Rare Synchronous Gastrointestinal Plasmacytomas of Colon and Stomach.

Gastrointestinal (GI) plasmacytomas, though relatively uncommon, can occur with or without multiple myeloma. The small intestine is the most commonly involved GI site, followed by stomach, colon, and esophagus. Synchronous plasmacytomas involving 2 anatomically distinct regions of gastrointestinal tract have never been reported in the literature. We report a case of a multiple myeloma patient who had acute-onset hematochezia and was found to have synchronous plasmacytomas of the colon and stomach.

Endoscopic management of post-liver transplant biliary complications.

Biliary complications are being increasingly encountered in post liver transplant patients because of increased volume of transplants and longer survival of these recipients. Overall management of these complications may be challenging, but with advances in endoscopic techniques, majority of such patients are being dealt with by endoscopists rather than the surgeons. Our review article discusses the recent advances in endoscopic tools and techniques that have proved endoscopic retrograde cholangiography with various interventions, like sphincterotomy, bile duct dilatation, and stent placement, to be the mainstay for management of most of these complications. We also discuss the management dilemmas in patients with surgically altered anatomy, where accessing the bile duct is challenging, and the recent strides towards making this prospect a reality.

Colonic perforation following polypectomy of a gastrointestinal follicular lymphoma masquerading as a colon polyp.

INTRODUCTION: The gastrointestinal (GI) tract is the predominant site for primary extranodal non-Hodgkin lymphomas (NHL), accounting for 5-10% of all extranodal disease. CASE: A 74-year-old man underwent colonoscopy for a positive fecal occult blood test. Colonoscopy revealed a 3.5-cm polyp in the descending colon and was removed by snare cautery polypectomy. Post-polypectomy site showed a 0.3-0.5-cm mucosal defect. Five endoclips were applied to close the mucosal defect. The patient remained stable during subsequent intensive monitoring and never required surgical intervention. Pathology of the polyp revealed follicular lymphoma (FL) involving the lamina propria of the mucosa with extension into the submucosa. The patient had no systemic symptoms, and staging for NHL with contrast computerized tomography of the chest, abdomen, and pelvis revealed no evidence suggestive of lymphoma. DISCUSSION: Approximately 6-20% of all primary GI-NHL are in the colon. The frequency of GI-FL accounts for 1-3.6% of all GI-NHL. After a search of the current literature, there have been no cases of a follicular lymphoma presenting solely as an isolated colon polyp. Likewise, bowel perforation due to polypectomy of such polyps has never been cited. Retrospectively, the diagnosis and extent of the polyp could have been established using endoscopic end-to-end forceps biopsy and/or endoscopic ultrasound with a radial scanning catheter probe and fine-needle aspiration of the lesion. Such a diagnosis could have changed the strategy for endoscopic removal of the polyp. Our case is interesting because it is the first report of a follicular lymphoma presenting as a single isolated colon polyp involving all layers of the colonic mucosa.

Gastric metastasis of merkel cell cancer--uncommon complication of a rare neoplasm.

Merkel cell cancer is an aggressive cutaneous malignancy of neuroendocrine cell lineage which carries a poor prognosis. It usually affects elderly Caucasians and presents as a firm, painless, nodular lesion on the sun exposed areas of the body. Though it is highly metastatic, metastasis to the gastrointestinal tract is rarely reported. We describe a case of gastric metastasis from merkel cell cancer presenting with upper gastrointestinal bleeding. To our knowledge, only 8 such cases have been reported in English literature so far.

Strongyloides duodenitis: case report and review of literature.

Strongyloides stercoralis affects 30 to 100 million people worldwide and is a common cause of abdominal pain and diarrhea. Strongyloidiasis is a chronic and limited disease; however, in immunocompromised patients, hyperinfection syndrome can occur. Diagnosing strongyloidiasis early is important, as almost all deaths due to helminths in the United States are due to S stercoralis hyperinfection. Patients infected with human immunodeficiency virus (HIV) do not appear to be at an increased risk for S stercoralis hyperinfection. We report a case of an HIV-infected Hispanic woman presenting with dyspepsia, emesis, abdominal pain, and diarrhea diagnosed with S stercoralis on an esophagogastroduodenoscopy biopsy of the duodenum. The diagnostic workup had been inconclusive and deciding to biopsy the small bowel based on the nonerythematous boggy appearance of the duodenal folds was the key step in making the correct diagnosis. Early diagnosis and treatment thwarted the developing hyperinfection syndrome and likely prevented further morbidity and probably saved her life.

Rare case of dysphagia.

Wound botulism is exceedingly rare and occurs almost exclusively among injection drug users. In 2008 there was a case of wound botulism in a noninjecting drug user reported to the Centers for Disease Control and Prevention (CDC). We report a case of a Caucasian male developing dysphagia due to wound botulism after having a motorcycle accident that left him with open fractures. The CDC was contacted and the patient was transferred to medical intensive care unit to be emergently started on hepatavalent Clostridium botulinum antitoxin. Early suspicion of wound botulism is essential for effective therapy with antitoxin in this life-threatening disease. If not suspected, this patient would likely have died. Nevertheless, the delay in diagnosis and treatment resulted in the patient's suffering dysphagia and neurological deficits. The patient required a percutaneous endoscopic gastrostomy tube and months of dysphagia therapy, supportive care, and rehabilitation. Our aim is to increase the awareness for wound botulism when a patient presents with dysphagia and diplopia after suffering open wounds. If suspected early, the morbidity and mortality from this disease can be prevented.

