Case Report of a Missed Small Bowel Adenocarcinoma on an Upper Endoscopy-A Review of Small Bowel Diagnostic Modalities.

Background: Small bowel neoplasms (SBN) are rare but pose a significant diagnostic challenge. The routine upper endoscopy delays the diagnosis, and most cases require multiple investigations increasing the health care burden. Case summary: A 74-year-old man presented with two months of progressively worsening postprandial bilious emesis and epigastric abdominal pain. He underwent outpatient evaluation with upper endoscopy and a computed tomographic enterography. The first endoscopy did not enable us to recognize the small bowel mass, leading to a diagnostic delay of two months. He subsequently developed a complete intestinal obstruction. A Second look upper endoscopy done with a push enteroscopy showed an apple core-like mass suggestive of a possible malignant neoplasm at the distal duodenum/proximal jejunum. Conclusion: Therefore, more sensitive, and specific diagnostic modalities like push enteroscopy, capsule endoscopy, and deep enteroscopy should be considered in case upper endoscopy is not conclusive.

Fish Bone-Induced Pancreatitis.

Fish bone-induced pancreatitis is an uncommon cause of pancreatitis, with only a few reported cases in the literature. The patients with the highest risk for fish bone-induced pancreatitis include those from cultures where unfilleted fish is a culinary delicacy. The etiology of foreign body-induced pancreatitis is very common, secondary to inflammation of the duodenal papilla or bile duct obstruction. CT imaging is key for visualization of the fish bone, as radiography rarely detects fish bones. Complications of fish bone-induced pancreatitis include thrombosis of the superior mesenteric vein, bacteremia (with Peptostreptococcus), pancreatic granuloma, and gastrointestinal perforation. Management of fish bone-induced pancreatitis includes either endoscopic resection or exploratory laparotomy, followed by supportive care until pancreatitis resolves. Here, we present a case of pancreatitis secondary to accidental fish bone ingestion, identified during upper gastrointestinal endoscopy and managed by bone removal and supportive care.

Strongyloides stercoralis Infection in Immunocompromised Host.

Strongyloides stercoralis is a soil-dwelling roundworm that causes an intestinal infection, Strongyloidiasis. In the United States, this helminth generally causes chronic asymptomatic infection, and severe symptomatic infections are reported in immunocompromised hosts like patients undergoing chemotherapy, receiving long-term corticosteroids, transplant patients, or patients with HIV. The clinicians should have a high index of suspicion to diagnose this infection, as the exposure is usually remote and symptoms are non-specific. The treatment is simple, with oral anti-helminthic drugs like ivermectin and albendazole.

What Happens When the Digested Screw Does Not Come Out of Ileum?

Adults with foreign body ingestion are mainly secondary to psychiatric disorders, alcoholic intoxication, and secondary gains. Conservative management without any intervention is successful in 80% of the ingested foreign bodies. Risk factors for complication include sharp objects, objects larger than 6 mm, recurrent ingestion, and previous gastrointestinal tract surgeries. Sharp objects specifically account for 35% perforation rates and impactions, most commonly at the ileocecal valve. There is limited evidence on the role of colonoscopy after the distal migration of foreign bodies into the ileum and colon. In our case report, we present a case of a 53-year-old-male with a history of recurrent foreign body ingestion secondary to a multitude of psychiatric disorders. It describes multiple foreign body ingestions, leading to failure of a screw at the ileocecal valve at day 5 of ingestion, despite conservative management with serial bowel preparations and abdominal radiographs. There is limited evidence on the management of foreign bodies after distal migration to the ligament of Trietz. Existing literature and guidelines suggest surgically managing the sharp foreign bodies after the failure of conservative management for three to five days. In the case report, we have attempted to emphasize the noninvasive, colonoscopic approach as initial management in removing impacted foreign bodies. This abstract has been presented and accepted at the American college of gastroenterology meeting held from October 22, 2021, to October 27, 2021, in Las Vegas as a poster.

Case of Stroke from Cerebral Vasculitis following Carfilzomib, Lenalidomide, and Dexamethasone Therapy in a Patient with Relapsing Multiple Myeloma.

Lenalidomide, a synthetic derivation of thalidomide, in recent years, has been the backbone of multiple myeloma treatment leading to improved survival. Common adverse effects from lenalidomide-based regimens include hypertension, heart disease, and venous thromboembolism. Hence, thromboprophylaxis is recommended to reduce the risk of stroke. We report a case of stroke from cerebral vasculitis in a patient receiving carfilzomib, lenalidomide, and dexamethasone for relapsing multiple myeloma, not previously published. Medical oncologists should be aware of other causes of stroke among multiple myeloma patients receiving a lenalidomide-based regimen to prevent its occurrence.

Changes in left and right ventricular function of donor hearts during the first year after heart transplantation.

