Rectal Hematoma Mimicking as a Gastrointestinal Stromal Tumor: An Atypical Endoscopic Ultrasound Finding.

Acute gastrointestinal bleeding (GIB) represents a frequently encountered condition that prompts individuals to seek urgent medical attention at the emergency department, often leading to subsequent hospitalization. GIB can range from self-limited bleeding to hemorrhagic shock. Multiple etiologies contribute to the occurrence of GIB. In this report, we present the case of an 84-year-old male with multiple medical comorbidities admitted with hemodynamically stable lower GIB. Colonoscopy demonstrated a submucosal mass without evidence of bleeding. He subsequently underwent an endoscopic ultrasound (EUS) with sonographic findings concerning for a gastrointestinal stromal tumor. However, pathological analysis from both colonoscopy and EUS indicated the presence of blood, but no evidence of malignancy. A follow-up EUS performed two months later showed a complete resolution of the previously observed submucosal mass, suggesting that the initial evaluation was likely a hematoma that has resolved completely.

An Extremely Rare Case of Metastatic Merkel Carcinoma of the Liver.

Merkel cell carcinoma (MCC) is a rare but highly aggressive skin cancer with neuroendocrine features. The important risk factors in the development of MCC include immunocompromised state, advanced age, and White skin complexion. The pathogenesis is associated with either the presence of Merkel cell polyomavirus or chronic exposure to ultraviolet radiation. MCC usually occurs in the sun-exposed areas of the skin and has the potential for regional and distant metastasis. Only 8% of the cases of MCC present with distant metastatic disease with liver, lungs, bone, and brain being commonly involved. Here, we report such an extremely rare case of a 78-year-old gentleman with a history of cutaneous T-cell lymphoma, who presented to the hospital with abnormally elevated liver enzymes, which on further evaluation was detected to have metastatic MCC of the liver.

Endoscopic management of pancreaticopleural fistula after recurrent acute pancreatitis.

Pancreaticopleural fistula is an extremely rare complication of pancreatitis. We present a case of pancreaticopleural fistula in a patient with recurrent acute pancreatitis who presented with right-sided symptomatic pleural effusion. Pancreatic sphincterotomy and pancreatic duct stenting led to resolution of pleural effusion and withdrawal of the chest tube within 3 weeks.

Outcomes of diverticulitis in patients with tobacco smoking: a propensity-matched analysis of nationwide inpatient sample.

BACKGROUND: Recent data shows a significantly increased risk of diverticulosis among smokers. There is limited data on the association between tobacco smoking and diverticulitis. We aim to determine in-hospital outcomes, length of hospital stay, and resource utilization in a contemporary cohort of diverticulitis patients based on tobacco smoking status. METHODS: A retrospective analysis was performed by utilizing the National Inpatient Sample database (2016 and 2017) and the International Classification of Diseases, Tenth Revision codes to identify the patients with the principal diagnosis of diverticulitis and smoking. We assessed all-cause in-hospital mortality, morbidity, length of hospital stay (LOS), and total costs between propensity-matched groups of tobacco smokers vs. nonsmokers with diverticulitis. RESULTS: We identified 442,273 diverticulitis patients, of whom 96,864 were tobacco smokers, and 345,409 were nonsmokers. Between the two groups, in-hospital mortality was not significant (OR 1.09, 95% CI 0.38-2.6; P = 0.98). Tobacco smokers with diverticulitis have higher odds of lower gastrointestinal bleeding (LGIB) (OR 1.6, 95% CI 1.4-3.8; P = 0.01), peritonitis (OR 1.5, 95% CI 1.9-3.3; P = 0.00), intestinal obstruction (OR 1.6, 95% CI 2.8-7.6; P = 0.00), sepsis (OR 2.1, 95% CI 1.05-4.4; P = 0.03), and shock requiring vasopressor (OR 1.5, 95% CI 1.2-2.2; P = 0.00). In tobacco smokers with complicated diverticulitis, there were higher odds of LGIB (OR 1.4, 95% CI 1.2-1.6; P = 0.00), sepsis (OR 2.1, 95% CI 1.05-4.4; P = 0.03), and colectomy (OR 1.2, 95% CI 1.1-1.2; P = 0.00). In-hospital mortality was not significant in smokers with complicated diverticulitis (OR 1.2, 95% CI 0.78-1.9; P = 0.3). CONCLUSIONS: In this propensity-matched analysis, there was no difference in in-hospital mortality between tobacco smokers vs. nonsmokers with diverticulitis. Smoking has been associated with an increased incidence of complications in diverticulitis with a higher length of hospital stay and resource utilization.

