Rare Case of Endoscopically Diagnosed Ischemic Colitis Secondary to Chronic Phentermine Use.

Phentermine is an amine anorectic that acts as a sympathomimetic agent and undergoes hepatic metabolism predominantly through CYP3A4. It is commonly used as a mediation to facilitate weight loss. Side effects of phentermine can include pulmonary hypertension, valvular heart disease, palpitations, increased heart rate or blood pressure, diarrhea, and cognitive impairment. Very rarely, phentermine usage has been associated with causing ischemic colitis. The mechanism of action for ischemic colitis from phentermine is not well defined but will be discussed in this review. We present a case of a woman who used phentermine daily for weight loss and was endoscopically confirmed to have ischemic colitis after presenting with abdominal pain and bloody diarrhea.

Correction to: Successful Endoscopic Retrograde Appendicitis Therapy Following a Recent ST-Elevation Myocardial Infarction.

[This corrects the article DOI: 10.14309/crj.0000000000001324.].

Successful Endoscopic Retrograde Appendicitis Therapy Following a Recent ST-Elevation Myocardial Infarction.

Acute appendicitis is one of the most common abdominal surgical emergencies. A laparoscopic or open appendectomy has traditionally been the gold standard. Antibiotic therapy has recently been found to be noninferior. The treatment of acute uncomplicated appendicitis remains a challenge, especially in the presence of an appendicolith. We present a case of a 59-year-old man with recent ST-elevation myocardial infarction who underwent successful endoscopic retrograde appendicitis therapy.

Pneumatosis Intestinalis Manifesting as an Atypical Presentation of Crohn's Disease.

Crohn's disease is an inflammatory bowel disease that has a bimodal distribution, occurring most frequently between ages 15 to 30 years and 40 to 60 years. It presents with a relapsing and remitting course. The most common area involved is the terminal ileum and right colon and the inflammation oftentimes leads to non-caseating granulomas and ulcerations in both the superficial mucosa and deeper layers. Additionally, pneumatosis intestinalis is defined as the presence of gas and free air in the extraluminal space of the intestines which is an abnormal occurrence and correlates with underlying pathology. There are only a few cases reported in the literature that present pneumatosis intestinalis in the setting of, and possibly linked to, Crohn's disease. Our case presents an elderly male patient with jejunal ulcerations and strictures suggesting Crohn's disease and associated pneumatosis intestinalis as evidenced on outpatient computed tomography (CT) enterography. Upon presentation to the hospital, the patient was non-toxic and was not complaining of any pain. During his inpatient stay, there was a suspicion of Crohn's disease and therefore he was started on Infliximab therapy. We will review the possible pathogenesis of Crohn's disease and other cases presenting pneumatosis intestinalis in the setting of Crohn's disease.

Acute Cholangitis Masquerading Biliary Neuroendocrine Carcinoma: A Rare Twist to a Typical Presentation.

Biliary neuroendocrine carcinoma (BNEC) develops in the biliary tract and is characterized by the presence of neuroendocrine cells and account for less than 1% of all malignancies. We present a patient with no significant risk factors of BNEC who presented with abdominal pain and jaundice. An endoscopic ultrasound with endoscopic retrograde cholangiopancreatography was concerning for neoplasm and less likely Mirizzi syndrome. Pathology revealed well-differentiated grade 3 large-cell neuroendocrine carcinoma of the common bile duct. BNEC has a poor prognosis with a reported 5-year survival rate of less than 20%, which is worse than other biliary tract malignancies such as cholangiocarcinoma. Additional cases and further studies of multimodal treatment are required in the future to improve prognosis. Providers should be aware of the risk factors of BNEC and consider the diagnosis when evaluating patients with the symptoms above.

A Rare Case of Achalasia Sigmoid Esophagus Obstructed by Food Bolus.

Achalasia is a primary esophageal motility disorder that involves a failure of the lower esophageal sphincter to relax in response to swallowing. Specifically, the lower esophageal sphincter becomes hypertensive, and there is an absence of peristalsis in the esophagus. The pathophysiology is thought to be due to a loss of inhibitory nerve function from an autoimmune attack that targets the esophageal myenteric nerves. As a result, these abnormalities lead to a functional obstruction at the gastroesophageal junction. In severe cases, achalasia may present as a "sigmoid esophagus," a term used to describe the dilation and distortion of the cervical esophagus. In this case report, we discuss a patient with a known history of achalasia who presented with extra-esophageal symptoms including respiratory distress and tracheal compression from an esophagus dilated with a food impaction. She was found to have a sigmoid esophagus and required direct endoscopy and removal of the food bolus. We will review the pathogenesis of achalasia as well as medical and surgical approaches to treating severe achalasia as presented through other case reports.

