Hepatobiliary strongyloidiasis presenting as an ampullary lesion on esophagogastroduodenoscopy/endoscopic ultrasound.

Strongyloidiasis is an intestinal infection caused by the parasitic nematodes of the Strongyloides species, most commonly Strongyloides stercoralis. We report a case of a 66-year-old immigrant male from Haiti who presented with complaints of diarrhea and an unintentional 80-lb weight loss over the past 5 years. Stool examination was positive for strongyloidiasis. Following albendazole therapy, esophagogastroduodenoscopy (EGD) showed a unique ampullary lesion. Histopathology of the ampullary lesion showed reactive epithelium with Strongyloides larva. In addition, endoscopic ultrasound (EUS) detected a large pancreatic cyst. Both these findings were absent on EGD 5 years previously, prior to the onset of his symptoms. This paper documents a rare case of an ampullary lesion and pancreatic cyst secondary to hepatobiliary strongyloidiasis in a non-Human Immunodeficiency Virus (HIV) patient. We review the epidemiology, life cycle, clinical presentation and treatment of strongyloidiasis.

A Case of Concurrent Gastric and Pancreatic Plasmacytomas in a Patient With Multiple Myeloma: An Extremely Rare Entity.

Multiple myeloma (MM), a plasma cell tumor, is primarily a disease of the bone marrow. Extramedullary plasmacytoma, also a plasma cell tumor, is very rare in the gastrointestinal tract and the pancreas, and only a handful cases have been documented till now. Gastric and pancreatic plasmacytomas are usually seen in elderly patients; however, cases in patients as young as 32 years of age have been reported. Commonly, patients with gastric plasmacytoma present with nonspecific symptoms like epigastric pain, abdominal fullness, anorexia, and weight loss, or serious conditions like massive upper gastrointestinal bleeding and gastric outlet obstruction. Patients with pancreatic plasmacytoma commonly present with obstructive jaundice. In this article, we present the case of a 79-year-old man with a history of MM for 3 years, diagnosed with gastric and pancreatic masses, which turned out to be plasmacytomas. To our knowledge, simultaneous occurrence of gastric and pancreatic plasmacytomas is extremely uncommon with less than 5 cases reported in the literature. We also compiled all the individual cases of gastric and pancreatic MM that have been reported in literature till now.

A Review of Double Common Bile Duct and Its Sequelae.

A double or accessory common bile duct (ACBD) is a rare congenital anomaly. We report the case of a 60-year-old American Asian male, who was found to have a double or duplicated common bile duct after being admitted for evaluation of a pancreatic mass. A duplicated bile duct has the same mucosa histologically as a single bile duct. However, the opening of a duplicated bile duct lacks a sphincter allowing retrograde flow of gut contents which results in a higher probability of intraductal calculus formation. On rare occasions, it can predispose to liver abscesses, pancreatitis, pancreatic cancer, gallbladder cancer, gastric cancer, and ampullary cancer depending on the location of the opening of the ACBD. We present an integrative review of the limited cases of ACBD with correlation to the current case and discussion regarding the aspects of diagnosis and management.

Transverse colon schwannoma treated by endoscopic mucosal resection: A case report.

Gastrointestinal (GI) schwannoma is one of the rarest tumors of the GI tract. We herein describe the case of a 70-year-old female patient who presented for surveillance colonoscopy. The examination detected a 1-cm polyp that was removed by snare cautery polypectomy. Immune and histochemical staining revealed spindle cells that were positive for S-100 and vimentin, but negative for CD34 and smooth muscle actin, consistent with GI schwannoma. This case is noteworthy as GI schwannomas usually present in the stomach, making the finding of a colonic schwannoma of clinical interest. Furthermore, the present case was treated by removing the tumor endoscopically, in contrast to more invasive methods.

Large Dermoid Cyst Presenting as Recurrent Pancreatitis.

Pancreatic dermoid cysts are rare and benign congenital abnormalities of germ cell origin. They occur equally in males and females without age predilection. Though radiographic imaging aids in the diagnosis, most times they are inconclusive and require fine-needle aspiration cytology for confirmation. We report the first case of a dermoid cyst presenting as recurrent pancreatitis in a 49-year-old male. Computed tomography scan, followed by magnetic resonance imaging, showed a complex cystic mass lesion adjacent to the pancreatic tail. Endoscopic ultrasound noted a large heterogeneous cystic lesion with hypoechoic wall layers in the tail of the pancreas without invading surrounding structures. Fine-needle aspiration cytology revealed numerous mature squamous cells consistent with a pancreatic dermoid cyst. We discuss the history, clinical presentation, diagnosis, and treatment of pancreatic dermoid cysts.

