Acute ischemic stroke as initial manifestation of undiagnosed iron deficiency anemia: case-report and literature review.

Cerebrovascular disease is the second leading cause of death in the United States in adults aged 65 years and older and is most commonly caused by atherosclerosis. More so, cryptogenic strokes account for one-third of all ischemic strokes. At the same time, iron deficiency anemia is prevalent worldwide and mostly affects females of childbearing age. Here we report a case of a 42-year-old female who presented with symptoms of acute ischemic stroke and was found to have severe iron deficiency anemia. After prompt investigation of other secondary causes, it was determined that her stroke was likely secondary to her iron deficiency anemia. Upon review of the literature, a few case reports showed an association between iron deficiency anemia and strokes in the adult population, but little evidence exists supporting a direct relationship between the two entities. In this case, we aim to evaluate the complex relationship between iron deficiency anemia and stroke and to define a new potential cause of ischemic stroke, which would have been considered earlier as cryptogenic. However, further studies in the future are warranted to validate our observation.

Diagnostic Yield of Colonoscopy in Young Adults with Lower Gastrointestinal Symptoms in a Multicenter Midwest Cohort.

BACKGROUND/AIMS: Serious gastrointestinal (GI) pathologies are common in older adults compared to young adults (≤40 years). Data on the diagnostic yield (DY) of colonoscopy in young adults with lower GI symptoms are lacking. We aimed to evaluate the overall DY of colonoscopy; and the DY stratified by the presence or absence of bright red blood per rectum (BRBPR) in young adults ≤40 years. METHODS: We reviewed diagnostic colonoscopies performed in young adults by 18 gastroenterologists at 2 different institutions from -October 2016 to April 2019. Patients with familial colorectal cancer (CRC) syndromes were excluded. DY was calculated based on the proportion of abnormal colonoscopy defined as having inflammatory bowel disease (IBD), microscopic colitis (MC), advanced adenoma, or CRC. RESULTS: We included 454 patients, mean (SD) age was 31 (3) years, 162 (36%) were males and mean (SD) BMI was 30 (8.5). BRBPR was the indication for colonoscopy in 194 (43%) patients, 260 (57%) patients had colonoscopy for other lower GI symptoms (abdominal pain, chronic diarrhea, constipation) but without BRBPR. Overall DY of colonoscopy in young adults with lower GI symptoms was 15%; IBD was seen in 43 (10%) patients, MC 10 (2%), and advanced neoplasia/CRC 20 (4%). Overall DY in patients with BRBPR was significantly higher than in patients without BRBPR (22 vs. 11%, p = 0.001). The DY for IBD was also higher in young adults with BRBPR versus without BRBPR (15 vs. 6%, p = 0.003). The DY of patients with both BRBPR and abdominal pain was 34%, for BRBPR and diarrhea was 40%, and for all 3 symptoms of BRBPR, diarrhea, and abdominal pain was 52%. CONCLUSIONS: Significant proportion of young adults with BRBPR have abnormal pathology (22%) justifying evaluation by colonoscopy. For other lower GI symptoms without BRBPR, the necessity of endoscopic evaluation should be determined clinically on a case-to-case basis due to the low overall DY.

Immediate dilation in esophageal food impaction is safe and effective but performed infrequently: observations from a large Midwest US cohort.

