No Stone Left Unturned: Using Choledocholithiasis to Open a Papillary Stenosis via a Choledochodudenal Fistula.

In a patient found to have cholelithiasis and choledocholithiasis, a choledochoduodenal fistula was used to gain access to the bile duct. Due to severe stenosis and atrophy of the major papilla, cannulation was not possible. Stones were purposely impacted in the native ampulla to cause bulging and stretching of the stenosis. Once the stenosis was stretched, the bile and pancreatic duct were accessed via the native ampulla, allowing for stone removal.

Case report of gastric outlet obstruction from metastatic lobular breast carcinoma.

BACKGROUND: The most common malignancy to cause gastric outlet obstruction is primary gastric adenocarcinoma and it is followed by carcinoma of the pancreas and gallbladder. Herein, we report a case of gastric outlet obstruction secondary to metastatic lobular breast carcinoma. CASE PRESENTATION: Fifty-seven year old Caucasian female with recently diagnosed metastatic lobular breast carcinoma to skin was referred to gastroenterology for evaluation of dyspepsia and dysphagia. She has past medical history significant for acid reflux and Clostridium difficile colitis. Computed tomography of her abdomen showed diffused bowel wall thickening without evidence of bowel obstruction. Due to persistent abdominal pain, an upper endoscopy was performed. The upper endoscopy showed gastritis and gastric stenosis in the gastric antrum. These lesions were biopsied and dilated with a balloon dilator. The biopsy of the gastric antrum later showed a metastatic carcinoma of breast origin with typical tumor morphology and immune-phenotype. CONCLUSIONS: Differentiating metastatic breast carcinoma from primary gastric adenocarcinoma cannot be done using histological examination alone. Immunohistochemistry is needed to differentiate the two based on staining for estrogen and progesterone receptors. The presence of gross cystic disease fluid protein 15 is also suggestive of metastatic breast carcinoma. The stomach has a significant capacity to distend (up to 2-4 L of food) and malignant gastric outlet obstruction is often undetected clinically until a high-grade obstruction develops. Our case demonstrates valuable teaching point in terms of broadening our differentials for gastric outlet obstruction. When patients present with gastric outlet obstruction, both non-malignant and malignant causes of gastric outlet obstruction should be considered. Once adenocarcinoma has been determined to be the cause of gastric outlet obstruction, further immunohistochemistry is needed to differentiate breast carcinoma from other carcinomas.

Hepatectomy cures a cough: giant cavernous hemangioma in a patient with persistent cough.

Cavernous hemangiomas are the most common type of benign liver tumor. Although these tumors are often asymptomatic, they can occur with an array of symptoms. The authors describe a case of a 51-year-old man who presented to the emergency department with a relentless cough, nausea, and abdominal pain. Results of a computed tomography scan suggested the patient had a giant cavernous hemangioma on his liver; microscopic evaluation confirmed this diagnosis. The hemangioma was initially deemed unresectable and the patient was treated with one session of hepatic artery embolization. The embolization was unsuccessful at easing the patient's symptoms, however, and a hepatic lobectomy and resection was performed. After surgical intervention, the patient's symptoms resolved. The present case illustrates an unusual instance in which chronic cough was cured through hepatectomy for giant cavernous hemangioma. To our knowledge, no reports of coughing as a primary symptom of giant cavernous hemangioma have been previously reported in the literature.