Large Cell Neuroendocrine Carcinoma of the Gallbladder: Where Survival Is a Rare Entity - Case Report and Review of the Literature.

Introduction: Carcinoma of the gallbladder is extremely rare, papillary adenocarcinoma comprises 90% of these cases. Although neuroendocrine neoplasms (NENs) comprise 0.5% of the cases of gallbladder cancer, the incidence is rising. NEN is classified into a well-differentiated neuroendocrine tumor and poorly differentiated neuroendocrine cancer (NEC). Histologically, NEC is small-cell or large-cell carcinoma. We present the extremely rare case, 15th in the literature to be precise, of large cell neuroendocrine carcinoma of the gallbladder. Case Presentation: A 72-year-old male presented to the emergency department with constipation and right upper quadrant pain for 3 months. Computed tomography scan of the abdomen demonstrated an ill-defined 7.2 × 4.9 cm hypodense lesion in the gallbladder fossa with extension into the liver. Histopathological and immunohistochemical analysis of the biopsy specimen confirmed the diagnosis of large cell neuroendocrine carcinoma of the gallbladder. He was started on palliative chemotherapy. Conclusion: The plethora of tumors present in the gallbladder necessitates a search for risk factors for gallbladder neoplasia, and underscores the need to more carefully examine the nature of "asymptomatic gallstones." Further studies may reveal subclasses of cholelithiasis, gallbladder morphology, or imaging to define which patients should be followed more carefully, and may clarify additional risk factors for cancer of the gallbladder.

Takotsubo Cardiomyopathy Associated With Acute Pancreatitis.

Takotsubo cardiomyopathy is classically associated with emotional stress in middle-aged women. In clinical practice, physical stressors are a more common cause of Takotsubo cardiomyopathy. Here, we present two patients who had acute pancreatitis as a physical stressor that caused Takotsubo cardiomyopathy, and an additional 13 cases identified in the literature. An important clinical feature of these cases is that because metabolic derangements are often encountered, close attention to electrolyte repletion with cardiac monitoring is indicated.

Granular Cell Tumor of the Ascending Colon.

Granular cell tumor (GCT) was first described by Abrikossoff in 1926. It is a mostly benign tumor with rare malignant transformation. It is defined as a soft tissue neoplasm with abundant eosinophilic cytoplasm. The mean age of diagnosis for GCT is around 45 years. It is rare for GCT to be found in the gastrointestinal (GI) tract. Within the subset of GI tract, the colon is an extremely rare site for it to be found. Franburg-Smith histopathology criteria are used to differentiate a benign from a malignant GCT. The malignant form is aggressive with high recurrence rates after resection. Histopathology and immunohistochemical stains are used to make a definitive diagnosis. Herein, we present a rare case of an ascending colon polyp that was resected and found to be a benign GCT.

Trends in Palliative Care, Hospice Utilization, and Outcomes in Hospitalized Pancreatic Cancer Patients: A Nationwide Analysis.

Background and objective The prognosis of pancreatic cancer (PC) is generally poor. PC responds only modestly to chemotherapy and chemoradiation, and surgical resection remains the only curative option. The risk of recurrence is high. PC patients are encountered in the hospital on initial diagnosis and later for surgeries and complications from PC. We analyzed PC hospitalizations in the United States as reported in the National Inpatient Sample (NIS) database from 2005 to 2011 to determine the extent to which aggressive interventions could be avoided, thereby decreasing the cost of hospitalization. We analyzed trends in palliative care utilization and hospice services. Methods The International Classification of Disease 9th Revision (ICD-9) codes were used to identify diagnoses and procedures performed. Weighted analysis was performed using SPSS Statistics 28.0 (IBM Corp., Armonk, NY). Dispositions at discharge were noted. Complications and procedures performed were also documented. Results A total of 574,522 cases with PC were identified. Trends are reported chronologically (2005 to 2011). Over time, inpatient deaths for PC have decreased (11.2%, 11.1%, 9.8%, 9.8%, 9.5%, 8.4%, 8.1%; p<0.001), and hospice discharges (HD) have increased (10.2%, 11.4%, 11.4%, 12,2%, 12.6%, 12.4%, 12.7%; p<0.001). Palliative care utilization has increased (2.9%, 3.9%, 3.8%, 5.6%, 8.8%, 10.2%, 11.9%; p<0.001). Complications including peritonitis, thrombosis, hypovolemia/shock, and acute kidney injury (AKI) have increased mortality rates and HD. Conclusion There is an increasing trend of palliative care and hospice service utilization among hospitalized PC patients. Until better-targeted treatments and screening become available, mortality and morbidity will remain high. The proportion of patients receiving aggressive interventions remains high and is associated with poor outcomes. It is desirable to conduct palliative care evaluation (PCE) early in patients with advanced disease and avoid aggressive interventions.