Sheehan syndrome presenting as central diabetes insipidus: a rare presentation of an uncommon disorder.

OBJECTIVE: To add to the current scant literature on rare clinical presentations of Sheehan syndrome. METHODS: We describe the study patient's clinical, laboratory, and imaging findings and review the literature for publications regarding varied clinical presentations of Sheehan syndrome. RESULTS: A 36-year-old multigravida woman developed severe postpartum hemorrhage and disseminated intravascular coagulation followed by Sheehan syndrome, with central diabetes insipidus as the primary presenting feature. This was diagnosed when, postoperatively, she developed polyuria with a urine output of 11 L in 24 hours with an accompanying rise in creatinine. She had laboratory evidence of diabetes insipidus, with serum osmolality greater than urine osmolality. Her clinical status improved significantly with intranasal desmopressin supplementation, thus confirming the diagnosis of Sheehan syndrome. Although Sheehan syndrome is a known complication of postpartum hemorrhage, central diabetes insipidus is seldom considered or suspected. Hypovolemia is usually presumed to be secondary to blood loss and polyuria resulting from a diuretic phase of acute renal failure. CONCLUSIONS: It is important to consider posterior pituitary ischemia resulting from Sheehan syndrome presenting as central diabetes insipidus as a cause of polyuria because appropriate hormonal replacement initiated early can possibly improve clinical status and patient outcomes.

Giant gastric hyperplastic polyp: not always a benign lesion.

Giant gastric hyperplastic polyps constitute of around 76% of all gastric polyps found. They are often found incidentally on upper GI endoscopy. They often present with occult GI bleeding causing iron deficiency anemia or partial gastric outlet obstruction. Although mostly benign, they do have potential for malignant transformation and hence must be excised endoscopically or surgically, whichever may be feasible. We hereby present a couple of cases of gastric hyperplastic polyps in an attempt to add to the current literature on this rather rare entity.

Cholangiocarcinoma: an endoscopist's perspective.

The incidence of cholangiocarcinoma is on the rise. This may be related in part to higher detection rates secondary to sophisticated endoscopic modalities. These tumors pose a significant diagnostic dilemma. High index of suspicion, careful interpretation of serum markers and utilization of endoscopic techniques, including endoscopic retrograde cholangiopancreatography and endoscopic ultrasound, help to establish the diagnosis. Imaging modalities are crucial in the evaluation of these tumors. They help to define the extent of the native lesion, which may dictate its resectability, as well as evaluate for metastasis. Therapeutic options are somewhat limited, short of surgical resection. Newer chemotherapeutic agents, as well as endoscopy-targeted therapy, may improve the overall treatment success rate, although experience is somewhat limited at this time. Endoscopic intervention is essential for palliation.

Promotion of melanoma growth by the metabolic hormone leptin.

We have previously shown that melanoma cells proliferate in response to the metabolic hormones TRH and TSH. The objective of the present study was to test the hypothesis that a third metabolic hormone, leptin, serves as a growth factor for melanoma. Using western blotting, indirect immunofluorescence, and RT-PCR, leptin receptors were found to be expressed by human melanoma cells. In contrast, cultured melanocytes expressed message for the receptor without detectable protein. Melanoma cells responded to treatment with leptin by activating the MAPK pathway and proliferating. Melanoma cells but not melanocytes, also expressed leptin protein, creating a potential autocrine loop. Examination of human melanoma tumors by immunohistochemistry revealed that melanomas and nevi expressed leptin at a high frequency. Melanomas also strongly expressed the leptin receptor, whereas nevi expressed this receptor to a much lesser degree. We conclude that leptin is a melanoma growth factor and that a leptin autocrine-loop may contribute to the uncontrolled proliferation of these cells.

Corrosive injury to the GI tract in adults: a practical approach.

Corrosive injury to the GI tract still poses great challenges with regards to the initial evaluation triage, as well as the optimization of medical management. Although relatively uncommon in the adult population, these injuries can cause significant morbidity and serious sequelae of complications, such as esophageal strictures and cancer. Prompt recognition of the process and aggressive measures towards the stabilization of the patient are key to a favorable outcome.

Carcinosarcoma of the colon: a rare cause of colovesical fistula.

Carcinosarcomas are relatively rare tumors composed of both carcinomatous and sarcomatous components. The most common sites involved by this tumor are the head and neck, respiratory tract, uterus, ovaries, and fallopian tubes. Within the gastrointestinal tract this tumor most often occurs in the esophagus, followed by the stomach. Carcinosarcomas are very aggressive tumors associated with a poor prognosis. The first case of carcinosarcoma of the colon was reported in 1986. The case reported here is the only one involving an associated colovesical fistula.