Comparison of Characteristics and Inpatient Outcomes of Patients With Inflammatory Bowel Disease and Colon Cancer: A Propensity-Based Nationwide Inpatient Sample Study.

Introduction Patients with inflammatory bowel diseases (IBDs) frequently develop colon cancer. Previous studies have identified the association between IBD and colon cancer. In this study, we explored the characteristics and outcomes of IBD patients with colon cancer admitted to the hospitals of the United States. Methods Patients who were hospitalized patients with diagnoses of IBD and colon cancer were compared with patients with IBD without colon cancer. The data were extracted from the Nationwide Inpatient Sample (NIS) from January 2016 to December 2017. Comparisons were made with regards to mortality, complications, in-hospital stay, and cost of treatment between the two groups. Results We identified 1,82,025 hospitalizations from January 2016 to December 2017 admitted with a diagnosis of IBD. Of these, 181,560 patients had IBD without colon cancer, and 465 patients had IBD with colon cancer. No statistically significant difference was observed with regards to the in-hospital mortality between the two groups. There were higher odds of acute kidney injury (AKI) (OR 1.54, 95% CI 6.6-9.8; p=0.00), colectomy (OR 1.2, 95% CI 1.3-2.5; p=0.0) and lower gastrointestinal bleeding (LGIB) (OR 1.6, 95% CI 1.8-3.7; p=0.04) in patients with IBD and colon cancer. A longer length of stay (7.1±6.9 vs.5.0±5.6, p=0.00) and higher mean total charge ($20,283 vs. $12,166, p=0.00) were observed in patients with IBD with colon cancer. Conclusions Patients with IBD-associated colon cancer appear to have higher complication rates, higher costs, and more extended hospital stays. Therefore, early identification and management of complications related to IBD among patients with colon cancer are particularly crucial to reduce morbidity as well as the cost of hospitalization and treatment.

Outcomes of Clostridioides difficile in Patients with Vitamin D Deficiency: A Propensity-Matched National Inpatient Sample Analysis.

OBJECTIVES: We aimed to determine in-hospital outcomes, length of hospital stay, and resource utilization in a contemporary cohort of Clostridioides difficile infection (CDI) and vitamin D deficiency (VDD). METHODS: The National Inpatient Sample database for 2016 and 2017 was used for data analysis using International Classification of Diseases, Tenth Revision, Clinical Modification/Procedure Coding System (ICD-10-CM/PCS) codes to identify the patients with the principal diagnosis of CDI and VDD. We assessed the all-cause in-hospital mortality, morbidity, length of hospital stay (LOS), and total costs between propensity-matched groups of CDI without VDD versus CDI with VDD. RESULTS: We identified 202,234 patients with CDI, 4515 of whom were patients with VDD and 197,719 of whom were without VDD. After propensity matching, there was no difference in the in-hospital mortality between the two groups (odds ratio [OR] 1.5, 95% confidence interval [CI] 0.58-4.3; P = 0.90). CDI with VDD has a higher odds of sepsis (OR 1.6, 95% CI 1.3-1.9; P = 0.0), and peritonitis (OR 1.6, 95% CI 1.4-3.8; P = 0.01). Mean LOS (5.9 ± 1.8 vs 5.4 ± 2, P < 0.01) and mean total charges ($11,500 vs $9971, P < 0.04) were higher in CDI with VDD. The factors affecting the LOS were acute coronary syndrome (P = 0.04), mechanical ventilation (P = 0.03), obesity (P = 0.004), acute kidney injury (P = 0.04), and sepsis (P = 0.05). CONCLUSIONS: In this large cohort in a propensity-matched analysis, VDD does not increase the in-hospital mortality in CDI. VDD increases the odds of complications with a higher LOS and resource utilization. These findings may be clinically relevant to guide clinicians to routinely monitor vitamin D status and supplement in patients at risk of CDI.

