Diffuse nodular lymphoid hyperplasia of intestine in selective IgG 2 subclass deficiency, autoimmune thyroiditis, and autoimmune hemolytic anemia: case report and literature review.

Diffuse Nodular Lymphoid Hyperplasia (DNLH) of the intestine is a rare lymphoproliferative disorder of uncertain etiology, which is characterized by the presence of multiple nodular lesions. It can present as an asymptomatic disease or manifest with gastrointestinal symptoms like abdominal pain, chronic diarrhea, occult bleeding or rarely intestinal obstruction. DNLH has been seen in association with common variable immunodeficiency (CVID) where it poses a risk of malignant transformation. We present a case of diffuse lymphoid nodular lymphoid hyperplasia in a patient who was presented with abdominal pain and diarrhea, and was later found to have IgG2 subclass immunodeficieny, autoimmune hemolytic anemia and Hashimoto's (autoimmune) thyroiditis. Through this report, we wish to review current literature as well as share our clinical experience in managing this rare entity.

Successful management of a gastric sleeve leak with an endoscopic stent.

Laparoscopic sleeve gastrectomy has been a recently developed technique for treating morbid obesity. Gagner and Patterson performed the first laparoscopic sleeve gastrectomy as part of a duodenal switch procedure at Mount Sinai Hospital in New York in 1999. Since then many surgeons and institutions have adopted this technique. One of the most dreaded complications of sleeve gastrectomy is a leak along the staple line. We present the case of a 23-year-old female with gastric sleeve leak managed successfully with a fully covered wall flex stent. Our aim is to examine the incidence, causes, classification, and presentation of gastric sleeve leaks and to evaluate the use of endoscopic stents in its management.

Endoscopic management of a primary duodenal carcinoid tumor.

Carcinoids are rare, slow-growing tumors originating from a variety of different neuroendocrine cell types. They are identified histologically by their affinity for silver salts and by positive reactions to neuroendocrine markers such as neuron-specific enolase, synaptophysin and chromogranin. They can present with various clinical symptoms and are difficult to diagnose. We present the case of a 43-year-old woman who was referred for evaluation of anemia. Upper endoscopy showed a duodenal bulb mass around 1 cm in size. Histopathological and immunohistochemistry staining were consistent with the diagnosis of a carcinoid tumor. Further imaging and endoscopic studies showed no other synchronous carcinoid lesions. Endoscopic ultrasound (EUS) revealed a 1 cm lesion confined to the mucosa and no local lymphadenopathy. Successful endoscopic mucosal resection of the mass was performed. Follow-up surveillance 6 months later with EUS and Octreoscan revealed no new lesions suggestive of recurrence. No consensus guidelines exist for the endoscopic management of duodenal carcinoid tumors. However, endoscopic resection is safe and preferred for tumors measuring 1 cm or less with no evidence of invasion of the muscularis layer.

Hepatic sarcoidosis presenting as portal hypertension and liver cirrhosis: case report and review of the literature.

Systemic sarcoidosis is a disease of unknown etiology, with the liver being the third most commonly affected organ. Most cases of hepatic sarcoidosis are not clinically apparent, but a few can progress to liver cirrhosis, portal hypertension and ultimately liver failure. The diagnosis of hepatic sarcoidosis is difficult, considering that no single laboratory test or radiographic finding can definitively diagnose this systemic disease. Diagnosis of hepatic sarcoidosis relies heavily on histopathologic evaluation of two or more organs, a diagnostic modality that is invasive and may not be applicable to all patients. The treatment of hepatic sarcoidosis is challenging, with no large randomized controlled trials done to date. Physicians must be aware of the complications of hepatic sarcoidosis, and must include the same in the differential diagnosis of liver cirrhosis. We present a case of hepatic sarcoidosis complicated by portal hypertension and liver cirrhosis.

Cytomegalovirus infection of the colon presenting as a mass-like lesion.

Cytomegalovirus (CMV) is responsible for the most common opportunistic infections in patients with acquired immunodeficiency syndrome (AIDS). The colon is a common site for these infections in patients positive for human immunodeficiency virus. CMV rarely presents as an intraluminal inflammatory mass in the colon. Here we report the case of a CMV infection presenting as a mass-like lesion in an AIDS patient. The clinical diagnosis of CMV infection is largely based on the characteristic endoscopic appearance. Endoscopic procedures are encouraged early in the course of CMV infection in immunocompromised patients. CMV pseudotumors along with malignancy should be part of the endoscopic evaluation in patients with AIDS.

