Schwann Cell Hamartoma Presenting as a Colonic Polyp: A Rare Case Report With a Literature Review.

Mucosal Schwann cell hamartomas (MSCHs) are non-common noncancerous growths derived from Schwann cells in the peripheral nervous system, often found unexpectedly during routine colonoscopy examinations. These growths primarily occur in the colon, although they can also appear in the esophagus and are not linked to familial cancer syndromes. Diagnosis relies on specific histological characteristics and staining patterns. It is essential to distinguish MSCHs accurately since their appearance can closely resemble that of malignant tumors. Characteristically, these hamartomas test positive for S-100 protein but do not exhibit markers typical of other gastrointestinal growths, such as gastrointestinal stromal tumors (negative for KIT), leiomyomas (negative for smooth muscle actin), neurofibromas (negative for CD34), and perineuromas (negative for epithelial membrane antigen or claudin-1). This report discusses the case of a 48-year-old woman who was diagnosed with MSCH during a screening colonoscopy.

Extended-Spectrum Beta-Lactamase Escherichia coli-Associated Acute Cholangitis: Uncommon Patient Characteristics and Clinical Implications.

Acute cholangitis is a potentially life-threatening condition caused by an infection of the biliary tract resulting from biliary obstruction. This case report highlights an unusual presentation of acute cholangitis in an elderly patient characterized by the presence of extended-spectrum beta-lactamase-producing Escherichia coli. We aim to emphasize the significance of recognizing diverse clinical manifestations in the elderly population to enhance timely diagnosis and appropriate management. The case highlights the importance of better understanding patient risk factors for potential causative organisms and their susceptibility to selecting proper antibiotics and improving clinical outcomes.

Emphysematous Gastritis: A Case Series on a Rare but Critical Gastrointestinal Condition.

Emphysematous gastritis (EG) is a rare and life-threatening condition characterized by gas-forming microorganisms causing gas to accumulate within the stomach wall. It has a high mortality rate and is associated with risk factors like gastroenteritis, alcohol use disorder, diabetes mellitus, renal failure, recent abdominal surgery, long-term corticosteroid use, and ingestion of corrosive agents. Diagnosis is challenging due to its rarity and nonspecific symptoms, including severe abdominal pain, coffee-ground emesis, fever, and signs of systemic infection. We present two cases of patients with signs and symptoms of EG, where prompt diagnosis and treatment were achieved, avoiding further complications. Surgical intervention was avoided due to the successful response to conservative treatment. These cases highlight the importance of early detection and intervention in improving patient outcomes and preventing complications associated with EG.

Ansa Pancreatica, an Uncommon Cause of Acute, Recurrent Pancreatitis.

The pancreatic duct is vulnerable to developmental anomalies which may produce variations in its course and/or its configuration. Ansa pancreatica is the least common anatomic variant. It is characterized by the formation of an "S-shaped loop" from the main pancreatic duct to the minor papilla. Ansa pancreatica has been implicated as a cause of recurrent acute pancreatitis. We review existing literature on pancreatitis secondary to the ansa deformity and present a case of recurrent acute pancreatitis in a patient who was ultimately found to have the ansa deformity on endoscopic ultrasound.

Hermansky-Pudlak Syndrome: A Rare Cause of Post-polypectomy Bleeding.

A colonoscopy is an effective tool for colorectal cancer screening, which aims at identifying precancerous polyps and removing them. Post-polypectomy bleeding (PPB) is one of the most common complications of endoscopic polypectomy. Here, we report a rare and interesting case of a 68-year-old man known to have Hermansky-Pudlak syndrome (HPS) who presented with two days history of rectal bleeding one day after he had a screening colonoscopy with polypectomy. He had a drop in his hemoglobin count and was admitted to the medicine floor and given 1-desamino-8-D-arginine vasopressin (DDAVP). Later, his bleeding stopped and he reported improvement in his symptoms. This case illustrates the importance of considering platelet transfusion and/or administration during minor surgical procedures for patients with bleeding diathesis such as Hermansky-Pudlak syndrome.

Kayexalate-Induced Esophageal Ulceration in a Patient with Decompensated Cirrhosis: A Review of the Literature.

