A Case of Metastatic Chromophobe Renal Cell Carcinoma Masked as Suspected Hepatic Abscesses.

Background: Characterizing multiple hepatic lesions on cross-sectional imaging, particularly differentiating abscesses from metastatic lesions, can be challenging. Case Presentation: A male aged 53 years with a history of chromophobe renal cell carcinoma presented with fevers and abdominal pain and was found to have multiple hepatic lesions concerning for hepatic abscesses. The lesions initially evaded diagnosis on imaging, laboratory tests, and biopsy, but ultimately were determined to be a rare case of metastatic chromophobe renal cell carcinoma of the liver. Conclusions: The finding of multiple new liver lesions on imaging during a febrile illness is concerning for hepatic abscess or malignancy, which can be difficult to diagnose with imaging alone. Differentiation between infectious and neoplastic etiologies may require additional imaging and/or tissue sampling.

A Rare Case of Metastatic Poorly Differentiated Neuroendocrine Tumor Arising From the Sigmoid Colon in an Active Duty Service Member.

Neuroendocrine tumors (NET) are rare malignancies that contain neural and endocrine cells with a median age of diagnosis of 63 years. NETs are typically located in the gastrointestinal (GI) tract, the pancreas, or the lungs. Within the GI tract, the most common locations for NETs are the small bowel, appendix, or rectum. They are often asymptomatic and found incidentally on imaging or during procedures. NETs arising from the left side of the colon are very uncommon. While most NETs are well-differentiated by histology and are slow growing, 7% are poorly differentiated and usually progress rapidly. While rare, it is vital to be vigilant for this reason We present such a case of poorly differentiated metastatic NET of the sigmoid colon in a young active duty service member.

Underreporting Supplements: A Case of Drug-induced Liver Injury Due to a Testosterone Booster.

Acute liver injuries (ALIs) are caused by a wide range of etiologies, and determining the cause can often be challenging. Detailed history taking is essential in patients with liver injuries to promptly determine the underlying source of injury and for timely treatment and prognosis. A 27-year-old active duty man presented to the emergency department (ED) with jaundice. On medication reconciliation, he only reported taking acetaminophen for a recent upper respiratory infection. The patient had an ALI and was treated with N-acetyl cysteine for presumed acetaminophen toxicity. Initially, his liver-associated enzymes (LAEs) improved, but 2 weeks after discharge, he returned to the ED upon referral from ship medical for jaundice and worsening liver injury. Repeated query into the patient's history revealed that he was using a testosterone booster supplement for 6 months preceding initial hospitalization. After evaluation of other etiologies for liver injury returned negative, drug-induced liver injury from the testosterone booster was determined to be the underlying etiology. With discontinuation of the supplement, his liver injury improved. Hepatotoxicity is a major concern in supplement use; however, it is largely underreported. Supplements are often not recognized or reported as medications by patients, leading to failure to identify them as potential toxicants. This case highlights the importance of including supplement education and questioning in the evaluation of ALI and maintaining a high index of suspicion when other common etiologies of liver disease are negative.

A Case of Refractory Eosinophilic Gastrointestinal Disease Successfully Treated With Dupilumab.

Eosinophilic infiltration of the gastrointestinal (GI) tract beyond the esophagus is a rare condition in adults with limited data on treatment. Current treatments with steroids and diet modifications have shown benefit, but when these treatments fall short, there is little research-driven guidance for further recommendations. We present a case of eosinophilic GI disease with extensive involvement of the GI tract successfully treated with dupilumab after failure of traditional treatment occurred.

Running for the Runs: Intermittent Intussusception From Vanek Tumor Manifesting as Constipation Improved With Exercise.

Constipation commonly affects adults and most often results from benign conditions. Certain associated symptoms (e.g., rectal bleeding or weight loss) raise concern for structural pathology and prompt further evaluation. Intussusception uncommonly affects adults and typically presents with abdominal pain and vomiting. Rarely, intussusception manifests with constipation as the primary symptom. We present a case of a patient with new onset constipation who was only able to induce bowel movements after exercising, a compensatory behavior in the setting of recurrent intussusception because of a Vanek tumor.

Rectal Bleeding in the Clinic.

Anal cancer is a rare malignancy with an estimated 8,580 new cases each year in the USA where hematochezia, a common condition, is often the initial presenting sign. We describe a 51-year-old woman who presented with painful hematochezia, with a delayed diagnosis of anal cancer in the setting of missed and misdiagnosed digital rectal exams in an otherwise low-risk patient. This case highlights the importance of maintaining a broad differential diagnosis for hematochezia and the utility of thorough physical exams.

Viral Hepatitis C-Related Care in Active Duty and Reserve Service Members: A Retrospective Review.