Inappropriate Use of Gastric Acid Suppression Therapy in Hospitalized Patients with Clostridium difficile-Associated Diarrhea: A Ten-Year Retrospective Analysis.

Purpose. The incidence of Clostridium difficile-associated diarrhea (CDAD) has steadily increased over the past decade. A multitude of factors for this rise in incidence of CDAD have been postulated, including the increased use of gastric acid suppression therapy (GAST). Despite the presence of practice guidelines for use of GAST, studies have demonstrated widespread inappropriate use of GAST in hospitalized patients. We performed a retrospective analysis of inpatients with CDAD, with special emphasis placed on determining the appropriateness of GAST. Methods. A retrospective analysis was conducted at a multidisciplinary teaching hospital on inpatients with CDAD over a 10-year period. We assessed the use of GAST in the cases of CDAD. Data collection focused on the appropriate administration of GAST as defined by standard practice guidelines. Results. An inappropriate indication for GAST was not apparent in a majority (69.4%) of patients with CDAD. The inappropriate use of GAST was more prevalent in medical (86.1%) than on surgical services (13.9%) (P < 0.001). There were more cases (67.6%) of inappropriate use of GAST in noncritical care than in critical care areas (37.4%) (P < 0.001). Conclusion. Our study found that an inappropriate use of inpatient GAST in patients with CDAD was nearly 70 percent. Reduction of inappropriate use of GAST may be an additional approach to reduce the risk of CDAD and significantly decrease patient morbidity and healthcare costs.

Lower extremity cutaneous lesions as the initial presentation of metastatic adenocarcinoma of the colon.

Cutaneous metastases from colorectal cancers are rare and are usually present on the abdominal wall or previous surgical incision sites. Remote cutaneous lesions have been reported, however, often occur in the setting of widespread metastatic disease including other visceral secondaries. We present a case of lower extremity cutaneous metastases as the first sign of metastatic disease in a patient with adenocarcinoma of the colon. This case illustrates that new skin lesions may be the initial presentation of metastatic disease in a patient with a history of cancer.

Colonic metastases from pleomorphic carcinoma of the lung presenting as an ileocecal intussusception.

Pleomorphic carcinoma is a rare aggressive type of lung cancer that uncommonly metastasizes to the bowel, leading to bleeding, perforation, obstruction, and rarely intussusception. Serving as a lead point, metastatic lesions in the bowel may precipitate intussusception and require immediate surgical intervention. We present a rare case of colonic metastases from a primary lung malignancy, causing ileocecal intussusception in a 57-year old male.

Cytomegalovirus infection presenting as a colonic mass in a patient with acquired immunodeficiency syndrome.

Cytomegalovirus (CMV) infection of the gastrointestinal tract occurs in both immunocompromised and immunocompetent hosts. Often presenting as ulcerative lesions, CMV infection rarely presents as a mass lesion in the gastrointestinal tract. We present a case of a discrete colonic mass caused by CMV infection in a patient with acquired immunodeficiency syndrome (AIDS). This case illustrates that an infectious process such as CMV should be considered along with malignancy as the etiology of a mass lesion present in the gastrointestinal tract of patients with AIDS.

Extrapulmonary Small Cell Carcinoma of the Stomach: A Lethal Entity.

Extrapulmonary small cell carcinoma of the stomach is a rare and aggressive malignancy with a poor prognosis that was first described in 1976 by Matsusaka et al. In 1989 it was recognized by the World Health Organization as an independent entity affecting the stomach. Pure and composite are the two types of gastric small cell carcinoma reported in the literature. We report a case of a 68-year-old African American male with metastatic pure-type extrapulmonary small cell cancer of the stomach. The primary lesion measured approximately 7 cm in diameter on endoscopy. The diagnosis was made on the basis of characteristic histological features of small, round, oval lymphocyte-like cells with hyperchromatic nuclei, and scant cytoplasm consistent with small cell carcinoma. Gastric small cell carcinoma is typically diagnosed at an advanced stage as demonstrated in our case. We conducted a literature review discussing the two types of extrapulmonary small cell carcinoma of the stomach and their prevalence.