Severe Acetaminophen Toxicity From the Use of Oxycodone-Acetaminophen With Normal Liver Function Tests and a Completely Asymptomatic Course of Hospitalization.

Acetaminophen (N-acetyl-p-aminophenol, APAP), after being metabolized to toxic N-acetyl-p-benzoquinone imine, can cause irreversible hepatic necrosis. The mainstay of treatment includes N-acetylcysteine and fomepizole or liver transplant in patients who further deteriorate. Currently, many overdoses unintentionally occur in the setting of ingesting combined products that contain APAP. We report a rare case of a 60-year-old woman who presented with altered mental status and APAP toxicity in the setting of oxycodone-APAP overdose. She had a toxic serum APAP level on arrival. During hospitalization, her APAP level remained at the toxic level on the Rumack-Matthew nomogram. However, her liver function tests remained within normal limits, and she remained completely asymptomatic. To our best knowledge, this is the second case report with asymptomatic APAP toxicity and normal liver function tests. We will explore the effect of concomitant oxycodone ingestion on possibly delaying APAP absorption and thus resulting in a more favorable prognosis without hepatotoxicity.

Myositis as an Extraintestinal Manifestation of Ulcerative Colitis: A Case Report and Literature Review.

Ulcerative colitis (UC) is an inflammatory bowel disease (IBD) that is thoroughly studied and known to have a strong genetic component. It affects the mucosa and submucosa of the colon and rectum, causing diffuse friability and superficial erosions leading to bleeding. Common presenting symptoms include diarrhea that is often bloody or purulent and abdominal pain or cramping. There are also extraintestinal manifestations of UC such as cutaneous rashes, eye inflammation, and oral ulceration. A rarer manifestation of IBD is myositis, either dermatomyositis, polymyositis, or even rhabdomyolysis. Based on the literature review, myositis has been documented more so in cases of Crohn's disease versus UC. In this report, we discuss a patient with known UC who presented during a flare and subsequently complained of diffuse myalgia. She was found to have an elevated creatine kinase (CK), thus suggesting some form of myositis. We will review possible pathogenesis and other cases of UC presenting with myositis that have been documented.

Nanoparticle Albumin­Bound Paclitaxel and Solvent-Based Paclitaxel as Chemotherapy Options for Patients With Advanced Gastric Cancer: A Systematic Review and Meta-Analysis.

The aim of this study is to assess and compare the effectiveness and safety of nanoparticle albumin-bound paclitaxel (nab-PTX) and solvent-based PTX (sb-PTX) as treatment options for advanced gastric cancer. This meta-analysis was reported according to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. We carried out a comprehensive search of PubMed, Google Scholar, and EMBASE from inception to June 15, 2023. The search strategy included the following keywords: "Nanoparticle albumin-bound paclitaxel," "solvent-based paclitaxel," and "advanced gastric cancer," along with their synonyms and medical subject heading (MeSH) terms. In this meta-analysis, the primary outcome was the comparison of overall survival and progression-free survival between the two groups. For safety purposes, we compared the risk of hematological and non-hematological events between the two groups. Four studies were included in this meta-analysis enrolling 1052 patients (483 received nb-PTX and 569 received sb-PTX). In terms of efficacy, nab-PTX showed favorable trends in overall survival and progression-free survival, despite no statistically significant differences being reported. The subgroup meta-analysis showed that nab-PTX seemed to have a better effect on peritoneal metastasis compared to sb-PTX. Regarding safety, the number of patients with neutropenia and leucopenia was significantly higher in the nab-PTX group compared to the sb-PTX group. However, the difference was statistically insignificant. Future research should focus on conducting more robust studies to further validate these findings and establish a stronger evidence base for the use of nab-PTX in this patient population.

Severe Ovarian Hyperstimulation Syndrome in the Setting of In Vitro Fertilization Treatment.

Ovarian hyperstimulation syndrome (OHSS) is one of the complications of pharmacological ovarian stimulation used in fertility treatments. This syndrome is characterized by increased vascular permeability secondary to stimulation, resulting in a fluid shift from the intravascular space to the third-space compartments. Patients developing OHSS can experience severe complications, including ascites, pleural effusions, and shock. Here, we present a case of OHSS in the setting of recent transvaginal oocyte retrieval, leading to severe ascites, pleural effusion, and hypotension requiring urgent intervention.

Comparison of High Ligation Versus Low Ligation of the Inferior Mesenteric Artery (IMA) on Short-Term and Long-Term Outcomes in Sigmoid Colon and Rectal Cancer Surgery: A Meta-analysis.