Cannabis Vaping-Induced Acute Pulmonary Toxicity: Case Series and Review of Literature.

The use of cannabis for recreational as well as medicinal use is on the rise recently with more states legalizing it. We conducted a review analysis of the literature published on acute respiratory failure from vaping cannabis oil. We have also summarized the clinical details (age, length of stay, mode of ventilation, common clinical findings, and steroid use) along with common laboratory abnormalities. This article aims to educate health care providers on the clinical manifestations and management strategies for vaping-induced acute respiratory failure. We also discussed the different available formulations of cannabis oil and key ingredients responsible for the vaping-associated lung injury.

Pulmonary Kaposi Sarcoma: an uncommon presentation in HIV heterosexual female on antiretroviral therpay.

Kaposi sarcoma (KS) is caused by Human Herpesvirus 8 (HHV-8), and it affects 15 times more common in men than women. It has varied clinical presentation from classic, endemic, organ transplant-related, and acquired immunodeficiency syndrome (AIDS)-related. Clinical features of pulmonary KS might be challenging to distinguish from pneumonia in immunocompromised patients and could lead to diagnostic challenges. Hence Pulmonary KS should also be considered in the differential when HIV-infected patients develop rapidly progressive respiratory symptoms after the initiation of glucocorticoid therapy and immunocompromised not responding to antibiotic treatment for pneumonia, especially when CD4 < 100 and viral load >10,000. Early diagnosis and treatment are essential for a better outcome and prevent morbidity and mortality. Highly active antiretroviral therapy (HAART) is the only proven therapy to prevent Kaposi sarcoma. We report the case of a young woman who presented with symptoms of pneumonia and was later found to have pulmonary KS (PKS).

Gastrointestinal Manifestations in COVID-19 Infection and Its Practical Applications.

The latest novel coronavirus (COVID-19) outbreak, which emerged in December 2019 in Wuhan, Hubei, China, is a significant cause of the pandemic. This outbreak is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and is also commonly known as COVID-19. A typical symptom includes cough and fever, but a considerable number of patients can manifest gastrointestinal (GI) symptoms, including diarrhea, which can be the initial presentations and may or may not present with respiratory symptoms or fever. COVID-19 virus may be present in stool samples of patients infected with COVID-19, and angiotensin-converting enzyme 2 (ACE2) is a receptor for this virus, which is substantially present in GI epithelial cells. The wide availability of this receptor facilitates COVID-19 infection to be proactive and multiply in the GI tract. Although no antiviral treatments have been approved, several approaches have been proposed, and at present, optimized supportive care remains the mainstay of therapy. Elective endoscopic procedures should be delayed, but the urgent procedures should be performed as indicated. Due to the rapidly evolving data on COVID-19, it is difficult to keep up with the outpouring of information. We reviewed the mechanisms, clinical manifestation, impact on pre-existing liver diseases, and recommendations endorsed by the several GI societies for the management and prevention of its transmission.

Outcomes of Direct-Acting Antiviral Treatment of Psychiatric Patients with Comorbid Hepatitis C Virus Infection.

BACKGROUND: The highest burden of hepatitis C virus (HCV) infection is seen in patients with psychiatric disorders who have been excluded from traditional treatments with Interferon due to treatment-emergent neuropsychiatric adverse effects. The goal of this study is to determine the tolerability, treatment retention, and efficacy of direct-acting antivirals with psychiatric disorders and comorbid substance use disorders in real-life settings. METHODS: This is a retrospective cohort observational study of HCV patients treated with direct-acting antivirals between January 2016 and December 2018. Patients were stratified and sub-stratified based on their psychiatric diagnosis and substance use. The primary assessment was the sustained virologic response at 12 weeks post-treatment (SVR12). RESULTS: Among the 291 patients analyzed, patients with psychiatric diagnosis and non-psychiatric patients made up 51.2% (n = 149) and 48.8% (n = 142) respectively. Majority of the patients included in the study were African-Americans (68.7%, n = 200). Overall, 95.3% (142/149) and 94.4% (134/142) of psychiatric and non-psychiatric patients, respectively, achieved SVR12 and treatment response was similar between the groups (p = 0.72). Among psychiatric patients, only the prior treatment status was identified as a predictor of treatment response (OR 0.153, 95% CI 0.03-0.79; p = 0.05). No statistical difference was observed among the patients with SVR12 based on their primary psychiatric diagnoses or by comorbid substance abuse. CONCLUSION: The results of our study show that direct-acting antiviral treatments are well tolerated in psychiatric patients, and an overwhelming majority of patients achieved SVR12. Our study highlights the need to integrate HCV screening with treatment linkage in psychiatry and primary care practice.

