The Traumatic Tube: Bleeding Rectal Ulcer Caused by Flexi-Seal Device.

Diarrhea and fecal incontinence are common in critically ill patients and present a challenging problem in patient management. The Flexi-Seal® Fecal Management System is a device to divert the stools away from the patient, thus improving the care to patients with fecal incontinence. There have been only few case reports describing the complications with the use of this device. Here, we present a case of a 77-year-old woman who was admitted due to massive hematochezia while on anticoagulation. She was found to have a large rectal ulcer caused by the Flexi-Seal device, used during the last hospital stay for fecal incontinence. Flexi-Seal device can be effective for the management of incontinence; however, caution should be exercised during handling and pressure from the retention balloon should be relieved periodically.

Celiac Disease Associated with a Benign Granulomatous Mass Demonstrating Self-Regression after Initiation of a Gluten-Free Diet.

Celiac disease is a chronic immune-mediated enteropathy in which dietary gluten induces an inflammatory reaction predominantly in the duodenum. Celiac disease is known to be associated with benign small bowel thickening and reactive lymphadenopathy that often regresses after the institution of a gluten-free diet. A 66-year-old male patient with celiac disease presented with abdominal pain and diarrheal illness. Computerized tomography of the abdomen revealed a duodenal mass. Endoscopic ultrasound-guided fine needle aspiration of the mass revealed bizarre stromal cells which represent a nonspecific tissue reaction to inflammation. This inflammatory mass regressed after the institution of a gluten-free diet. This case report describes a unique presentation of celiac disease in the form of a granulomatous self-regressing mass. Also, this is the first reported case of bizarre stromal cells found in association with celiac disease. In addition to lymphoma and small bowel adenocarcinoma, celiac disease can present with a benign inflammatory mass, which should be serially monitored for resolution with a gluten-free diet.

Unusual Clinical Presentation of Hemobilia with Recurrent Vasovagal Episodes.

Hemobilia is caused by the abnormal connection between a blood vessel and the bile duct, which is usually iatrogenic and caused by hepatobiliary procedures. The classic triad of hemobilia includes biliary colic, obstructive jaundice, and gastrointestinal bleeding. We present the case of an 80-year-old man who had laparoscopic cholecystectomy complicated by hemobilia. He had an unusual presentation of hemobilia in the form of transient vasovagal episodes in addition to abdominal pain and hematochezia.

Urinary Tract Infection Associated with a Celiac Crisis: A Preceding or Precipitating Event?

Celiac crisis is a rare life-threatening presentation of celiac disease that manifests as profuse diarrhea, hypoproteinemia, and severe metabolic disturbances. It may be precipitated by a general immune stimulus such as surgery, infection, or pregnancy. We report the case of a 26-year-old woman who presented with a celiac crisis, potentially triggered by a preceding urinary tract infection. Metabolic derangement is caused by malabsorption and profuse diarrhea, which can be unremitting unless the celiac crisis is recognized, and treatment with gluten restriction is initiated.

Recognition of Extraperitoneal Colonic Perforation following Colonoscopy: A Review of the Literature.

Colon perforation is an uncommon but serious complication of colonoscopy. It may occur as either intraperitoneal or extraperitoneal perforation or in combination. The majority of colonic perforations are intraperitoneal, causing air and intracolonic contents to leak into the peritoneal space. Rarely, colonic perforation can be extraperitoneal, leading to the passage of air into the retroperitoneal space causing pneumoretroperitoneum, pneumomediastinum, pneumopericardium, pneumothorax, and subcutaneous emphysema. A literature review revealed that 31 cases of extraperitoneal perforation exist, out of which 20 cases also reported concomitant intraperitoneal perforation. We report the case of a young female with a history of ulcerative colitis who developed combined intraperitoneal and extraperitoneal perforation after colonoscopy. We also report the duration of onset of symptoms, clinical features, imaging findings, site of leak, and treatment administered in previously reported cases of extraperitoneal colonic perforation.

Tianeptine interferes with microtubule organization and hormone secretion of pheochromocytoma cells.