Early Colonoscopy in Hospitalized Patients With Acute Lower Gastrointestinal Bleeding: A Nationwide Analysis.

Background: Performing colonoscopy within 24 h of presentation to the hospital is the accepted standard of care for patients with an acute lower gastrointestinal bleed (LGIB). Previous studies have failed to demonstrate the benefit of early colonoscopy (EC) on mortality. In this study, we wanted to see if there was a change in inpatient deaths (primary outcome), length of stay (LOS), and hospitalization charges (TOTCHG) (secondary outcomes) with EC compared to previous studies. Methods: Adults diagnosed with LGIB were identified using the International Classification of Disease 10th Revision codes from the National Inpatient Sample database for 2016 to 2019. EC was defined as the procedure performed within 24 h of hospitalization. Delayed colonoscopy (DC) was defined as a procedure performed after 24 h of presentation. The patient population was divided into EC and DC groups, and the effects of several covariates on outcomes were measured using binary logistic and multivariate regression analysis. Inverse probability treatment weighting (IPTW) was performed to adjust for confounding covariates. Results: There were 1,549,065 cases diagnosed with LGIB, of which 285,165 cases (18.4%) received a colonoscopy. A total of 107,045 (6.9%) patients received early colonoscopies. EC was associated with decreased inpatient deaths (0.9% in EC, and 1.4% in DC, P < 0.001). However, upon IPTW, this difference was not present. EC was associated with a decreased LOS (median 3 days vs. 5 days, P < 0.001) and TOTCHG (median $32,037 vs. $44,092, P < 0.001). Weekend admissions (WA) were associated with fewer EC (31.6% in WA, and 39.5% in non-WA, P < 0.001). WA did not affect inpatient deaths. Conclusions: EC was not associated with decreased inpatient deaths. There was no difference in endoscopic interventions in both EC and DC groups. The difference in inpatient deaths observed between the two groups was not evident upon adjusting the results for confounders. EC was associated with a decreased LOS, and TOTCHG in patients with LGIB.

Ingested Potassium Chloride Pills on Imaging Misdiagnosed As Foreign Bodies in the Stomach: An Insight on Radiopaque/Hyperdense Substances in the Gastrointestinal Tract.

Foreign bodies are very common in the GI tract. Around 100,000 cases are reported each year in the United States. A total of 80% of those foreign body ingestions occur in the pediatric population. There are several reasons for foreign body impaction in the GI tract in adults. Psychiatric problems, anatomical abnormalities in the GI tract such as esophageal web, diverticula, stricture, and eating big food boluses are frequent causes of foreign body impaction in adults. Rarely do radio-opaque ingested materials appear as a foreign body in imaging studies. Such objects include several commonly used medications such as iron preparations, potassium chloride pills, amiodarone, spironolactone, bisoprolol, and lisinopril. Herein, we present one such case of potassium chloride pill ingestion, where it appeared as a foreign body in the stomach. However, on the endoscopic examination and repeat X-ray, the foreign body had been digested and disappeared.

An Extremely Rare Case of Rectal Signet Ring Cell Carcinoma.

