The Resolution of a Cerebrovascular Accident With Phlebotomy in a Hemodialysis Patient With Sickle Cell Disease.

Anemia is commonly observed in patients with end-stage renal disease (ESRD) on maintenance hemodialysis (HD) and can be quite severe, particularly when there is an additional comorbidity. With the use of erythropoietin-stimulating agents (ESAs), anemia is effectively treated, but the complete normalization of hemoglobin is not recommended since these agents increase the risk of thrombosis. With improvements in the therapy of sickle cell disease (SCD), patients now survive longer and may more frequently reach end-stage renal disease and require renal replacement therapy. Their anemia can be severe but does respond to ESAs. The goal hemoglobin in these patients is not established and likely should be lower than others on maintenance hemodialysis (HD) since SCD patients already have an increased risk of thrombosis, and the use of ESAs may exacerbate this risk. We present a 57-year-old African-American female with SCD on maintenance HD admitted with an acute cerebrovascular accident (CVA) that occurred in spite of the fact that her hemoglobin was within the accepted range for the general population on maintenance HD. Her neurologic status did not improve with blood pressure control and exchange transfusions, the suggested initial therapy for an acute CVA in a patient with sickle cell disease (SCD). However, with phlebotomy, the patient's symptoms rapidly improved when her hemoglobin was lowered and subsequently maintained with a lower dose of ESAs. Our experience suggests that the hemoglobin goal in SCD patients on maintenance HD should be lower than in other HD patients. The role of phlebotomy during an acute thrombotic event needs to be explored further.

Recurrent Acute Pancreatitis and Superior Mesenteric Venous Thrombosis - Cause or Course.

The management of pancreatitis can be daunting, especially when associated with other comorbidities. These complexities in management are conflicting in the presence of comorbidities with a similar presentation, such as abdominal pain. Acute pancreatitis (AP) has been associated with mesenteric thrombosis but less commonly with superior mesenteric vein thrombosis (SMVT) as a causal or complicating dilemma. This case report describes the careful intrigues and overlaps in presentation. Furthermore, this paper presents a dilemma in that contrast-enhanced computed tomography (CT) may not be recommended in the early stage of diagnosis of AP according to the 2013 American College of Gastroenterology (ACG) guideline, but SMVT, which can be fatal, sometimes, complicates AP, and contrast-enhanced CT is important in its diagnosis. This paper attempts to address this dilemma. Managing these two potentially fatal pathologies requires promptness and thoughtfulness in averting a deadly outcome. Because SMVT is fatal, in this paper, we reiterate the use of contrast-enhanced CT in the early stages of the management of AP. Fatal complications from AP should not be missed. Although contrast-enhanced CT is not recommended in the early stages of diagnosis of AP in the ACG guideline, fatal complications such as SMVT can be avoided.

Upper Gastrointestinal Bleeding Secondary to an Incidental, Impacted Foreign Body in the Duodenum.

A 68-year-old woman presented with a three-week history of upper abdominal discomfort, vomiting of coffee ground substance, and passage of tarry stools. There were no typical risk factors for gastroduodenal or liver disease. Gastroscopy done showed a fishbone impacted in the wall of the pyloric opening with its free end abutting on the wall of the duodenum resulting in a duodenal ulcer. Antral erosions were also noted. Retrieval forceps were used to retrieve the fishbone. The patient did not remember eating any fish containing meal, and there was no odynophagia. This case emphasizes the importance of considering foreign bodies as a cause of upper gastrointestinal bleeding as well as the need for an endoscopic review of all patients with upper gastrointestinal bleed.