This study aimed to determine the rate and safety of immediate esophageal dilation for esophageal food bolus impaction (EFBI) and evaluate its impact on early recurrence (i.e. prior to interval esophageal dilation) from a large Midwest US cohort. We also report practice patterns among community and academic gastroenterologists practicing in similar settings. We identified adult patients with a primary discharge diagnosis for EFBI from January 2012 to June 2018 using our institutional database. Pregnant patients, incarcerated patients, and patients with esophageal neoplasm were excluded. The primary outcome measured was rate of complications with immediate esophageal dilation after disimpaction of EFBI. Secondary outcomes were recurrence of food bolus impaction prior to scheduled interval endoscopy for dilation, practice patterns between academic and private gastroenterologists, and adherence to follow-up endoscopy. Two-hundred and fifty-six patients met our inclusion criteria. Esophageal dilation was performed in 46 patients (18%) at the time of disimpaction. A total of 45 gastroenterologists performed endoscopies for EFBI in our cohort. Twenty-five (62%) did not perform immediate esophageal dilation, and only 5 (11%) performed immediate dilation on greater than 50% of cases. Academic gastroenterologists performed disimpaction of EFBI for 102 patients, immediate dilation as performed in 20 patients and interval dilation was recommended in 82 patients. Of these 82, only 31 patients (38%) did not return for interval dilation. Four patients who did not undergo immediate dilation, presented with recurrent EFBI prior to interval dilation, within 3 months. None of the patients had complications. Complications with immediate esophageal dilation after disimpaction of EFBI are infrequent but are rarely performed. Failure of immediate dilation increases the risk of EFBI recurrence. Given poor patient adherence to interval dilation, immediate dilation is recommended.

The benefits of a model of interval comprehensive assessments (MICA) in hereditary cancer Syndromes: Hereditary diffuse gastric cancer (HDGC) as an example.

A high percentage of individuals at risk for hereditary cancer syndromes are unaware of their risk. This is especially detrimental in syndromes such as hereditary diffuse gastric cancer due to a CDH1 germline mutation, for which lifesaving prevention is possible. Surveillance for diffuse gastric cancer in the syndrome is limited, hence the recommendation for prophylactic total gastrectomy for mutation carriers. Genetic counseling and testing is crucial in suspected families but initial contact could be limited, leading to the importance of an interval comprehensive review every 5-8 years to identify and screen additional high-risk individuals. Our contact with a hereditary diffuse gastric cancer family in Jordan in 2011 led to a number of family members receiving education and genetic counseling. Our model of interval comprehensive assessment (MICA) was constructed and implemented by conducting family information service, video call and emails to the high-risk individuals 7 years after initial contact. Using an updated family pedigree we reached out to an additional thirteen high-risk members in six different countries and provided them with genetic education, counseling, and testing. Six members agreed to CDH1 testing (46%). Four tested positive (66%) and one member (25%) underwent prophylactic total gastrectomy.

Trends and Outcomes of Hospitalizations Related to Acute Pancreatitis: Epidemiology From 2001 to 2014 in the United States.

OBJECTIVES: The aim of this study was to determine the recent trends of the rates of hospitalization, mortality of hospitalized patients, and associated health care utilization in patients with acute pancreatitis (AP). METHODS: We identified adult patients with primary discharge diagnosis of AP from the National Inpatient Sample database. Patients with chronic pancreatitis and/or pancreatic cancer were excluded. Primary outcomes included age-adjusted incidence of AP and in-hospital mortality based on US standard population derived from the 2000 census data. Secondary outcomes were length of stay, inflation-adjusted hospital costs in 2014 US dollars, and procedural rates. Subgroup analysis included disease etiologies, age, race, sex, hospital region, hospital size, and institution type. RESULTS: From 2001 to 2014, the rate of primary discharge diagnosis for AP increased from 65.38 to 81.88 per 100,000 US adults per year. In-hospital case fatality decreased from 1.68% to 0.69%. Mortality rate is higher in patients with AP who are older than 65 years (3.4%). Length of stay decreased, with a median of 3.8 days; cost per hospitalization decreased since 2007 from $7602 to $6766 in 2014. CONCLUSIONS: The rate of hospitalization related to AP in the United States continues to increase. Mortality, length of stay, and cost per hospitalization decrease. The increase in volume of hospitalization might contribute to an overall increase in health care resource utilization.

Docetaxel-Induced Stevens-Johnson Syndrome in a Patient with Metastatic Prostate Adenocarcinoma.

Docetaxel is a commonly used chemotherapeutic agent in a variety of cancer treatment regimens. We present a case of apparent docetaxel-induced Stevens-Johnson syndrome (SJS) in a patient recently treated for metastatic prostate cancer. This medication is not classically associated with the development of SJS but in our case, along with a number of other case reports, and a single phase II clinical trial, an association was recognized. We encourage clinicians who employ the use of this medication to be aware of this relationship.