A symptomatic gastric sarcoidosis and asymptomatic pulmonary sarcoidosis: a rare manifestation.

Sarcoidosis is a granulomatous disease of unknown etiology which may present with systemic manifestations. The diagnosis of gastric sarcoidosis needs much effort to accomplish as it is exceedingly rare, and the treatment is usually recommended exclusively for symptomatic disease. Here, we present a case of gastric sarcoidosis in a 31-year old black female patient with symptoms of nausea and epigastric pain. A diagnosis of gastric sarcoidosis was mainly based on the presence of non-necrotizing granulomas on biopsy following esophagogastroduodenoscopy (EGD). She was treated with steroid with high dose at first, followed by a slow taper and the symptoms responded to the treatment.

Prevalence of Portal Hypertensive Gastropathy in Chronic Liver Disease and Correlation with the Severity of Liver disease.

Background Portal hypertensive gastropathy (PHG) is an underappreciated condition in patients with chronic liver disease (CLD). It is a common endoscopic finding in CLD patients, but its relation with esophageal varices (EV) and the severity of the liver disease is controversial. Herein, we aimed to study the prevalence of PHG in CLD patients and to determine its association with EV and the severity of the liver disease. Methods This descriptive, cross-sectional, analytical study was conducted at the Hepatology department, Bir Hospital Kathmandu from 19th March to 30th June 2019. A total of 404 patients with CLD of various etiology fulfilling the inclusion criteria were approached, and informed consent was taken before enrolling in the study. All patients underwent EGD, and the findings related to EV and PHG were noted. The severity of PHG was graded according to the McCormack classification and EV were graded according to the American Association for the study of liver diseases guideline. The severity of liver disease was stratified based on Child-Pugh class and Model for End-Stage Liver Disease (MELD score). Data was entered on Statistical Package for the Social Sciences (SPSS) Version 25 for further analysis. Results Of 404 CLD patients, the mean (±SD) age was 49.14 (±10.5) years. Portal hypertensive gastropathy was observed in 269 (66.6%) patients, of which 80.6% (217) had mild PHG while 19.4% (52) had severe PHG. EV were present in 362 (89.6%) patients. One hundred and thirty-two (36.5%) had small EV, and 230 (63.5%) had large EV. No significant association was observed between grades of gastropathy and size of varices (p = 0.36). There was a non-significant association with the MELD score and other biochemical parameters. However, there were significant associations between Child-Pugh class and PHG and Child-Pugh class and PHG severity, p = 0.001 and p = 0.01 (p <0.05), respectively. Conclusions In our study, the prevalence of PHG in the Nepalese population in CLD is 66.6 %. PHG is significantly associated with the severity of CLD in terms of Child-Pugh class but not associated with MELD. Also, no association has been found with the size of varices.

A Successful Percutaneous Endoscopic Gastrostomy Tube Feeding over Two Decades with No Complication: A Rare Case Report.

Percutaneous endoscopic gastrostomy (PEG) feeding is a common and widely performed procedure appropriate for long-term enteral nutrition in patients with multiple indications. We present the case of a 59-year-old woman with a PEG tube placed owing to complication following thyroid surgery approximately 20 years ago, representing the most extended duration of PEG tube feeding without any significant complication for chronic mechanical dysphagia. This case highlights the importance of PEG feeding, where this route can be used indefinitely in an appropriate clinical setting without complications. Interestingly, self-replacement of PEG tube was performed by the patient herself whenever she noticed clogging up of tube while self-feeding.

Ecstasy induced acute systolic heart failure and Non-Ischemic Cardiomyopathy in a young female: a rare case report and literature review.