This study was done to compare the perioperative outcomes and long-term outcomes between low ligation and high ligation of the inferior mesentric artery (IMA) in sigmoid colon and rectal cancer surgery. This study was conducted following the recommendations of the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA). A literature search was performed in electronic databases including PubMed, CINAHIL, EMBASE, and Web of Science to identify studies published between January 1, 2015, and April 30, 2023. The outcomes assessed in this meta-analysis included postoperative complications (anastomotic leakage, surgical site infection, and postoperative ileus), intraoperative outcomes (duration of surgery in minutes, total intraoperative blood loss in milliliters, total lymph nodes harvested, and total number of metastatic lymph nodes), recovery outcomes (time to first flatus and length of hospital stay), and long-term outcomes (five-year mortality rate and disease-free survival rate). A total of 17 studies were included in this meta-analysis. Of these, six were randomized control trials (RCTs) and 11 were retrospective cohort studies. This meta-analysis suggests that lower ligation may be associated with a lower risk of anastomotic leakage compared to higher ligation in patients undergoing colon cancer surgery. However, there was no significant difference between the two techniques in terms of surgical site infection, postoperative ileus, total lymph nodes harvested, number of metastatic lymph nodes, duration of surgery, intraoperative blood loss, and length of hospital stay. Time to first flatus was significantly shorter in patients who underwent lower ligation. Additionally, there were no significant differences in the five-year mortality rate and disease-free survival rate between the two techniques. The results of this study indicate that both techniques are comparable in most aspects and suggest that the choice of technique should be based on individual patient factors and surgeon preference.

Dormant Crohn's Disease Reactivated by Clostridioides difficile Infection.

Crohn's disease (CD) is a type of inflammatory bowel disease (IBD) characterized by chronic transmural inflammation of any portion of the gastrointestinal tract. The etiology of CD remains unknown although genetic, immunological, and acquired factors have been recognized as contributing to its development. Alterations of intestinal microbiota, including Clostridioides difficile (C. difficile), are theorized to alter humoral immunity and contribute toward CD flare pathogenesis. As such, cases of IBD remission can be undone by alterations in the gut microbiota and subsequently confound the diagnosis of inflammatory or infectious etiologies of diarrhea. We present a case of a 73-year-old female with dormant CD for 25 years who experienced an atypical course of diarrhea found to have a CD flare in the setting of acute C. difficile colitis.

Comparison of Effectiveness and Safety of Ustekinumab and Adalimumab As Induction or Maintenance Therapy in Patients With Moderate to Severe Crohn's Disease: A Systematic Review and Meta-Analysis.

This meta-analysis has been conducted to compare ustekinumab and adalimumab as induction or maintenance therapy in patients with moderate to severe Crohn's disease (CD). The current meta-analysis was conducted in accordance with the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Two investigators independently searched online databases including PubMed, Cumulated Index to Nursing and Allied Health Literature (CINAHL), and Cochrane Library for relevant articles published up to April 2023. The initial search terms were "ustekinumab," "adalimumab," and "Crohn's disease". Three studies (with a total of 612 patients) were included in the present meta-analysis. We did not find any significant difference in clinical remission (OR: 1.31, 95% CI: 0.68-2.52), clinical response (OR: 1.39, 95% CI: 0.39-4.91), endoscopic remission (OR: 1.56, 95% CI: 0.66-3.64), and steroid-free remission (OR: 0.98, 95% CI: 0.67-1.42) between patients who received ustekinumab and patients who received adalimumab. In conclusion, this meta-analysis provides valuable insights into the efficacy and safety of ustekinumab and adalimumab in the treatment of moderate to severe CD. Our findings indicate that both drugs have similar effectiveness in achieving clinical remission, clinical response, radiological remission and steroid-free remission.

Factors Associated With Non-adherence to Anti-depressant Medication in Adults: A Systematic Review and Meta-Analysis.

The present meta-analysis has been conducted to review currently available literature to examine the factors associated with adherence to anti-depressant medications in adults. This meta-analysis and systematic review followed the MOOSE (Meta-analysis of Observational Studies in Epidemiology) guidelines. According to this analysis, the three most important electronic resources for research were CINAHL, EMBASE, and Medline. Google Scholar was used to supplementing the articles already available for review. Keywords used to find relevant articles included "predictors," "non-adherence," "anti-depressants," and "adults." Medical subject headings (MeSH) terms and Boolean operators ("AND" and "OR") were used in the search strategy to refine the search further. Studies included in this meta-analysis had information on factors associated with non-adherence to anti-depressant medication. The study evaluated samples of adult participants over 18 years with a diagnosis of depression and who had been prescribed anti-depressants. In conclusion, this meta-analysis examined the relationship between demographic factors and non-adherence to anti-depressant medications. The findings revealed that gender, educational status, income level, marital status, and area of residence did not significantly predict non-adherence to anti-depressants. However, older age and polypharmacy were significant predictors of adherence to anti-depressants. The study also found that individuals living in urban areas were more likely to adhere to anti-depressants, but the difference was not statistically significant.