Hyperkalemia is one of the most common electrolyte abnormalities encountered in clinical practice. The treatment of hyperkalemia includes removal of excess potassium from the body using cation exchange resins, e.g., sodium polystyrene sulfonate (Kayexalate) is one of the most practiced modalities in clinical medicine. Colonic mucosal necrosis and perforation are the serious gastrointestinal side effects associated with sodium polystyrene sulfonate (SPS) use, which have been reported with or without concomitant use of sorbitol. However, the catastrophic bleeding esophageal ulcer has been rarely described in our literature search. Due to the risk of colonic necrosis, the FDA has issued a warning to avoid concomitant sorbitol use with Kayexalate. We present an individual with acute hematemesis due to bleeding esophageal ulcer immediately after treatment with Kayexalate therapy. Though the exact mechanism by which Kayexalate causes esophageal ulcer to be elucidated, nonetheless it is worthwhile to be vigilant about its potential adverse effects. Our case highlights the rare but certainly the life-threatening complication of Kayexalate therapy.

Endoscopic Repair of Gastrocolic and Colocutaneous Fistulas Complicating Percutaneous Endoscopic Gastrostomy Tube.

Percutaneous endoscopic gastrostomy (PEG) tube feeding has become one of the options for supplemental feeding in a selected group of patients. It is a generally safe procedure usually undertaken by a gastroenterologist or a surgeon in most cases but with over 200,000 tubes being placed yearly, there is bound to be complications. Some of the encountered complications include bleeding, site infection, tube migration, and inadvertent creation of fistula. We present our index patient admitted from a long-term care facility for feculent vomiting and fecal material through the PEG tube. Imaging and colonoscopy confirmed the presence of both a gastrocolic and a colocutaneous fistula, both closed endoscopically with an over-the-scope and through-the-scope clips, respectively. Feeding through a nasogastric tube was resumed after 48 hours, and by the second week of admission, the patient was discharged back to the facility after placement of a new PEG tube.

An Unusual Case of Polymicrobial Bacteremia From Methicillin-Resistant Staphylococcus Aureus and Shigella.

Bloodstream infections (BSIs) are a significant cause of morbidity and mortality worldwide. Patients with polymicrobial BSI have a two-fold risk of hospital mortality as compared with patients with monomicrobial BSI. We present a case of a 53-year-old African American male with a medical history significant for hyperlipidemia, coronary artery disease, hypertension, anxiety, depression, and human immunodeficiency virus non-adherent to antiretroviral therapy who presented to the hospital with complaints of shoulder pain and diarrhea. The physical exam was significant for multiple skin abscesses, the largest being 5x6 cm. Blood culture grew Shigella and methicillin-resistant Staphylococcus aureus (MRSA), stool culture grew Shigella, and wound culture after incision and drainage grew MRSA. Transthoracic echocardiogram showed no vegetations. He was treated with vancomycin and ceftriaxone. The patient's clinical condition improved, and diarrhea resolved. Patient repeat cultures showed no growth. As polymicrobial bacteremia is associated with higher morbidity and mortality, early initiation of antibiotics and appropriate antibiotic therapy are pivotal.

Clinical relevance of endoscopically identified extrinsic compression of the oesophagus and stomach.

BACKGROUND: Various degree of extrinsic compression of the oesophagus and stomach are experienced during upper endoscopy. However, its utility in clinical practice has not been studied. METHODS: Electronic chart review of all upper gastrointestinal endoscopies done at our hospital between 2005 and 2016 was performed. A total of 79 patients with documented extrinsic compression on upper gastrointestinal procedure report who had a preceding or subsequent abdomen/chest CT imaging performed within 6 months were included. RESULTS: 30 (38%) out of 79 patients had abnormal finding on CT scan. 14 (47%) out of 30 patients had an associated malignant lesion, whereas remaining had a benign lesion. Overall, patients with associated gastrointestinal symptoms (60% vs 22%, p=0.001) or history of weight loss (50% vs 16%, p=0.001) had increased odds of having an abnormal finding on CT scan compared with the patients who lacked such symptoms. Pancreatic cancer was the most commonly diagnosed malignancy. On subgroup analysis of patients with extrinsic compression and malignant lesion on imaging study, the likelihood of a malignancy was higher in blacks as compared with Hispanics (71%:29% vs 39%:61%, p=0.031), and with presence of gastrointestinal symptoms (64% vs 22%, p=0.003), presence of weight loss (64% vs 16%, p=0.0001) and hypoalbuminaemia (p=0.001). CONCLUSION: Finding an extrinsic compression of the oesophagus and stomach on an upper endoscopy may suggest malignancy, and hence should prompt further work-up. Posterior wall gastric body compression may signal the presence of pancreatic cancer.