Signet ring cell carcinoma of the rectum is a rare variant of colorectal cancer. When found, it is often diagnosed in late stages and has poor prognosis. This case depicts a patient with a history of Crohn's disease who presented to the hospital for perirectal abscesses. During the evaluation of both the abscesses and Crohn's disease, he was found to have stage IV adenocarcinoma with signet ring cell features. The patient was started on chemotherapy before surgical resection was considered, however, showed little response. The patient's family eventually pursued hospice care with comfort measures only. Colorectal signet ring cell carcinoma is rare but has poor prognosis as it is diagnosed generally at late and advanced stages. There is a need for more research in earlier detection of these rare cancers.

Recurrent aseptic liver abscesses in a patient with Crohn's disease: True infection or a Crohn's flare?

A liver abscess is identified as a rare extraintestinal manifestation of Crohn's disease, with an incidence of approximately 150 in 100,000 patients with this condition. In many of these patients, infectious causes are identified, and the patient's condition is often noted to improve with antibiotics. An aseptic abscess (AA) is an increasingly recognized entity, especially in patients with inflammatory bowel disease, where repetitive evaluations to identify the infectious cause are futile. The average age of diagnosis for an AA is 29 years. The most common site is the spleen, followed by the lymph nodes and then the liver. In this study, we present a unique case of extensive aseptic liver abscesses extending into the pleural cavity in a young patient with Crohn's disease.

Idiopathic Sclerosing Mesenteritis: An Extremely Rare Cause of Mesenteric Mass.

Idiopathic sclerosing mesenteritis (ISM) is an extremely rare condition in which mesenteric adipose tissue undergoes necrotic and fibrotic changes. It is also known as "retractile mesenteritis", "mesenteric panniculitis" or "fat necrosis of the mesentery". Most cases are seen in Caucasian males between the fifth and seventh decades of life. Some of the suggested causes of this extremely rare condition include autoimmune disorders, abdominal trauma, malignancy, abdominal infections and even IgG4-related diseases; however, the actual cause remains unknown. Most cases are either self-limiting or improve with medical therapy. However, aggressive cases requiring emergent surgical interventions to relieve intestinal obstruction have been reported in the literature. We present a case of a 60-year-old male patient who presented to the emergency room with severe abdominal pain and was diagnosed with ISM that required surgical intervention to relieve the symptoms.

Neuromuscular and Vascular Hamartoma: Starting Point in Crohn's Disease?

Neuromuscular and vascular hamartoma (NMVH) is a benign and rare lesion comprising abnormal proliferation of cellular elements in the mucosa of the small intestine. NMVH shares certain histological features with inflammatory conditions like Crohn's disease, radiation and ischemic enteritis, and has been a part of ongoing debate since it was first described in 1982. We intend to describe an interesting case of small bowel obstruction caused by NMVH and emphasize the importance of keeping it as an important differential diagnosis in cases of small bowel obstructions for general practitioners and gastroenterologists. After detailed analysis of the 28 cases of the NMVH in the literature we are also suggesting NMVH as a starting point in Crohn's disease, and if proven it will change the management strategies for Crohn's disease.

Jejunal Ectopic Pancreas: A Rare Cause of Small Intestinal Mass.

Ectopic pancreas (EP) is defined as the presence of pancreatic tissue outside the pancreas with no anatomical connection to the pancreas. It is also known as pancreatic heterotopia, accessory pancreas, aberrant pancreas, or pancreatic rest. The first case of EP was described in 1727 when pancreatic tissue was identified in the ileal diverticulum. Abdominal pain and lower gastrointestinal bleeding are the most common symptoms. On histopathological examination, EP can be classified into four subtypes. Once identified and diagnosed, the treatment is surgical resection and the post-operative course is asymptomatic in most cases. We describe a rare case of EP, which was discovered on the CT scan of the abdomen as a jejunal mass and successfully treated with surgical resection. We have also described the possible role of chromogranin A for diagnosing EP cases and for post-operative follow-up.

Gastropancreatic Fistula: A Rare Complication of Peptic Ulcer Disease.

