Rectal ulcers: a complication from stool management system use.

Fecal management System (FMS) is widely used across medical facilities in United States. These devices have helped in preventing problems associated with fecal incontinence. Although highly efficient, these devices can also lead to certain complications including rectal ulcer and lower Gastrointestinal (GI) bleed. Here, we report a case of a 56-year-old male being treated for pneumonia and atrial fibrillation, who had significant lower GI bleed while being on FMS for stool incontinence. A colonoscopy was performed, which showed multiple rectal ulcers with one large ulcer having a visible pulsating vessel. This case highlights a rarely reported complication of rectal ulcers and GI bleed associated with use of FMS.

Iron-Deficiency Anemia in an Elderly Caucasian Female: An Unusual Colonoscopic Finding.

Iron-deficiency anemia (IDA) is common in the elderly population. It is usually the result of chronic gastrointestinal diseases which could lead to iron losses, malabsorption, or both. IDA is most often the result of chronic gastrointestinal blood loss caused by esophagitis, gastritis, ulcer, colon cancer, pre-malignant polyps, or angiodysplasia. We are presenting a unique case that describes the unusual finding of intestinal helminthiasis in an elderly patient during endoscopic evaluation for IDA. It also touches on the risk factors, clinical manifestations, diagnosis, and treatment of enterobiasis.

Unusual Case of Ischemic Colitis Caused by Low-Dose Sumatriptan Therapy in a Generally Healthy Patient After Strenuous Physical Activity.

Ischemic colitis refers to an inflammatory condition of the large bowel caused by ischemia. It usually presents with an acute onset abdominal pain followed by hematochezia. It can occur as a result of arterial occlusion (embolic or thrombotic), venous thrombosis, or hypoperfusion of mesenteric circulation secondary to dehydration, surgery, or medications. Herein, we present an unusual case of sumatriptan-induced ischemic colitis. Sumatriptan succinate is a selective serotonin (5-hydroxytryptamine-1) receptor agonist that is usually prescribed for refractory migraine headaches. This is a 59-year-old female who presented with acute onset abdominal pain followed by bloody diarrhea after vigorous physical activities. She has a past medical history of non-specific colitis (one time, 15 years ago) and chronic migraine for which she was on low-dose sumatriptan therapy (one tab once or twice a week). On the day of the event, the patient took sumatriptan in the morning and had strenuous activities throughout the day, and overnight she developed abdominal pain. It was followed by bouts of bloody diarrhea. The colonoscopy revealed erythematous mucosa with significant ulceration and necrosis involving the distal transverse colon, splenic flexure, descending colon, and proximal colon, suggestive of ischemic colitis. Unlike previously reported cases, this patient was only on low-dose sumatriptan therapy without frequent dosing. So, her risk of ischemic colitis from triptan therapy could have been accelerated by excessive sweating and strenuous physical activities. The patient was treated with intravenous hydration, bowel rest, intravenous antibiotics, and withdrawal of sumatriptan and her condition improved within the next two to three days.

A Case of Acute Esophageal Necrosis from Unruptured Thoracic Aortic Aneurysm.

Acute esophageal necrosis (AEN), also known as black esophagus due to its appearance on endoscopy, classically involves the distal esophagus (97% of cases). AEN affecting the midesophagus with sparing of the distal esophagus is rare and usually occurs in patients with thoracic aortic aneurysmal (TAA) rupture or aortic dissection. Herein, we report a unique case of AEN in the midesophagus in a patient with an unruptured and undissected TAA.

Abdominal Wall Hematoma Secondary to Dissection of the Deep Circumflex Iliac Artery: A Rare Complication of Ultrasound-Guided Paracentesis.

Paracentesis of the abdominal cavity is carried out to analyze ascitic fluid for diagnostic and therapeutic purposes. In recent years, the modern ultrasound-guided method is favored over the landmark-based approach as the latter carries a higher risk of complications. Dissection of the inferior epigastric artery is the most frequent complication encountered on either approach. We present a unique case of iatrogenic laceration of the deep circumflex iliac artery due to abnormal vessel anatomy in a patient with ascites.

Pancreatic Pseudoaneurysm from a Gastroduodenal Artery.

Pancreatic pseudoaneurysm is a rare vascular complication of pancreatitis, resulting from erosion of the pancreatic or peripancreatic artery into a pseudocyst. However, it may happen after pancreatic or gastric bypass surgery or trauma. It may lead to fatal complications if left untreated. Herein, we report a unique case of pseudoaneurysm from a gastroduodenal artery in a patient with recurrent episodes of acute pancreatitis, which was managed successfully with coil embolization.

Acute Esophageal Necrosis: A View in the Dark.

Acute esophageal necrosis (AEN), also known as Gurvits syndrome, black esophagus, or acute necrotizing esophagitis, is a rare clinical entity and an unusual reason for upper gastrointestinal bleeding. It is typically described in critically ill patients with multiple medical conditions, arising from a combination of ischemic insult to the esophageal mucosa due to low-flow vascular states, corrosive injury caused by reflux of acid and pepsin, and decreased function of the mucosal barrier systems and reparative mechanisms as occurs in malnourished and debilitated physical states. Patients with AEN tend to be older men, as medical comorbidities including vascular disease, diabetes, hypertension, renal insufficiency, cardiac disease, pulmonary disease, stroke, and cirrhosis may be more common. Typically, patients present with upper gastrointestinal bleeding, and hematemesis or melena is seen in up to 90% of cases. Herein we present 3 cases of AEN in critically ill patients. We also provide a review of the literature to highlight what is currently known about this relatively uncommon esophageal disease.

Gastrointestinal Stromal Tumors: Deception to the Eyesight.