A Case of Amitriptyline-induced Myocarditis.

Amitriptyline is a widely prescribed tricyclic antidepressant (TCA) with a very concerning cardiotoxicity profile, but it is one that has not been discussed much in literature. Here, we present a case of amitriptyline toxicity presenting as myocarditis with pericardial involvement. A 21-year-old male with no previous cardiac history presented to the emergency department (ED) with a decreased level of consciousness after an amitriptyline overdose as a suicidal attempt. For concerns with airway protection, the patient was intubated and subsequently admitted to the intensive care unit (ICU). An electrocardiogram (EKG) showed sinus tachycardia, prolonged QRS complex, prolonged QTc interval, and nonspecific ST-T wave changes. Intravenous fluid resuscitation and sodium bicarbonate were administered with a target blood pH of 7.5 to 7.55. Two days later, the patient was taken off mechanical ventilation and improved clinically. However, troponin levels began to rise with a peak level of 4.08 µg/L. He then began having fevers, elevated white blood cell counts (WBCs), and elevated inflammatory markers. Transthoracic echo (TTE) revealed an ejection fraction (EF) of 45%-50%, no wall segment motion abnormalities, and a mild-to-moderate pericardial effusion. Cardiac magnetic resonance (CMR) was done, which revealed changes indicative of acute myocarditis, moderate pericardial effusion, a calculated EF of 45% with a moderate left ventricular dilation, and no coronary artery stenosis or anomalous coronary artery origin. Given the patient's age, the absence of cardiac risk factors, and the presence of an amitriptyline overdose along with his EKG, TTE, and CMR findings, we hypothesize that this myocarditis with pericardial involvement is due to amitriptyline-induced direct toxicity.

Cerebral Sinus Venous Thrombosis in a Patient Using Etonogestrel/Ethinyl Estradiol Vaginal Ring.

A case of 43-year-old female presented to the emergency department (ED) with a new onset grand mal tonic-clonic seizure lasting at least two minutes with post-ictal confusion. Imaging was consistent with cerebral sinus venous thrombosis (CSVT) associated with intracranial hemorrhage. After ruling out most common causes of thrombosis, the etiology was attributed to estrogen vaginal ring. The patient was treated with anticoagulation therapy and had increasing hemorrhagic changes in the first few days, which eventually improved. The estimated annual incidence of cerebral sinus vein thromboses is approximately 3-4 cases per 1 million adults, mostly occurring in females. More than 80% of patients have favorable neurologic outcomes due to increased awareness of the condition as well as availability of advanced imagining and treatment options. The treatment is still controversial due to the high risk of intracranial hemorrhage with sinus thrombosis, especially for patients on anticoagulation. Still, most guidelines support starting anticoagulation. In this report, we highlight the association of CSVT with estrogen vaginal ring and discuss recent management recommendations per different society guidelines.

Fenofibrate: A Nonlithogenic Means of Recurrent Drug-Induced Pancreatitis.

Medications account for a small portion of the various etiologies of acute pancreatitis. Prompt identification of drugs as the inciting factor decreases disease recurrence and unnecessary invasive diagnostic intervention. This case is a report of fenofibrate-induced acute pancreatitis including a disease recurrence with continuation of fenofibrate which subsequently resolved after drug discontinuation. The patient underwent invasive diagnostic evaluation including endoscopic ultrasound with fine needle aspiration and endoscopic retrograde cholangiopancreatography (ERCP). Based on exclusion of other disease etiologies and a positive drug rechallenge, fenofibrate fits as a class 1A medication in the classification of drug-induced pancreatitis.

Meckel's Diverticulum in Crohn's Disease Revisited: A Case of Meckel's Diverticulitis in a Patient with Stricturing Crohn's Disease.