Peptic ulcer disease (PUD) has a significant health burden. Penetration is a rare complication of PUD, where an ulcer erodes into another organ. To the best of our knowledge, we present the fourth case in the literature where a gastric ulcer has penetrated the pancreas. A 67-year-old man with a history of PUD presented to the emergency department for epigastric pain. Endoscopy revealed a large gastric ulcer at the incisura with magnetic resonance imaging demonstrating gastropancreatic fistula. Our case emphasizes on the importance of timely identification and treatment strategies for gastropancreatic fistula, the rarest complications of PUD.

Solid Pseudopapillary Neoplasm of the Uncinate Process of the Pancreas: A Case Report and Review of the Literature.

Solid pseudopapillary neoplasm (SPN) is a rare pancreatic neoplasm that accounts for 1-3% of all pancreatic tumors. SPNs are most commonly found in females in their third and fourth decades of life. Even though the majority of the tumors are benign, malignant tumors have also been reported. Given its rare occurrence, it remains a clinical dilemma in gastroenterology, oncology, and pathology. It is critical to diagnose it early and differentiate it from other similar pancreatic tumors or cysts to ensure favorable patient outcomes. Advanced imaging techniques, characteristic histologic findings, and immunohistochemical analysis can help in diagnosing solid pseudopapillary tumors. Early diagnosis and surgical resection can result in a cure in most cases, and tumor recurrence is extremely rare. In this report, we present a case of a 40-year-old female patient who presented to the emergency room and was diagnosed with SPN of the pancreas.

Gastric Carcinoid: The Invisible Tumor!

Neuroendocrine tumor (NET) of the stomach or gastric carcinoid (GC) is a rare tumor derived from enterochromaffin-like (ECL) cells of the stomach and is more common in women after the fifth decade of life. The incidence of GC has been recently trending up. While most GC are visible lesions upon direct visualization on endoscopy, one-fourth of these tumors are intramucosal and not readily identified on upper endoscopy. Thus, a complete gastric map with biopsies of antrum, body, and fundus is required to confirm the presence of carcinoid growth. Herein we report a rare case of GC which was identified on a random gastric biopsy specimen.

Sister Mary Joseph's Nodule: Where Umbilicus Holds the Truth!

An umbilical metastasis from an internal visceral malignancy is defined as Sister Mary Joseph's nodule (SMJN), and, although a rare finding, it is a very poor prognostic indicator. We describe an interesting case of metastatic colon cancer with SMJN, emphasizing the significance of this classic finding. A 64-year-old female with a history of stage IV colon cancer with palliative right hemicolectomy and left hepatectomy presented to the hospital with nausea and abdominal discomfort. A computed tomography (CT) scan of the abdomen was performed, which showed small bowel obstruction secondary to metastatic tumor mass compressing the duodenum. She refused to undergo any chemotherapy or endoscopic intervention and was eventually discharged on hospice care. During the hospital stay an umbilical ulcerative lesion was also noted, which was violaceous, measuring 4.5 x 4 cm in size, firm in consistency with irregular borders, and tender to touch. Therefore, further history was obtained from the patient about it. Several months ago, she had developed localized swelling around the umbilicus, which gradually enlarged and ulcerated later. She eventually underwent the biopsy of that umbilical lesion, which confirmed it as SMJN with metastasis from the colonic primary. However, the patient refrained from the surgical intervention of the umbilical lesion. SMJN presents as a palpable periumbilical metastatic mass with diameter usually not exceeding 5 cm in size. It can be variable in color from violaceous to reddish brown. Once discovered, such lesions should be worked up with biopsy and imaging studies such as CT scan of the abdomen, as the nodule may be indicative of underlying malignancy or cancer recurrence. Its presence indicates a poor prognosis, with average survival time after diagnosis of SMJN of 10 months.

Fidaxomicin Use for Clostridium Difficile Infection Probably Decreases the Effect of Coumadin® in Elderly.

The incidence of Clostridium difficile infection (CDI) has been decreasing in the last decade, though the incidence of community-acquired CDI has remained stable. In an elderly patient on Coumadin®, we report an unexpected decrease in international normalized ratio (INR) during the treatment of second recurrence of CDI treated with fidaxomicin. According to the available information, fidaxomicin does not interfere with warfarin. However, in this case, warfarin effects diminished, and only with increased dosage therapeutic INR was achieved.