Jejunal Volvulus Around Gastrostomy Tube: An Exceptional Complication in Cerebral Palsy.

BACKGROUND Cerebral palsy may be accompanied by gastrointestinal disorders. Percutaneous endoscopic gastrostomy (PEG) tube placement is an increasingly performed procedure in these patients. While PEG tube feeding can result in weight gain and a decrease in aspiration episodes, this insertion of a PEG tube is not without complications. Specifically, intestinal volvulus following PEG tube insertion is an exceedingly rare complication. CASE REPORT A 34-year-old man with cerebral palsy was brought to the emergency department with a history of recurrent vomiting. He had a history of PEG tube insertion 2 months prior to his presentation. The physical examination was non-contributory. Abdominal computed tomography was suggestive of an intestinal volvulus around the PEG tube. Subsequently, the patient underwent an exploratory laparotomy, which confirmed the diagnosis and enabled successful management. Unexpectedly, the patient suffered cardiac arrest 5 days following the operation. Cardiopulmonary resuscitation was performed with pharmacological intervention and defibrillation in accordance with the advanced cardiac life support guidelines. He recovered successfully and was discharged after a 4-day observation. CONCLUSIONS Clinicians should have a high index of suspicion for small bowel volvulus in patients who had a PEG tube inserted, along with intestinal obstruction. Furthermore, caregivers should be educated to recognize the early signs of intestinal obstruction and seek medical attention, since a delay can result in fatal outcomes.

Gangliocytic Paraganglioma: A Rare Etiology of Obstructive Jaundice.

BACKGROUND Gangliocytic paraganglioma is an extremely rare tumor, with only 263 reported cases. This tumor has heterogeneous clinical presentation, with gastrointestinal bleeding being the most common. However, jaundice is a relatively unusual presentation, seen in less than 5% of all cases. CASE REPORT We report the case of a 32-year-old man who presented with abdominal pain and jaundice. He reported having similar episodes of this pain recently, but they were milder in severity. On examination, there was a tenderness in the right upper quadrant with a positive Murphy sign. Laboratory investigation revealed total bilirubin of 3.6 mg/dL with a direct bilirubin of 3.0 mg/dL, alkaline phosphatase of 323 IU/L, and g-glutamyltransferase level of 1153 IU/L, giving the impression of obstructive jaundice. The abdominal ultrasound examination revealed a normal common bile duct diameter with no thickening or pericholecystic fluid noted. Subsequently, the patient underwent endoscopic retrograde cholangiopancreatography, which revealed a mass in the second part of the duodenum. Histopathological examination of biopsy specimens obtained by fine-needle biopsy revealed an unencapsulated submucosal lesion with epithelioid, spindle, and ganglion cells. The spindle cells expressed positive immunohistochemical staining for S100, synaptophysin, and chromogranin. These findings were consistent with the diagnosis of gangliocytic paraganglioma. Surgical resection of the tumor was advised. However, the patient refused the operation despite the recommendation of the oncology team. CONCLUSIONS Gangliocytic paraganglioma is a very rare tumor that may present with a clinical picture mimicking a biliary disease. Clinicians should have a high index of suspicion for duodenal lesions in patients presenting with obstructive jaundice with no evidence of biliary stones.