Ecstasy or 3,4-methylenedioxymethamphetamine (MDMA) is an illicit recreational drug. Effects include euphoria, increased sensory awareness, and central stimulation. Although various arrhythmias, as well as dilated cardiomyopathy, have been previously noted to occur with chronic use, cardiac toxicities are seldom reported in an acute setting. Herein, we present a 28-year-old female patient with no prior medical condition that presented to the Emergency Department with chest pain following intake of MDMA. Electrocardiographic findings, as well as laboratories, were suggestive of possible Acute Non-ST elevation myocardial infarction. Upon admission, cardiac catheterization revealed patent coronary arteries. Stark regional wall motion abnormalities were observed along with reduced ejection fraction. Acute systolic heart failure was treated with standard medical management. Subsequent reassessment of ventricular function with Echocardiography revealed marked improvement. This article describes a case of MDMA induced heart failure, including details of evaluation, management, and monitoring of patient progress. It brings further attention to potential acute harmful effects of MDMA on cardiac function and viability.

National Trends and Hospitalizations Related to Pancreatic Cancer in Acute Pancreatitis Patients: A Nationwide Inpatient Sample Study.

Background Pancreatic cancer (PC) is one of the common cancers in the United States (U.S.) and is associated with high mortality and morbidity. In spite of the modest improvement in survival, cancer care costs including PC continue to rise and inpatient costs contribute a significant chunk to cancer care, which is often ignored. Acute pancreatitis (AP) is a rare manifestation of PC. This study aims to determine the national trends and associated health care utilization of PC patients hospitalized with AP in the U.S. Methods We used National Inpatient Sample (NIS) to extract data for patients hospitalized with a primary diagnosis of PC in AP in 2016 using International Classification of Diseases, 10th revision, and Clinical Modification (ICD-10-CM) codes. The analysis included disease etiologies, age, race, sex, hospital region, hospital size, institution type, mortality, length of hospital stay (LOS), and commonly associated comorbidities were correlated. Results There were 250 patients with a discharge diagnosis of PC in patients admitted with AP. Most of the patients were whites (76.6%) with the mean age of 39.42 ± 2.51 years, had Medicare (63.26%) as primary insurance, were from Southern region (46%) and had higher Charlson comorbidity index (CCI) (76.00% with CCI > = 3). The mean hospital charges were $48,462.13, and mean LOS was 5.24 days. The LOS was significantly impacted by race, hospital region, endoscopic retrograde cholangiopancreatography (ERCP), and comorbidities such as dementia, smoking, and seizure. Out of the 250 patients admitted with PC, 245 patients (98%) were discharged alive. Conclusions Our study shows a downward trend in LOS, hospital charges, and in-hospital mortality as compared to other studies despite PC and AP presenting together versus PC with or without other etiologies.

Triad of Diabetic Ketoacidosis, Hypertriglyceridemia, and Acute Pancreatitis: Severity of Acute Pancreatitis May Correlate with the Level of Hypertriglyceridemia.

A 50-year-old African-American male with no known previous medical comorbidities presented to the emergency room with complaints of three days of worsening epigastric pain associated with nausea and vomiting. Laboratory parameters on admission revealed high lipase: 1796 U/L (normal range 0-160 U/L), high blood glucose level: 300 mg/dl, anion gap metabolic acidosis, ketonuria, significant hyperlipidemia (triglyceride: 1226 mg/dl (normal range <150 mg/dl), and LDL cholesterol: 307 mg/dl (normal range <100 mg/dl)). Treatment with intravascular volume and electrolytes replacement as well as administration of intravenous insulin successfully resolved diabetic ketoacidosis (DKA) and hypertriglyceridemia (HTG) with a drop in triglyceride (TG) level from 1226 mg/dl to 193 mg/dl. Radiologic imaging studies by ultrasonography (USG) and CT of the abdomen showed features suggestive of interstitial pancreatitis. Glycated hemoglobin (HbA1) was 10.7% suggesting uncontrolled diabetes mellitus. Here, we explain the possible pathophysiology and management of this uncommon triad-DKA, hypertriglyceridemia, and acute pancreatitis-followed by discussion and literature review, which highlight the diagnostic challenge and possible relation of the severity of pancreatitis with the degree of hypertriglyceridemia.

A Case of Sudden Very Late Onset of Severe Clozapine-induced Agranulocytosis Following an Influenza Vaccine.