OBJECTIVE: Expected values of tissue Doppler imaging (TDI) velocities and myocardial performance index (MPI) after heart transplantation (HTx) have not been evaluated. This study assessed left and right ventricular (LV and RV) structure and function during the first year after HTx using these indexes. METHODS AND RESULTS: Echocardiography including MPI and TDI systolic (S'), early (E') and late (A') diastolic velocities of RV and LV were performed in 20 donors (mean age 35 ± 13 years) and serially in 20 recipients (mean age 59 ± 9 years) during the first year after HTx. Increase in LV mass occurred at 7 days, with normalisation at 3 months (p < 0.001). An increase in MPI (p<0.001) and a decrease in E', S' velocities on TDI occurred at week 1 with gradual improvement during the first year (p < 0.001). Normalisation of LV and RV MPI occurred at 6 months (p < 0.001) and LV TDI velocities at 1 year (p < 0.001). TDI velocities of both ventricles, however, at 1 year remained lower than at baseline. No patient had greater than grade IA rejection during the follow-up. No significant change was found in myocyte size within the first year. However, there was a 3.3-fold increase in fibrosis. CONCLUSIONS: This study is the first to identify the normal changes of TDI and MPI of both ventricles during the first year after HTx. An increase in LV mass and impairment of bi-ventricular systolic and diastolic function occur early after HTx with gradual improvement during the first year. No significant changes in myocyte size were observed, but there was a substantial increase in fibrosis.

Coronary revascularization alone or with mitral valve repair: outcomes in patients with moderate ischemic mitral regurgitation.

We sought to evaluate retrospectively the outcomes of patients at our hospital who had moderate ischemic mitral regurgitation and who underwent coronary artery bypass grafting (CABG) alone or with concomitant mitral valve repair (CABG+MVr).A total of 83 patients had a reduced left ventricular ejection fraction and moderate mitral regurgitation: 28 patients underwent CABG+MVr, and 55 underwent CABG alone. Changes in mitral regurgitation, functional class, and left ventricular ejection fraction were compared in both groups.The mean follow-up was 5.1 +/- 3.6 years (range, 0.1-15.1 yr). Reduction of 2 mitral-regurgitation grades was found in 85% of CABG+MVr patients versus 14% of CABG-only patients (P < 0.0001) at 1 year, and in 56% versus 14% at 5 years, respectively (P = 0.1), as well as improvements in left ventricular ejection fraction and functional class. One- and 5-year survival rates were similar in the CABG+MVr and CABG-only groups: 96% +/- 3% versus 96% +/- 4%, and 87% +/- 5% versus 81% +/- 8%, respectively (P = NS). Propensity analysis showed similar results. Recurrent (3+ or 4+) mitral regurgitation was found in 22% and 47% at late follow-up, respectively.In patients with moderate ischemic mitral regurgitation, either surgical approach led to an improvement in functional class. Early and intermediate-term mortality rates were low with either CABG or CABG+MVr. However, an increased rate of late recurrent mitral regurgitation in the CABG+MVr group was observed.

Induction therapy with thymoglobulin after heart transplantation: impact of therapy duration on lymphocyte depletion and recovery, rejection, and cytomegalovirus infection rates.

BACKGROUND: This retrospective single-center study compared lymphocyte depletion in 144 heart transplant recipients using 2 different induction protocols with Thymoglobulin (Genzyme Transplant, Cambridge, MA). METHODS: Thymoglobulin (1.5 mg/kg) was given to 105 patients for 7 days (Thymo7) and 39 patients for 5 days (Thymo5). RESULTS: Patient clinical characteristics were similar except that the Thymo7 group had a higher prevalence of women (33% vs 15%, p = 0.04), gender mismatch (35% vs 19%, p = 0.07), donor African American race (19% vs 2%, p = 0.008), older donor age (35 +/- 13 vs 31 +/- 12, p = 0.08), and higher pre-transplant creatinine (1.43 +/- 0.67 vs 1.25 +/- 0.48 mg/dl, p = 0.095). Seventy-five percent of the Thymo7 group reached target (absolute lymphocyte count or=1B) within the first year (7% vs 22%, p = 0.02). No humoral rejection occurred. At 1 year, freedom from rejection was 93% in the Thymo7 group vs 80% in the Thymo5 group (p = 0.007), and cytomegalovirus disease (9% and 5%, p = 0.5) and bacterial infection (26% vs 32%, p = 0.5) were similar. One-year actuarial survival was 92% +/- 3% in the Thymo7 and 100% in the Thymo5 group (p = 0.07), and at 3 years, 85 +/- 4% and 90 +/- 6%, respectively (p = 0.4). CONCLUSIONS: Both Thymoglobulin regimens were well tolerated. The 7-day treatment led to more efficient and prolonged lymphocyte depletion and significantly less rejection at 1 year, without an increase in cytomegalovirus infection rate.