INTRODUCTION: Hepatitis C Virus (HCV) infection is a leading cause of chronic liver disease and hepatocellular carcinoma, and universal screening of all adults is recommended. Treatment with new direct antiviral agents are well tolerated and highly effective and decrease morbidity and mortality from HCV. The timely treatment of active-duty Service members (SMs) is essential to prevent complications of HCV and to ensure medical readiness and safety of the Department of Defense blood supply. We performed a retrospective review of the quality of care of Navy Active Duty (AD) and reserve SMs diagnosed with HCV to assess rates of successful treatment and compliance with national guideline recommendations and identify potential challenges to receiving curative HCV therapy. MATERIALS AND METHODS: A retrospective chart review was completed on the health records of 54 AD and reserve US Navy SMs diagnosed with HCV. The records were reviewed for timeliness of subspecialty evaluation, achievement of sustained virologic response (SVR), and documentation of the completion of HCV-associated recommendations from national organizations and guidelines. Challenges and barriers to care were identified. RESULTS: Ninety-eight percent of AD and reserve Navy SMs diagnosed with HCV were prescribed treatment, 81% achieved an SVR after completing initial treatment, which reached 92% after initial nonresponders underwent a second round of treatment. Fifty percent of SMs experienced a delay in care due mostly to military-related obligations and patient noncompliance or both. There was a small number of delays in care as a result of prolonged notification of results and referral time. CONCLUSION: As HCV screening recommendations expand to include all adults, more HCV infections will be identified in both the active and reserve components. Modern HCV therapies are both relatively short in duration as well as curative, allowing for the restoration of medical readiness and military service retention. Despite these advantages, we identified challenges of effecting HCV cures in a mobile military population. We recommend centralized compliance monitoring of not only HCV force screening but also HCV treatment to ensure maximized military medical readiness.

Loop-and-Let-Go: Treatment of a Large Colonic Lipoma After Unsuccessful Unroofing.

Gastrointestinal lipomas are benign subepithelial tumors arising from adipose tissue. Most colonic lipomas are clinically silent and do not require intervention. However, if the lipomas are large or symptomatic, removal can be considered. Of the endoscopic techniques available, endoscopic ligation, also known as "loop-and-let-go," provides a safe and easy alternative to other endoscopic therapies and does not require any specialized equipment or advanced training. We describe a case of a patient found to have large colonic lipoma that recurred after endoscopic unroofing but was successfully treated with "loop-and-let-go."

Systems-based Strategies Improve Positive Screening Fecal Immunochemical Testing Follow-up and Reduce Time to Diagnostic Colonoscopy.

INTRODUCTION: Fecal immunochemical testing (FIT) is the most commonly used colorectal cancer (CRC) screening tool worldwide and accounts for 10% of all CRC screening in the United States. Potential vulnerabilities for patients enrolled to facilities within the military health system have recently come to light requiring reassessment of best practices. We studied the impact of a process improvement initiative designed to improve the safety and quality of care for patients after a positive screening FIT given previously published reports of poor organization performance. METHODS: During a time of increased utilization of nonendoscopic means of screening, we assessed rates of colonoscopy completion and time to colonoscopy after positive FIT after a multi-faceted process improvement initiative was implemented, compared against an institutional control period. The interventions included mandatory indication labeling at the time of order entry, as well as utilization of subspecialty nurse navigators to facilitate rapid follow-up even the absence of a referral from primary care. RESULTS: Preintervention, 34.8% of patients did not have appropriate follow-up of a positive FIT. Those that did had a variable and prolonged wait time of 140.1 ± 115.9 days. Postintervention, a standardized order mandating test indication labeling allowed for proactive gastroenterology involvement. Colonoscopy follow-up rate increased to 91.9% with an average interval of 21.9 ± 12.3 days. CONCLUSION: The addition of indication labels and patient navigation after positive screening FIT was associated with 57.1% absolute increase in timely diagnostic colonoscopy. Similar highly reliable systems-based solutions should be adopted for CRC screening, and further implementation for other preventative screening interventions should be pursued.

Brunner's Gland Hamartomas: Two Cases of This (Sometimes) Distinctive Lesion.

Brunner's gland hamartomas (BGHs) are rare, benign, primary duodenal tumors. The clinical presentations can vary, and confirming a diagnosis can be challenging because of the submucosal nature of the lesions. We report two cases of BGHs with different clinical presentations. The diagnoses were not determined initially, despite utilizing endoscopy, mucosal biopsies, endoscopic ultrasound, and, in one case, fine-needle aspiration. Confirmation of BGHs was subsequently made following endoscopic or surgical resection.

Colon Cancer Metastatic to the Pancreas Presenting as of Diabetic Ketoacidosis.

Most of the malignant pancreatic lesions are primary pancreatic tumors with only a small percentage due to metastases. Pancreatic malignancies often present with symptoms such as jaundice and weight loss. Less commonly, new-onset diabetes mellitus has been seen in the setting of pancreatic adenocarcinomas. Although colon cancer commonly presents with metastatic disease, it typically spreads to the liver, lung, and peritoneum. We present a rare case of colon cancer metastatic to the pancreas presenting as diabetic ketoacidosis.

Jaundice in a Service member Returning From Taiwan; Diagnostic Challenges in a Case of Acute Hepatitis E.

When the evaluation of newly elevated liver enzymes is unrevealing, a common diagnosis of exclusion is drug-induced liver injury. A 39-year-old active duty service member who presented with jaundice after returning from a mission in Thailand was found to have an acute hepatitis and developing acute liver failure. He was ultimately diagnosed with acute hepatitis E, but his diagnosis was initially confounded by multiple exposures to supplements known to cause drug-induced liver injury. This case illustrates the importance of broadened serologic testing in patients with acute liver injury returning from countries endemic with hepatitis E and also highlights the challenges in diagnosis of acute hepatitis E with currently available testing.