Agranulocytosis can be a life-threatening condition because of its high risk of serious infection. It is extremely rare, with an incidence of one to five cases per million in the population per year. About 70% of the cases are associated with medications. Clozapine-induced leukopenia is a well-known clinical entity, justifying regular hematologic surveillance. Most cases of clozapine-induced neutropenia and agranulocytosis occur during the first three months of treatment. It's extremely rare after the first year of treatment. However, we present the case of a late-onset of sudden severe agranulocytosis following an influenza vaccine, after more than 156 months of stable neutrophil counts on clozapine. Clinicians must keep in mind that this complication can occur at any time during the treatment course and may wish to increase the frequency of hematologic surveillance following an influenza vaccine or even consider a risk-benefit approach. Considering the importance of the influenza vaccination and the seriousness of agranulocytosis, further studies are needed to elucidate a potential increase in the risk of severe neutropenia in patients on clozapine receiving the influenza vaccine.

Gastric diffuse large B-cell lymphoma with bilateral adrenal metastasis.

Extranodal adrenal involvement in non-Hodgkin's lymphoma is very rare, estimated to be around less than 0.2%. Most common sites involved are stomach, intestine and testis. It is very rare for adrenal tumours to present as primary adrenal insufficiency, with an incidence of around 1.2% in patients diagnosed with adrenal masses. Diffuse large B cell lymphoma (DLBL) originating from the stomach and metastasizing to bilateral adrenal glands is an extremely uncommon occurrence with only three cases found on review of the literature. We present a case of a 62-year-old African-American man who presented with nausea, vomiting, abdominal pain and hypotension, later being diagnosed as DLBL of the gastric antrum metastasized to bilateral adrenal glands. Initial laboratory workup revealed including hormonal analysis and cosyntropin test revealed adrenal insufficiency. The patient later died during the hospitalisation after developing respiratory failure, severe hypotension refractory to vasopressors and severe metabolic acidosis.

Ventriculoperitoneal Shunt Migration Inside the Gastric Lumen: A Rare Case Report.

Ventriculoperitoneal (VP) shunt placement is one of the more common procedures in neurosurgery and has a variety of indications. However, shunt placement can be associated with multiple complications, one of which is proximal and distal shunt migration. There have been reported cases of migration of the distal end of a VP shunt from the intraperitoneal cavity into different organs resulting in a variety of complications. Most of the reported cases are the result of spontaneous migration. However, shunt catheter migration could be iatrogenic as well. We present a case of intragastric VP shunt migration in a patient following placement of a percutaneous endoscopic gastrostomy tube.

Precipitating Factors and Treatment Outcomes of Hepatic Encephalopathy in Liver Cirrhosis.

Background Hepatic encephalopathy (HE) is a common cause of hospital admission in patients with liver cirrhosis (LC). The aims of this study were to evaluate the precipitant factors and analyze the treatment outcomes of HE in LC. Methods All the LC patients admitted between February 2017 and January 2018 for overt HE were analyzed for precipitating factors and treatment outcomes. Treatments were compared among three treatment groups: receiving lactulose, lactulose plus L-ornithine L-aspartate (LOLA), and lactulose plus rifaximin. The primary endpoints were mortality and hospital stay. The chi-square test was used to compare the different treatment outcomes with hospital stay and mortality with significance at p<0.05. Results A total of 132 patients (mean age 49.2 ± 10.2 years; male/female ratio of 103:29) were studied. The most common precipitating factor of HE was infection 65 (49.2%), followed by electrolyte imbalance 54 (41%), constipation 44 (33.33%), and gastrointestinal bleeding 21 (16%) patients. At the time of admission, 29 (22%), 76 (57.5%), 21 (16%), and six (4.5%) patients had grade I, II, III, and IV HE, respectively. The difference in mortality was not statistically significant (p=0.269) in three groups but the hospital stay was shorter among patients in groups B and C than in group A alone (7.36 ± 4.58 and 7 ± 3.69, 9.64 ± 5.28 days, respectively, p=0.015). Conclusions Infection, especially spontaneous bacterial peritonitis, was the commonest precipitating factor of HE. The combination of lactulose either with LOLA or rifaximin is equally effective in improving HE and reducing the duration of hospital stay than lactulose alone.