Evaluation of the combined effect of factors influencing bowel preparation and adenoma detection rates in patients undergoing colonoscopy.

BACKGROUND: Colonoscopy is a commonly used modality for screening and surveillance of colorectal cancer (CRC). Therefore, it is essential to have adequate bowel preparation (prep) for the procedure which depends on type of bowel regimens, diet before colonoscopy and timing of the procedure. AIMS: The purpose of this study is to analyse the effect of multiple factors on adenoma detection rate (ADR) and prep quality of colonoscopy. This is the also the first study determining outcomes based on various combinations of diet, timing of the procedure and bowel prep regimens. METHODS: This is a retrospective single-centre observational study. Data about diet before procedure, bowel prepprep regimen and timing of the procedure was collected for patients coming for screening colonoscopy. RESULTS: Patients with split prep had higher good prep rates (73.8% vs 56.2%) and higher ADRs (34.2 % vs 29.9%) as compared with non-split prep. The good prep quality (65.8% vs 62.1%) and ADRs (31.9% vs 31.5%) were comparable in patients who received clear liquid diet as compared with low residue diet. The good results of bowel prep were obtained with split prep with either clear liquids or low residue diet irrespective of the timing of procedure. The poor prep was noticed in patients who underwent procedure in afternoon, with a low restrictive diet and non-split bowel regimen. CONCLUSIONS: The current study adds to our knowledge about the combined effect of multiple variables affecting the bowel prep quality and ADR. It is imperative to opt for the best combination required for colonoscopy, as this will influence the effectiveness of colonoscopies regarding timely cancer detection and prevention.

A Rare Etiology of Abnormally Large Gastric Folds: Menetrier's Disease.

Menetrier's disease (MD) is described as hypertrophied giant gastric folds causing hypoproteinemia due to protein losing gastropathy and is associated with higher risk of gastric adenocarcinoma. We present a case of a 58-year-old male who presented to our clinic with Melena and endoscopic work up showed enlarged gastric folds and erythematous mucosa in the antrum and three nonbleeding angioectasias in the duodenum. Mucosa biopsies were negative for H. pylori infection. He underwent polypectomy which showed fundic gland polyps. After 1½ years, EGD was repeated for abnormal computerized tomography of abdomen which showed enlarged gastric folds and biopsy revealed gastric fundic mucosa with foveolar hyperplasia, dilated fundic glands, and chronic gastritis. Stomach biopsy results were consistent with MD. Our patient had progressive disease in one and half years. It is important to follow patient with large gastric folds regular as they can develop MD over time which has increased risk of gastric adenocarcinoma.

A Rare Cause of Abdominal Pain and Mass in an 18-Year-Old Patient: A Diagnostic Dilemma.

We present a case of an 18-year-old male who presented with complains of abdominal pain, nausea and vomiting for 2 years. An esophagogastroduodenoscopy (EGD) revealed a 3 mm nodule on the lesser curvature of the stomach and prominent gastric folds. Biopsy of the nodule revealed a well-differentiated neuroendocrine tumor (NET) in lamina prop with focal extension into muscularis mucosa consistent with a gastric carcinoid. Tumor cells stained with neuron-specific enolase (NSE), chromogranin and synaptophysin only. The prominent gastric fold biopsy revealed gastric fundic mucosa with mucosal edema and focal mild chronic inflammation. Serum gastrin level was found to be 2,083 pg/mL. Abdomen CT and endoscopic ultrasound (EUS) revealed a mass near the pancreatic neck. These findings were consistent with a functional gastrin producing well-differentiated grade 1 neuroendocrine neoplasm (gastrinoma). The patient underwent exploratory laparotomy with resection of the mass and resulting in normalization of gastrin levels.

A Rare Cause of Abdominal Pain in Adults: Meckel's Diverticulitis.

