseudomembranous colitis on further testing due to persistence and worsening of symptoms. In the diagnosis of C. difficile infection, healthcare providers should consider clinical symptoms, although diarrhea, which is a major sign of CDI, can be due to other causes. Even in the presence of negative PCR results, if a patient displays symptoms consistent with C. difficile-associated disease, healthcare providers may still contemplate treatment.

McKittrick-Wheelock Syndrome: A Rare Case of Secretory Diarrhea.

McKittrick-Wheelock syndrome commonly presents with a triad of chronic secretory diarrhea, electrolyte disturbances, and renal failure. Secretory diarrhea is due to active ion secretion secondary to secretagogue secretion (cyclic adenosine monophosphate and prostaglandin E2). The mainstay of treatment for these lesions is surgical since it will arrest the loss of electrolytes that may lead to serious clinical consequences. Nonsteroidal anti-inflammatory drugs (NSAIDs) such as indomethacin may be used to decrease electrolyte secretion in patients that desire a nonsurgical approach. Our patient is unique in that this is the first case of a tubular adenoma with high-grade dysplasia leading to MWS and progressing to circulatory collapse with severe electrolyte disturbances. Aggressive replacement of fluids and electrolytes is essential to the survival of these patients.

A Unique Case of Mantle Cell Lymphoma Masquerading as a Cecal Mass.

Mantle cell lymphoma (MCL), a type of B-cell non-Hodgkin's lymphoma, is a rare and aggressive disease with a poor prognosis due to its advanced presentation at diagnosis. It is characterized by a translocation in the Bcl-1 gene, which results in overexpression of cyclin D1. MCL is frequently seen in the form of multiple lymphomatous polyposis (MLP) in which innumerable polyps are observed in the gastrointestinal (GI) tract. In rare instances, MCL presents a single mass. The most common presentation involves male patients in their sixties, with generalized lymphadenopathy, extranodal involvement, and B symptoms (night sweats, fever, and weight loss). Endoscopic findings of MLP include cerebroid folding of the gastric mucosa and innumerable polyps extending from the duodenum to the large intestine and are reported in approximately 9% of all GI lymphomas. Less commonly, only 2-4% of GI malignancies present as a primary GI MCL as a single mass, usually in the stomach and ileocecal region in the intestine. Radiologic findings include lymphadenopathy, splenomegaly, multiple polyposis, or wall thickening with ulceration or mass formation. In most instances, advanced disease is found at diagnosis, for which 5-year survival ranges only from 26 to 46%, even when appropriate treatment is initiated. High mitotic rate, or Ki-67 index, is of prognostic value and is associated with poor prognosis. Treatment involves conventional chemo-immunotherapy consisting of R CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) or RB (rituximab and bendamustine), with the latter being better tolerated and associated with longer progression-free survival. Surgical resection is usually limited to patients in which complications are seen such as bleeding, perforation, or bowel obstruction. We present a unique case of a 70-year-old male with nonbilious, nonbloody emesis, and symptomatic anemia who was found to have a cecal mass consistent with MCL.

Unique Communication: A Case Report of Acquired Esophageal Pulmonary Fistula.

Esophageal respiratory fistula represents a connection between esophagus and the respiratory system. Esophageal tracheal and esophageal bronchial fistulas are common whereas esophageal pulmonary fistula is rarely seen. We report a case of esophageal pulmonary fistula in a middle aged African American male with a history of bronchoesophageal fistula who presented with pneumonia. The diagnosis was confirmed with fluoroscopy esophagram. Management with endoscopic stent placement was planned however the patient refused treatment. A diagnosis of esophageal pulmonary fistula should be kept in mind for patients with pulmonary symptoms and dysphagia. Early diagnosis and treatment are required to prevent complications and improve quality of life in these patients.