Gastrointestinal stromal tumors (GISTs) are rare soft tissue tumors. Despite their rarity, these tumors are the most common gastrointestinal (GI) mesenchymal tumors. They can involve various parts of the gastrointestinal tract. GISTs growth can be intramural, intraluminal or exophytic. Symptoms are usually related to GI bleeding and to adjacent organ compression by the tumor. Endoscopy can suggest the diagnosis, but tissue sampling is required for the diagnosis. Herein, we present a unique case of GIST where the patient had negative endoscopic findings despite the large size of the tumor, thus abdominal computed tomography scan and endoscopic ultrasound was required to make the diagnosis.

Endoscopic Ultrasound: Reaching Where Others Can't.

Endoscopic ultrasound (EUS) has been increasingly used for the diagnosis and staging of pancreatic cancer. It has recently become the modality of choice in assessing pancreatic lesions overcoming other traditional modalities. Typically lesions located at the tail of the pancreas are best accessed through the stomach. We present a patient with pancreatic tail mass occurring in the setting of a large hiatal hernia, intrathoracic stomach, and severe lumbar levoscoliosis. Due to altered anatomy and extensive vascular connections of the mass, any surgical or radiological intervention was considered high risk for the patient. EUS was the only modality capable of providing a pancreatic mass tissue sample in this patient with challenging thoraco-abdominal anatomy. Moreover, pancreatic tail lesions are traditionally best accessed through the gastric fundus; however, in view of the patient's altered anatomy, EUS-fine needle aspiration (FNA) had to be performed through the duodenum. This case raises the importance of EUS when surgical and radiological interventions are restricted.

IgA-dominant post-infectious glomerulonephritis presenting as a fatal pulmonary-renal syndrome.

Over the last decades, post-infectious glomerulonephritis underwent major changes in its epidemiology, pathophysiology, and outcomes. We are reporting a case of IgA-dominant post-infectious glomerulonephritis (IgA-PIGN) presenting as a fatal pulmonary-renal syndrome. An 86-year-old Filipino man presented with worsening dyspnea, hemoptysis, and decreased urine output over 2 weeks. Past medical history is significant for hypertension, chronic kidney disease stage III, and pneumonia 3 weeks prior treated with intravenous cefazolin for methicillin-sensitive Staphylococcus aureus bacteremia. Physical examination was remarkable for heart rate of 109/min and respiratory rate of 25/min saturating 99% on 3 liters via nasal cannula. There were bibasilar rales in the lungs and bilateral ankle edema. A chest radiograph showed bibasilar opacifications. Blood work was significant for hemoglobin of 8.3 g/dL and creatinine of 9.2 mg/dL (baseline of 1.67). TTE showed EF 55%. Urinalysis revealed large blood and red blood cell casts. Kidney ultrasound showed bilateral echogenicity compatible with renal disease. Pulse methylprednisolone therapy and hemodialysis were initiated with patient's condition precluding kidney biopsy. Serology workup for rapidly progressive glomerulonephritis was negative. On day 7, the patient required mechanical ventilation; bronchoscopy showed alveolar hemorrhage and plasmapheresis was initiated. Renal biopsy revealed IgA-PIGN with endocapillary and focal extracapillary proliferative and exudative features. IgA-PIGN occurs in diabetic elderly (mean age of 60 years), 0-16 weeks after an infection mainly by Staphylococcus. However, this nondiabetic patient had normal complement IgA-PIGN with fatal pulmonary-renal syndrome. Understanding the pathogenesis and identifying the nephrotoxic bacteria species and the aberrant IgA molecule will open new insights toward prevention and treatment.

Predictors of quality of life in patients with end-stage renal disease on hemodialysis.

BACKGROUND: Assessment of quality of life (QOL) of end-stage renal disease (ESRD) patients (physical, mental, and social well-being) has become an essential tool to develop better plans of care. Objective of this study is to determine which demographic and biochemical parameters correlate with the QOL scores in patients with ESRD on hemodialysis (HD) using Kidney Disease QOL-36 surveys (KDQOL). METHODS: A retrospective chart review of all ESRD patients who underwent HD at an outpatient center. The five components of the KDQOL were the primary end points of this study (burden of kidney disease, symptoms and problems, effects of kidney disease on daily life, mental component survey, and physical component survey). Scores were grouped into three categories (below average, average, and above average). In addition to demographics (age, sex, and race), the independent variables such as weight gain, number of years on dialysis, urea reduction ratio, calcium, phosphorus, parathyroid hormone, albumin, and hemoglobin in the serum were collected. Chi-square analysis for dependent variables and the nominal independent variables was used, and analysis of variance analysis was used for continuous independent variables. Ordinal regression using PLUM (polytomous universal model) method was used to weigh out possible effects of confounders. RESULTS: The cohort size was 111 patients. Mean age was 61.8 (±15.5) years; there were more males than females (64.9% vs 35.1%), the mean time-on-dialysis at the time of the study was 4.3 (4.8) years. Approximately two-thirds of the responses on all five domains of the questionnaire ranked average when compared to the national numbers. The remainders were split between above average (20.6%) and below average (13.4%). In our cohort, no relationships were statistically significant between the five dependent variables of interest and the independent variables by chi-square- and t-test analyses. This was further confirmed by regression analysis. Of note, sex carried the strongest statistical significance (with a P-value of 0.16) as a predictor of "the burden of kidney disease on daily life" in ordinal regression. CONCLUSION: Prior studies have shown variables such as serum phosphate level, intradialytic weight gain, and dialysis adequacy are associated with lower KDQOL scores; however, this was not evident in our analysis likely due to smaller sample size. Larger size studies are required to better understand the predictors of QOL in ESRD patients on HD.