Pheochromocytoma originates from chromaffin cells in the adrenal medulla and sympathetic paraganglia. 36-53% of pheochromocytoma becomes malignant and, thereafter, resistant to conventional treatments. Pheochromocytoma also causes hyper-secretion of catecholamines that cause severe hypertension. We found that an antidepressant, tianeptine, interfered with normal life cycle of pheochromocytoma cells at its clinical doses. Treatment with tianeptine caused microtubule bundling and specific degradation of cytoplasmic dynein, a retrograde microtubule motor that mediates various microtubule-dependent processes during interphase and mitosis, in the rat pheochromocytoma PC12 cells. Tianeptine also increased the levels of pro-apoptotic proteins, slowed cell cycle progression, and increased apoptosis in PC12 cells. Importantly, tianeptine treatment decreased high K(+)-stimulated secretion of norepinephrine and chromogranin A in PC12 cells and of epinephrine in the mouse pheochromocytoma MPC cells. Our study demonstrates, for the first time, that tianeptine interferes with normal life cycle of pheochromocytoma cells.

Gitelman syndrome manifesting in early childhood and leading to delayed puberty: a case report.

INTRODUCTION: Gitelman syndrome is an inherited autosomal recessive renal salt-wasting disorder. It presents with variable clinical symptoms including muscle weakness and fatigue, and the diagnosis is based on metabolic alkalosis, hypokalemia, hypomagnesemia and hypocalciuria. It is usually diagnosed incidentally in early adulthood. There are rare cases of Gitelman syndrome presenting in early childhood; however, to the best of our knowledge it has not previously been associated with delayed puberty. CASE PRESENTATION: A 17-year-old South Asian man with recurrent episodes of generalized muscle weakness, fatigue and cramps from the age of two years was admitted for further workup. Before the age of 12 years, the episodes had been mild, but they then got progressively worse. Other symptoms include polyuria, polydipsia, nocturia, paresthesia and occasional watery diarrhea. He also had a history of short stature, poor weight gain and delayed developmental landmarks. His family history was unremarkable except for the consanguineous marriage of his parents. An examination revealed a thin and lean man with blood pressure of 95/60mmHg. His height and weight were below the third percentile and his sexual development was at Tanner Stage II. Laboratory work revealed serum sodium of 124mmol/L, potassium 2.4mmol/L, calcium 6.5mmol/L and magnesium of 1.2mg/dL. His testosterone level was low (0.85ng/mL, normal for his age 2.67 to 10.12ng/mL) with normal levels of luteinizing hormone and follicle-stimulating hormone. The sex hormone findings were attributed to delayed puberty. A 24-hour urinary analysis revealed decreased excretion of calcium (25.9mg/24 hours). Based on the findings of hypokalemic metabolic alkalosis without hypertension, severe hypomagnesemia and hypocalciuria, a diagnosis of Gitelman syndrome was made. Treatment was started with oral supplementation of potassium, magnesium and calcium along with spironolactone and liberal salt intake. CONCLUSION: Diagnosis of Gitelman syndrome is usually made incidentally during adolescence or early adulthood based on clinical and biochemical findings. We report that Gitelman syndrome can present during the early childhood years. If undiagnosed and untreated, it can lead to growth retardation and delayed puberty.

Gestational diabetes mellitus is rare in primigravida Pakistani women.

BACKGROUND: Gestational diabetes mellitus is a metabolic disorder defined as glucose intolerance with onset or first recognition during pregnancy. Similar to other members of the Asian race, Pakistani women are also considered to be at a high risk for developing gestational diabetes. MATERIALS AND METHODS: In order to better understand whether this heightened risk attributed to race really exists, we conducted a prospective study to assess the glycemic status of primigravida women presenting to our hospital. RESULTS: The mean age of 135 subjects enrolled was 22 (16-31), with 21 (16%), 60 (44%), and 54 (40%) subjects in the first, second, and third trimesters of pregnancy, respectively. The mean fasting, 1-hour, and 2-hour plasma glucose levels were 69.9 mg/dL (3.9 mmol/L), 129 mg/dL (7.2 mmol/L), and 103.6 mg/dL (5.76 mmol/L), respectively. Of 135 women, 6 had a blood pressure reading ≥140/90 mm Hg and only one met the criteria for gestational diabetes mellitus. In our study, despite using the newly proposed International Association of Diabetes and Pregnancy Study (IADPS) cut-offs for diagnosis of gestational diabetes, the incidence rate of gestational diabetes mellitus in primigravida was still <1%. CONCLUSION: Larger trials are needed to truly assess the disease burden of gestational diabetes mellitus in Pakistani women.