Combination of Percutaneous Transhepatic Balloon-Assisted Transjugular Intrahepatic Collateral Caval Shunt and Embolization for Successful Hemostasis of Lower Gastrointestinal Bleeding Associated With Extremely Enlarged Anorectal Varicose Veins.

Ectopic varices may frequently occur in the rectum in the context of portal hypertension. Although rectal variceal bleeding is not a frequent bleeding situation, it can be life-threatening unless diagnosed and treated immediately. However, there is no specific treatment strategy established so far. We report a case of a man with extrahepatic portal hypertension and severe hematochezia due to rectal variceal bleeding. The patient was diagnosed in the past with portal vein thrombosis, in the context of myelodysplastic syndrome/myeloproliferative neoplasm overlap syndrome, with ectopic varices in the small intestine, colon, rectum and anal canal, peritoneum and perisplenic veins, treated with mesorenal shunt placement and an oral beta-blocker. After the initial stabilization with fluid replacement and red blood cell transfusion, he underwent endoscopic injection sclerotherapy, with no effect on bleeding episodes, while the large size of the varices precluded the option of endoscopic band ligation. Due to the presence of large collateral veins next to the inferior vena cava, the patient underwent combination therapy with Percutaneous Transhepatic Balloon-Assisted Transjugular Intrahepatic Collateral Caval shunt placement, to decompress portal pressure, followed by angiographic embolization of the feeding vessels resulting in successful hemostasis. Hematochezia ceased, hemoglobin was stabilized and the patient was safely discharged from the hospital. Controlling and treating rectal varices can be a challenging task indicating the need of a multidisciplinary approach. In the absence of well-established treatment guidelines for rectal varices, we highly recommend treatment of refractory ectopic variceal bleeding, non-responsive to endoscopic treatments, with portocaval shunt placement in combination with embolization.

Olmesartan-Induced Enteropathy: A Report of an Unusual Cause of Chronic Diarrhea.

Olmesartan, an angiotensin II receptor blocker indicated in the treatment of hypertension, has been associ-ated with a seronegative sprue-like enteropathy that should be considered in the differential diagnosis of patients with unexplained chronic diarrhoea. It typically presents with severe chronic diarrhoea, considerable weight loss, and villous atrophy on biopsy and may be difficult to recognize because of its clinical and histological similarities to other clinical entities. Practically, discontinuation of the drug leads to dramatic recovery of the symptoms. We report a 76-year-old Caucasian female who was admitted to our hospital with complaints of chronic diarrhea and significant weight loss. Medical history was notable for hypertension being treated with olmesartan. Initially, investigation for all potential infectious causes and celiac disease was negative. Both upper and lower endoscopy was performed with duodenal biopsies revealing total villous atrophy and colonic biopsies showing lymphocytic colitis. In the presence of negative serology for celiac disease and after a thorough review of the patient's medications, olmesartan in-duced-enteropathy was the most possible diagnosis. Olmesartan was discontinued and the symptoms rapidly resolved. A follow-up done a few months later showed no recurrence of the symptoms. In olmesartan-associated enteropathy, discontinuation of olmesartan results in immediate clinical recovery. Although rare, it is considered an emerging and underdiagnosed enteropathy. This case report illustrates the need for a thorough medication history evaluation and regular review during workup. We aim to increase the awareness of olmesartan-induced enteropathy among clinicians and gastroenterologists. We hope it will add to the current literature and help to understand this rare phenomenon in order to avoid unnecessary testing.

Chilaiditi Syndrome With a Large Colonic Loop in a Patient With Autonomic Nervous System Dysfunction.

Chilaiditi syndrome is an unusual condition in which radiographic evidence of a large bowel interposition between the liver and the right hemidiaphragm appears in the chest X-ray. The etiology is unknown and the clinical symptoms vary from case to case. The special characteristics of the syndrome can easily lead to a misdiagnosis and a CT scan is needed to avoid surgical interventions for a suspected pneumoperitoneum. We present a 48-year-old female patient with a medical history of autonomic nervous system dysfunction who referred to the Emergency Department (ED) due to abdominal pain. Chest radiography revealed a radiographic sign of pneumoperitoneum but a CT scan of the abdomen showed interposition of the right colon in the right hemithorax between the diaphragm and the liver without any signs of perforation. The patient was treated with bowel decompression and her symptoms resolved gradually. So far, there is no other case of Chilaiditi syndrome in a patient with autonomic nervous system dysfunction in the published literature. To conclude, Chilaiditi's sign is an unusual radiographic sign presenting as a pneumoperitoneum in the chest X-ray. In order to avoid misdiagnosis and unnecessary surgical interventions, a CT scan should be ordered.

Sweet Syndrome Associated With Crohn's Disease Developed After a Combo Therapy With Infliximab and Azathioprine: A Case Report.

Sweet syndrome, also known as Acute Febrile Neutrophilic Dermatosis, is a rare inflammatory condition. The exact pathogenesis of Sweet syndrome is unclear, however, autoimmune and inflammatory conditions including inflammatory bowel disease have been linked as underlying etiologies. Since its description, in 1964, there have been published less than fifty reports of Crohn's-associated Sweet syndrome. We report a 43-year-old male patient with a medical history of Crohn's disease who subsequently developed Sweet syndrome. Two years after the diagnosis of Crohn's disease the patient was administered a combo therapy with Infliximab and Azathioprine followed by deep remission. A few months later the patient manifested with skin lesions with histopathological findings suggestive of Sweet syndrome. Sweet syndrome, although rare, may occur as an extra-intestinal manifestation of Crohn's disease. This report illustrates the need for a thorough investigation of patients with Crohn's disease presenting with skin lesions. We hope it will add to the current literature and help understand this rare phenomenon in order to achieve a proper diagnosis.