According to anecdotal reports in literature, encountering Meckel's diverticulum in a patient with Crohn's disease is not uncommon, but differentiating between the overlapping complications of Mickel's diverticulum and the natural manifestations of Crohn's disease can be challenging and may impact lifelong therapy. In this report, we present a case of Meckel's diverticulitis in a patient with stricturing ileocolonic Crohn's disease. A 29-year-old male has been suffering from recurrent bouts of abdominal pain and diarrhea which were initially thought to be due to recurrent flares of Crohn's disease. The patient was started on different medical regimens to control his disease, but complete remission was not achieved. He was found to have an inflamed Meckel's diverticulum during laparotomy with sections of transmural inflammation extending into the diverticulum with absence of heterotopic mucosa. Although Meckel's diverticulum and Crohn's disease involve separate disease processes and different pathogenesis, several hypotheses to explain a correlation have been suggested. We believe it is important to consider the presence of an inflamed Meckel's diverticulum in the differential diagnosis for patients with refractory Crohn's disease who do not have an adequate response to medical therapy.

A Case of Levamisole-Induced Agranulocytosis.

A sixty-eight-year-old male with a past medical history of recurrent cocaine use presented to the emergency department with recurrent diarrhea and was found to have a white blood cell (WBC) count of 1.9 × 109/L with agranulocytosis (absolute neutrophil count (ANC) of 95 cell/mm3). At admission, the patient disclosed that he used cocaine earlier during the day, and a urine drug screen tested positive for this. On hospital day one, the patient was found to have a fever with a maximum temperature of 313.6 K. After ruling out other causes and noting the quick turnaround of his neutropenia after four days of cocaine abstinence, the patient's neutropenia was attributed to levamisole-adulterated cocaine.

A Challenging Case of Acute Mercury Toxicity.

BACKGROUND: Mercury exists in multiple forms: elemental, organic, and inorganic. Its toxic manifestations depend on the type and magnitude of exposure. The role of colonoscopic decompression in acute mercury toxicity is still unclear. We present a case of acute elemental mercury toxicity secondary to mercury ingestion, which markedly improved with colonoscopic decompression. CLINICAL CASE: A 54-year-old male presented to the ED five days after ingesting five ounces (148 cubic centimeters) of elemental mercury. Examination was only significant for a distended abdomen. Labs showed elevated serum and urine mercury levels. An abdominal radiograph showed radiopaque material throughout the colon. Succimer and laxatives were initiated. The patient had recurrent bowel movements, and serial radiographs showed interval decrease of mercury in the descending colon with interval increase in the cecum and ascending colon. Colonoscopic decompression was done successfully. The colon was evacuated, and a repeat radiograph showed decreased hyperdense material in the colon. Three months later, a repeat radiograph showed no hyperdense material in the colon. CONCLUSION: Ingested elemental mercury can be retained in the colon. Although there are no established guidelines for colonoscopic decompression, our patient showed significant improvement. We believe further studies on this subject are needed to guide management practices.

A Case of Imatinib-Induced Hepatitis.

A 71-year-old female with a past medical history of Philadelphia chromosome-positive chronic myelogenous leukemia on imatinib therapy, Sjogren's syndrome, and hypothyroidism presents with acute hepatitis. After a comprehensive workup ruling out viral, infectious and metabolic etiologies imatinib is stopped which results in immediate improvement. The biopsy is consistent with drug-induced liver damage; the patient is started on oral prednisone and discharged. Unfortunately, our patient's liver function does not improve over the course of the next week and she is readmitted for hepatic and renal failure. During this second admission patient's condition continues to deteriorate with concomitant gastric bleeding, renal injury, and cellulitis. She ultimately chooses a palliative approach.

Major hereditary gastrointestinal cancer syndromes: a narrative review.

Gastrointestinal cancer is one of the major causes of death worldwide. Hereditary gastrointestinal cancer syndromes constitute about 5-10% of all cancers. About 20-25% of undiagnosed cases have a possible hereditary component, which is not yet established. In the last few decades, the advance in genomics has led to the discovery of multiple cancer predisposition genes in gastrointestinal cancer. Physicians should be aware of these syndromes to identify high-risk patients and offer genetic testing to prevent cancer death. In this review, we describe clinical manifestations, genetic testing and its challenges, diagnosis and management of the major hereditary gastrointestinal cancer syndromes.