Interval Squamous Cell Carcinoma of the Rectum.

Squamous cell carcinoma (SCC) of the rectum is a rare clinical entity with an incidence rate of 0.1-0.25% per 1,000 cases. Though its etiology and pathogenesis remains unclear, it has been associated with chronic inflammation and infections. Herein, we report a case of an 82-year-old female who presented with a 2-month history of worsening abdominal pain, hematochezia, and bilateral inguinal lymphadenopathy with right-sided purulent discharge. Two years prior, she had had an unremarkable screening colonoscopy which met all quality indicators. Abdominal CT scan showed an irregular rectal mass with bulky pelvic and retroperitoneal adenopathy. Colonoscopy revealed one large circumferential nonobstructing lesion in the rectum. Endoscopic ultrasound confirmed its origin from the rectal wall with an enlarged perirectal lymph node. Cold biopsy followed by histopathology revealed SCC of the rectum.

Hiatus Hernia: A Rare Cause of Acute Pancreatitis.

Hiatal hernia (HH) is the herniation of elements of the abdominal cavity through the esophageal hiatus of the diaphragm. A giant HH with pancreatic prolapse is very rare and its causing pancreatitis is an even more extraordinary condition. We describe a case of a 65-year-old man diagnosed with acute pancreatitis secondary to pancreatic herniation. In these cases, acute pancreatitis may be caused by the diaphragmatic crura impinging upon the pancreas and leading to repetitive trauma as it crosses the hernia; intermittent folding of the main pancreatic duct; ischemia associated with stretching at its vascular pedicle; or total pancreatic incarceration. Asymptomatic hernia may not require any treatment, while multiple studies have supported the recommendation of early elective repair as a safer route in symptomatic patients. In summary, though rare, pancreatic herniation should be considered as a cause of acute pancreatitis. A high index of suspicion for complications is warranted in cases like these.

Association between caffeine consumption and nonalcoholic fatty liver disease: a systemic review and meta-analysis.

OBJECTIVES: Caffeine consumption is reported to be associated with reduced hepatic fibrosis in patients with chronic liver diseases. We performed a systematic review and meta-analysis to assess the association between caffeine consumption and prevalence or hepatic fibrosis of nonalcoholic fatty liver disease (NAFLD) in observational studies. METHODS: We searched the literature of all languages from PubMed, EMBASE, and the Cochrane library from 1 January 1980 through 10 January 2015. Total caffeine consumption was defined as the daily intake of caffeine (mg/day) from all caffeine-containing products. Combined and subgroup analyses stratified by study designs, study locations, and type of caffeine intake were performed. RESULTS: Four cross-sectional and two case control studies with a total of 20,064 subjects were included in the meta-analysis. Among these, three studies with 18,990 subjects were included in the analysis for prevalence of NAFLD while the other three studies with 1074 subjects were for hepatic fibrosis. Total caffeine consumption (mg/day) was not significantly associated with either the prevalence [pooled mean difference (MD) 2.36; 95% confidence interval (CI) -35.92 to 40.64] or hepatic fibrosis (higher versus lower stages; pooled MD -39.95; 95% CI -132.72 to 52.82) of NAFLD. Subgroup analyses stratified by study designs and locations were also not significant. However, after stratifying by type of caffeine intake, regular coffee caffeine intake (mg/day) was significantly associated with reduced hepatic fibrosis of NAFLD (pooled MD -91.35; 95% CI -139.42 to -43.27; n = 2 studies). CONCLUSION: Although total caffeine intake is not associated with the prevalence or hepatic fibrosis of NAFLD, regular coffee caffeine consumption may significantly reduce hepatic fibrosis in patients with NAFLD.

Rectal ulcers and massive bleeding after hemorrhoidal band ligation while on aspirin.

Endoscopic hemorrhoidal band ligation is a well-established nonoperative method for treatment of bleeding internal hemorrhoids (grade 1 to 3). It is a safe and effective technique with a high success rate. Complications with this procedure are uncommon. Although rectal ulceration due to band ligation is a rare complication, it can cause life-threatening hemorrhage especially when patients are on medications which impair hemostasis like aspirin or non steroidal anti-inflammatory drugs. We present 2 cases of massive lower gastro-intestinal bleeding in patients who had a band ligation procedure performed 2 wk prior to the presentation and were on aspirin at home. Both the patients were hemodynamically unstable requiring resuscitation. They required platelet and blood transfusions and were found to have rectal ulcers on colonoscopy done subsequently. The rectal ulcers corresponded to the site of band ligation. The use of aspirin by these patients would have caused defects in the hemostasis and may have predisposed them to massive bleeding in the presence of rectal ulcers occurring after the band ligation procedure. Managing aspirin before and after the ligation may be difficult especially since adequate guidelines are unavailable. Stopping aspirin in all the cases might not be safe and the decision should be individualized.