A 42-year-old man presented to the emergency room with complaints of periumbilical abdominal pain. A contrast-enhanced computed tomography revealed mucosal thickening in the small bowel of the right abdomen. There was a fairly large small bowel diverticulum associated with this segment. Findings were suggestive of small bowel diverticulitis or possibly focal enteritis. A Meckel's diverticulum scan was diagnostic of Meckel's diverticulum. The patient was then immediately taken to the operating room for emergency laparotomy and was intra-operatively found to have a thickened Meckel's diverticulitis with adjacent small bowel obstruction. Meckel's diverticulectomy was performed in continuity with the adjacent inflamed small bowel. The patient had a stable postoperative course without any complications and was discharged within 10 days. At the 3-month follow-up, the patient was well and remained asymptomatic.

Recombinant Factor VIIa Use for Endoscopic Retrograde Cholangiopancreatography With Sphincterotomy in a Patient With Choledocholithiasis and Unusual Coagulopathy.

Endoscopic retrograde cholangiopancreatography (ERCP) is a procedure that combines the use of endoscopy and fluoroscopy to diagnose and treat pancreaticobiliary disorders. The risks of ERCP include pancreatitis, infection, bleeding and perforation. Bleeding during ERCP typically develops after sphincterotomy, hence patients should be screened and tested for coagulopathy before undergoing ERCP. Coagulopathy is a major risk factor for ERCP-related bleeding. Inherited factor VII (FVII) deficiency is a rare autosomal recessive hemorrhagic disorder that can lead to significant coagulopathy and severe bleeding if not appropriately recognized and treated preoperatively. Clinically, the disease ranges between an asymptomatic state to lethal hemorrhage and the degree of FVII deficiency does not correlate with the severity of bleeding. The use of FVII replacement therapy has been reported to prevent bleeding during surgery. We present the first report of a patient with a rare cause of coagulopathy due to inherited FVII deficiency who successfully underwent ERCP with sphincterotomy without bleeding where we used recombinant factor VIIa before and after the procedure.

Anemia, intractable vomiting, chronic diarrhea, and syndrome of inappropriate antidiuretic secretion: a diagnostic dilemma: Disseminated strongyloidosis in a patient with newly diagnosed HTLV infection-case report and review of literature.

RATIONALE: Strongyloidiasis hyperinfection and disseminated disease have high mortality rates due to several complications and early detection of Strongyloides infection is therefore prudent. PATIENT CONCERNS: A 37-year-old male patient came with chronic diarrhea, intractable vomiting and was found to have hyponatremia, and anemia on the initial laboratory tests. DIAGNOSES: Further work up revealed syndrome of inappropriate antidiuretic secretion to be the cause of the hyponatremia in addition to gastrointestinal loses. His hospital course was complicated by persistent hyponatremia and later development of partial small bowel obstruction. INTERVENTIONS: Considering his symptoms we had a suspicion of small bowel pathology for which he underwent an esophagogastroduodenoscopywith biopsies that revealed strongyloidosis as the cause of his symptoms. He was also found to have human T-cell lymphotropic virus infection, likely contributing to the disseminated disease. OUTCOMES: He was started on ivermectin with complete resolution of symptoms and improvement of hyponatremia. LESSONS: It is very important to suspect Strongyloides infection in a patient presenting with syndrome ofinappropriate antidiuretic secretion as hyperinfection and disseminated disease can be life threatening without antihelmintic therapy.

Influence of perception of colorectal cancer risk and patient bowel preparation behaviors: a study in minority populations.

