Gastroduodenal Fistula: A Rare Finding With an Atypical Presentation.

Gastroduodenal fistula (GDF) or double pylorus is a rare, often asymptomatic condition with a prevalence of approximately 0.02-0.08%. The reported cases have been mainly in Asian countries and more prevalent in males than females. Although the etiology is unclear, Helicobacter pylori and nonsteroidal anti-inflammatory drug use have been associated with the formation of GDF. We present the case of a 65-year-old female with alcoholic cirrhosis and recurrent vomiting who was found to have an antral ulcer. The case includes the serial endoscopic examinations over the period of 7 years and shows the antral ulcer which fistulized into the duodenal bulb creating double pylorus.

Clostridioides difficile co-infection with Enterohemorrhagic Escherichia coli (EHEC)-a potentially fatal combination.

There has been a significant increase in hospital and community acquired Clostridioides difficile infection in the past decade. In addition to CDI, the rate of infection with enterohemorrhagic Escherichia coli (EHEC) has also increased by 28% in United States in the last five years. Concomitant CDI and EHEC infections are rare and if not identified early such co-infections can be fatal. We present the case of patient with hematochezia who was found to be positive for Clostridioides difficile and EHEC. She had a complicated hospital course that required timely identification of complications and management.

Diphyllobothrium latum Mimicking Subacute Appendicitis.

Diphyllobothrium latum (D. latum) infection in humans is uncommon in the United States. Although there has been a drastic decline in the report of D. latum infection in this region, physicians should be aware of an uncommon presentation and its clinical relevance. We report a case of 55-year-old female of Ecuadorian/Peruvian origin who presented with an unknown cause of chronic right lower quadrant abdominal pain for 2 months without other particular symptoms. Initial workup revealed evidence of iron deficiency anemia, and stool occult blood test was positive. She was scheduled for a colonoscopy to assess the source of occult gastrointestinal bleeding. During her bowel preparation, she passed a 25 cm long white tapeworm-like material confirmed microscopically. Despite passing a worm she continued to have abdominal pain. During the colonoscopy, another worm was found lodged in the appendiceal orifice. The colonoscopic images revealed a segmented tapeworm showing contractile motility, approximately 12 cm in length and 6 mm wide in the appendiceal orifice. The scope was unsuccessful in removing the worm. The parasitological and microbiological examination of the passed worm was positive for D. latum. D. latum a fish tapeworm that infects humans after the ingestion of raw or undercooked fish. The patient had a history of often eating lightly marinated raw fish ("ceviche") in Peru several months before presentation. It is uncommon for D. latum infection to present with iron deficiency anemia. As the worm absorbs approximately 80% of dietary vitamin B12, prolonged D. latum infection usually causes vitamin B12 deficiency and megaloblastic anemia, which is reported to affect about 40% of cases. Abdominal pain related to mechanical obstruction is reported, but this case is unique in that the worm preferentially attached to the appendiceal orifice causing subacute focal appendiceal pain. She was treated with a single dose of oral praziquantel. After the treatment, she developed minor cramping for the next 2 days which resolved by day 3, and recalled passing half-inch sized pieces of white tissue and subsequently improved. Although D. latum infection is an uncommon cause of chronic abdominal pain with iron deficiency anemia, it is crucial to consider because of the potentially treatable outcome.

Cronkhite-Canada Syndrome: A Rare Cause of Chronic Diarrhea.

Cronkhite-Canada syndrome (CCS) is a rare non-hereditary disease characterized by chronic diarrhea, diffuse intestinal polyposis and onychodystrophy. We present here a case of a middle-aged female who presented with chronic intermittent bloody diarrhea associated alopecia and loss of finger and toe nails. Labs were remarkable for microcytic anemia and severe hypoalbuminemia. Endoscopy showed numerous polyps scattered throughout the colon. She was treated with nutritional support and corticosteroid with complete resolution of her symptoms and endoscopic findings. CCS is associated with high mortality and gastrointestinal malignancies. Clinicians should consider CCS in a patient with unexplained chronic diarrhea and ectodermal abnormalities.

Refractory Celiac Disease Successfully Treated With Azathioprine.

Refractory celiac disease (CD) is a clinical diagnosis defined by the persistence of signs/symptoms, laboratory abnormalities or villous atrophy typical of CD despite strict adherence to a gluten-free diet for at least 6 - 12 months. It should be suspected when patients with CD fail to respond primarily or secondarily to a gluten-free diet, especially if there is significant weight loss. Differentiation between types is important both for management and predicting prognosis. Type I can be managed with mild immunosuppression with nutritional support. Type II requires strong immunosuppression like azathioprine. Recently, autologous stem cell transplantation has also been used to treat type II.

Association of Autoimmune Hepatitis and Celiac Disease: Role of Gluten-Free Diet in Reversing Liver Dysfunction.

Autoimmune hepatitis (AIH) is a chronic inflammation of liver with unclear etiology. It is frequently associated other autoimmune diseases, and its association with celiac disease (CD) is well established. In this article, we describe the case of a 50-year-old male with long-standing AIH taking azathioprine for 10 years, evaluated for flares in transaminases. Despite adding high-dose corticosteroids, his transaminases and bilirubin remained high. Serology for CD was ordered, which revealed elevated tissue transglutaminase antibody IgG and endomysial IgA, which was further confirmed by endoscopic biopsy. Strict gluten-free diet was advised and now for over 2 years he is in remission with azathioprine and budesonide. This emphasizes the role of gluten-free diet in reversing liver dysfunction in patients with AIH, and clinicians should consider screening for CD in patients with AIH with persistent elevation of liver enzymes despite immunosuppressant treatment.

Isolated duodenal varices as the initial presentation of hepatocellular carcinoma.

Duodenal varices are an uncommon, life-threatening cause of acute gastrointestinal (GI) bleeding commonly caused by portal hypertension. Though generally regarded as a complication of advanced cirrhosis and portal hypertension, often overlooked is that in about 2.7% of cases, it can be the first presenting symptom of advanced hepatocellular carcinoma (HCC). We report a case of an isolated, duodenal variceal bleeding as the first clinical manifestation of HCC, complicated by portal venous thrombosis. Diagnosis of HCC was established by a markedly elevated α-fetoprotein, hepatitis B surface and core antibody positivity and consistent radiological findings. Although not the first choice, variceal bleeding was successfully arrested with endoclips. The patient thereafter declined further evaluation and unsurprisingly died within a few weeks from a massive GI bleed. An initial bleed from a duodenal varix often confers a poor prognosis. Patients with HCC who present with variceal bleeding reportedly have a median survival of 71 days.