The relationship of vitamin D status, smoking, and colorectal adenoma: a retrospective study in an ethnically diverse community.

OBJECTIVE: Circulating 25-hydroxyvitamin D (25OHD) level is suggested to be negatively correlated with risk of colorectal cancer (CRC) and colorectal adenoma (CRA), but most of the epidemiological data were originated amongst Caucasians and African Americans. This study aimed to investigate the relationship between vitamin D status, smoking and CRA in an ethnically diverse community with a high Hispanic density. METHODS: In this retrospective study, we included 233 patients who underwent complete colonoscopies from 2009 to 2011, and their serum 25OHD levels in the winter season had been measured. Among them, 65 adenoma cases and 168 adenoma-free controls were identified and evaluated for the association of CRA with smoking, ethnicity and serum 25OHD level using unstratified and stratified multivariate logistic regression analyses. RESULTS: In our study participants, the mean serum 25OHD level and the percentage of Hispanics were lower in the adenoma group versus the control group, while no black-white difference was noted in the CRA prevalence. When adjusted for 25OHD level, the lower rate of adenoma in Hispanics compared to non-Hispanics was attenuated and became statistically insignificant. A mild protective effect of vitamin D (6% reduction) on the CRA risk was found significant for active smokers, but not for non-smokers. A detrimental impact of smoking in the CRA risk was only shown among non-Hispanic patients, but not among Hispanics irrespective of vitamin D status. CONCLUSIONS: Our data suggest a marked distinction between Hispanics and non-Hispanics in the risk of CRA. The reduced adenoma prevalence among Hispanics vs. non-Hispanics could be partially explained by vitamin D status, cigarette smoking and their interactions. Future larger-sized multi-center studies on vitamin D status and ethnicity, as well as dietary, behavioral, genetic factors and their interactions for CRA and CRC are needed. This article is part of a Special Issue entitled 'Vitamin D Workshop'.

Germ cell cancer presenting as gastrointestinal bleeding and developing brain metastases: case report and review of the literature.

This paper describes a rare case of germ cell cancer with duodenum, brain and lung metastases. The patient presented with melena and left testicle enlargement. Orchiectomy revealed mixed germ cell cancer, enteroscopy revealed duodenal choriocarcinoma, and chest x-ray and computed tomography (CT) showed bilateral lung metastases. The patient received and tolerated cisplatinum-based chemotherapy, and responded well. However, he developed seizures 3 months later. MRI showed brain metastases and he was treated with whole-brain radiation. One month later, he developed progressive dyspnea. Chest CT showed worsening lung metastases. He received second-line chemotherapy, but died due to multiorgan failure. Germ cell cancer with nonpulmonary metastases has poor prognosis and the management of these patients requires a multimodal approach. Head CT should be considered as routine screening for all germ cell cancer patients on initial diagnosis and brain MRI should be considered for high-risk patients (with an embryo- or choriocarcinoma histology, dramatically elevated ß-human chorionic gonadotropin and lung involvement).

Diffuse alveolar hemorrhage: a rare life-threatening condition in systemic lupus erythematosus.

Diffuse alveolar hemorrhage (DAH) is a rare life-threatening complication in systemic lupus erythematosus (SLE) associated with high mortality rates. DAH is more common in women, and mean age of onset is around 30 years. It mostly occurs in patients with established diagnosis of SLE but can be the initial presentation of lupus in approximately 20%. DAH should be suspected in lupus patient presenting with new pulmonary infiltrates, decline in hemoglobin, hemoptysis, dyspnea, hypoxemia, and increase in carbon monoxide diffusion capacity. Radiographic evidence of bilateral pulmonary alveolar infiltrates that are usually perihilar or basilar with sparing of apices is seen. DAH can often mimic clinically and radiologically severe pneumonia or ARDS. Treatment includes high-dose corticosteroids, cyclophosphamide, and plasmapheresis. We report a case of diffuse alveolar hemorrhage complicating SLE flare-up in a male patient.

A case report of eosinophilic esophagitis accompanying hypereosinophilic syndrome.