BACKGROUND: Large disparities exist in the utilization rates of screening modalities for colorectal cancer (CRC) in different socioeconomic areas. In this study, we evaluated whether the quality of bowel preparation differed significantly among populations with a high risk of CRC compared with that among the general population after matching for potential confounding factors. METHODS: Hispanic and African American patients who underwent routine screening or surveillance colonoscopies in an outpatient setting between 2003 and 2013 were included in this retrospective study. Patients who underwent colonoscopies for emergent indications and repeat routine screening colonoscopies because of prior history of inadequate bowel preparation were excluded from this study. The patients were divided into three groups: patients having an average risk of being diagnosed with CRC (group 1); patients having a high risk of being diagnosed with CRC because of a personal history of adenomatous polyps (group 2); and patients having a high risk of being diagnosed with CRC because of a family history of CRC in first-degree relatives (group 3). All the patients were given preprocedural counseling and written instructions for bowel preparation. Data on demographic information, method of bowel preparation, quality of bowel preparation, comorbidities, and prescription medications were collected. RESULTS: In all, 834 patients had a "high-risk for CRC" surveillance colonoscopy in view of their personal history of adenomatous polyps and were included in group 2. In total, 250 patients had a "high-risk for CRC" screening colonoscopy in view of their family history of CRC in first-degree relatives and were included in group 3. Further, 1,000 patients were selected to serve as controls (after matching for age, sex and ethnicity) and were included in group 1. Bowel preparation was graded as good, fair, or poor by the endoscopist performing the study. We observed a significantly higher number of good bowel preparations in group 2 and group 3 (P=0.0001) when compared with group 1 (controls) after adjusting for comorbidities and usage of prescription medication that could potentially cause colonic dysmotility. These differences were significant in both Hispanic and African American patients. CONCLUSION: Our study showed that perception of CRC risk significantly influenced the bowel preparation behaviors of patients belonging to minority populations, with a significantly greater number of patients with a high risk of CRC having adequate bowel preparations.

Gallstone ileus with multiple stones: Where Rigler triad meets Bouveret's syndrome.

A 53-year-old man with multiple medical conditions presented to the emergency department with complaints of vomiting, anorexia and diffuse colicky abdominal pain for 3 d. A computed tomography scan of the abdomen and pelvis showed radiographic findings consistent with Rigler triad seen in small proportion of patients with small bowel obstruction secondary to gallstone impaction. In addition there was a gastric outlet obstruction, consistent with Bouveret's syndrome. The patient underwent an exploratory laparotomy and enterotomy with multiple stones extracted. The patient had an uneventful post-surgical clinical course and was discharged home.

Visceral arterial aneurysms complicating endoscopic retrograde cholangiopancreatography.

We report this case of a 74-year-old man with altered anatomy secondary to Billroth-II surgery who underwent endoscopic retrograde cholangiopancreatography (ERCP) for choledocholithiasis and subsequently developed severe diffuse abdominal pain with drop in hemoglobin. Patient was found to have hemorrhagic shock requiring aggressive resuscitative measures. Patient was found to have large peripancreatic hematoma secondary to bleeding from gastroduodenal and superior pancreaticoduodenal artery pseudoaneurysms. Gastroduodenal artery aneurysm is the rarest of all the splanchnic artery aneurysms, and to our knowledge this is the only reported case of a gastroduodenal artery pseudoaneurysm complicating ERCP.

A rare coexistence: drug induced hepatitis and meningitis in association with Ibuprofen.

Ibuprofen, a commonly used NSAID is reported to be associated with drug induced liver injury. Ibuprofen is also known to be associated with drug-induced meningitis especially in patients with connective tissue disorders. However presentation of hepatitis and meningitis in association with Ibuprofen use in the same individual has never been reported. We present a case of young woman who developed abnormal liver chemistries and neurological symptoms while on Ibuprofen. Her liver biopsy findings were suggestive of drug induced liver injury and cerebrospinal fluid analysis was suggestive of aseptic meningitis. Clinical and biochemical improvement was noted on cessation of Ibuprofen.

"Downhill" Esophageal Varices due to Dialysis Catheter-Induced Superior Vena Caval Occlusion: A Rare Cause of Upper Gastrointestinal Bleeding.

"Downhill" varices are a rare cause of acute upper gastrointestinal bleeding. Rarely these varices are reported in patients receiving hemodialysis as a complication of chronic dialysis vascular access. We present a case of acute upper gastrointestinal bleeding in an individual with end-stage renal disease receiving hemodialysis. Esophagogastroduodenoscopy revealed "downhill" varices in the upper third of the esophagus without any active bleeding at the time of the procedure. An angiogram was performed disclosing superior vena caval occlusion, which was treated with balloon angioplasty. Gastroenterologists should have a high index of suspicion for these rare "downhill" varices when dealing with acute upper gastrointestinal bleeding in patients receiving hemodialysis and manage it appropriately using endoscopic, radiological, and surgical interventions.