Hypereosinophilic syndrome is a blood disorder characterized by the overproduction of eosinophils in the bone marrow with persistent peripheral eosinophilia, associated with organ damage by the release of eosinophilic mediators. Although HES can involve multiple organ systems, GI tract involvement is very rare. Few cases of HES presenting with gastritis or enteritis have been reported worldwide. To date, HES presenting with esophagus involvement has only been reported once. Here, we present a 39-year-old Hispanic female patient with history of HES presenting with complaints of dysphagia and generalized pruritus.

Eosinophilic gastrointestinal diseases: review and update.

Eosinophilic gastrointestinal disorders (EGIDs) are a progressively more frequent diverse group of intestinal diseases. The intention of this paper is to present the newest developments in the care of patients with EGIDs and to sum up a rising literature defining the clinical features and mechanistic elements of eosinophils and their intricate associations with the gastrointestinal tract. Clinicians ought to stay sensitive to EGIDs as a diagnostic likelihood for patients with general gastrointestinal symptoms. Further research is warranted to establish various methods leading to dysfunction coupled with eosinophilic gastrointestinal inflammation.

Unexplained findings of kayser-fleischer-like rings in a patient with cryptogenic cirrhosis.

Cryptogenic cirrhosis (CC) is defined as cirrhosis occurring in an individual without an identifiable cause of liver disease, such as excessive alcohol consumption, viral hepatitis infection, hemochromatosis, autoimmune hepatitis, primary biliary cirrhosis, primary sclerosing cholangitis, chronic intake of medications that could induce cirrhosis, alpha-1-antitrypsin deficiency, Wilson's disease, or any other rare cause of cirrhosis according to the clinical context. Cryptogenic cirrhosis is a common cause of liver-related morbidity and mortality in the United States. Nonalcoholic fatty liver disease is now recognized as the most common cause of cryptogenic cirrhosis. A biopsy specimen is also important for detecting histological advanced disease, which may be clinically silent and undetected by liver-related tests or diagnostic imaging. We are presenting an unusual case of a patient with cryptogenic cirrhosis found to have Kayser-Fleischer-like rings without evidence of Wilson's disease.

Gastrointestinal stromal tumors: a review of case reports, diagnosis, treatment, and future directions.

Gastrointestinal stromal tumor (GIST) is a nonepithelial, mesenchymal tumor first described by Mazur and Clark in 1983. Since then, its molecular biology has been studied in great detail. Special interest in the role of tyrosine kinase in its regulation has been the target by different drug research. Mutation in c-kit exons 9, 11, 13, 17 and PDGFRA mutation in exons 12, 14, 18 are responsible for activation of gene signaling system resulting in uncontrolled phosphorylation and tissue growth. However, 5 to 15% of GISTs does not harbor these mutations, which raises additional questions in another alternate signaling pathway mutation yet to be discovered. Diagnosis of GISTs relies heavily on KIT/CD117 immunohistochemical staining, which can detect most GISTs except for a few 3% to 5% that harbors PDGFRA mutation. Newer staining against PKC theta and DOG-1 genes showed promising results but are not readily available. Clinical manifestation of GISTs is broad and highly dependent on tumor size. Surgery still remains the first-line treatment for GISTs. The advancement of molecular biology has revolutionized the availability of newer drugs, Imatinib and Sunitinib. Together with its advancement is the occurrence of Imatinib/Sunitinib drug resistance. With this, newer monoclonal antibody drugs are being developed and are undergoing clinical trials to hopefully improve survival in patients with GISTs.

Cancers of the appendix: review of the literatures.

Cancers of the appendix are rare. Most of them are found accidentally on appendectomies performed for appendicitis. When reviewed, majority of the tumors were carcinoid, adenoma, and lymphoma. Adenocarcinomas of appendix are only 0.08% of all cancers and the treatment remains controversial. Here we are reporting a 46-year-old male presented with symptoms of appendicitis, diagnosed with adenocarcinoma of the appendix. The patient was treated with appendectomy and refused further surgical intervention to complete hemicolectomy. Up to date, he remains asymptomatic. We performed literature review of the tumors of the appendix. Most of the benign conditions are treated with surgery alone. Lymphomas require CHOP-like chemotherapy and carcinoid syndrome treatment with somatostatin analogues. It is generally recommended that right hemicolectomy is the preferred treatment for adenocarcinoma of appendix. The role of chemotherapy is unclear due to lacking randomized trials but seems to be accepted if there is lymph node involvement or peritoneal seeding.