Duodenal Fibrosis Mimicking Neoplastic Obstructive Hepatopathy in the Setting of Lynch Syndrome.

Intestinal fibrosis is a rare complication of chronic inflammation resulting from various etiologies, including surgery, abdominal radiation, and inflammatory bowel disease. Consequences of intestinal fibrosis include intestinal dysmotility, malabsorption, and obstruction. Patients with Lynch syndrome are predisposed to developing intestinal adenocarcinoma including in the small intestines which typically require intra-abdominal procedures that expose them to fibrogenic triggers. Here, we present a rare case of duodenal fibrosis involving the sphincter of Oddi leading to malabsorption and gastrointestinal symptoms in a patient with Lynch syndrome requiring advanced endoscopy interventions.

Per-Oral Endoscopic Myotomy-Induced Gastroesophageal Reflux Disease and Review of the Efficacy of Proton Pump Inhibitors as a Management Strategy: Review of the Literature.

Per-oral endoscopic myotomy (POEM) is a minimally invasive procedure that is very effective in the treatment of achalasia, a rare esophageal motility disorder. POEM has become the first-line treatment for achalasia, with high success rates reported in the literature. However, a known complication of POEM is gastroesophageal reflux disease (GERD). The exact cause and risk factors of post-POEM GERD are not fully understood; however, a number of factors have played a role in its development. The management of post-POEM GERD is mainly by conservative measures, such as lifestyle changes and medications, like proton pump inhibitors (PPI), which are often the first-line method of treatment. However, surgical procedures, such as fundoplication, may be necessary in some patients. This literature review will discuss the effectiveness of the use of PPIs as a management strategy for post-POEM GERD, the factors that lead to PPI-resistant GERD, and other management strategies utilized in these cases.

Management of Esophageal Squamous Cell Carcinoma With Esophageal Stent Placement in an Elderly Patient With Dysphagia.

Esophageal cancer is typically identified as squamous cell carcinoma or adenocarcinoma. There are multiple risk factors that may contribute to esophageal squamous cell carcinoma including smoking, alcohol consumption, and the human papillomavirus. Lesions may appear ulcerated, friable, and circumferential and may obstruct the esophagus. Therefore, patients may complain of non-specific symptoms including dysphagia, weight loss, and retrosternal discomfort. Clinicians often rely on an upper endoscopy with biopsy to confirm the diagnosis. Computed tomography scans and endoscopic ultrasounds are also employed to assess the extent of malignant spread. Management may involve endoscopic resection for superficial lesions or surgical resection for lesions penetrating the submucosa. Esophageal stents may play a role, specifically as a palliative measure for enhancing oral intake. We present an instance of utilizing a self-expandable, metal-covered esophageal stent with balloon dilation in the setting of a newly diagnosed esophageal squamous cell carcinoma lesion in a 73-year-old female. Ultimately, the use of an esophageal stent in this patient helped improve the patient's oral intake during her course of hospitalization. Her diet was slowly advanced to clear liquids and progressively to a low-residue diet before being discharged to follow-up with her diagnosis as outpatient with gastroenterology.

Rare Case of Primary Adenoid Cystic Carcinoma of the Lung With Bilateral Kidney and Liver Metastasis.

Adenoid cystic carcinoma (ACC) is a rare epithelial tumor that is found in the salivary glands. It is typically slow-growing and follows an indolent course. While it can hematogenously spread to the lungs, distant metastases are rarely reported. Primary ACC in the lung is not common and makes up only 0.04-0.2% of all primary lung tumors. In addition, metastasis of the ACC to liver and bilateral kidneys is not common frequently documented. In this case report, we present a patient with unusual metastases of ACC, as well as non-specific symptoms that warrant discussion for ACC as potential differentials in the appropriate clinical setting.

Unusual Presentation of Isolated Nonbacterial Thrombotic Tricuspid Valve Endocarditis in Systemic Lupus Erythematosus With Secondary Antiphospholipid Syndrome: A Case Report.

Nonbacterial thrombotic endocarditis (NBTE), or marantic endocarditis, is one of the most prevalent cardiac presentations seen in patients with systemic lupus erythematosus (SLE). It is a condition that is characterized by noninfectious lesions affecting cardiac valves. The most common sight for this disease to affect is the left-sided mitral and aortic cardiac valves. It rarely involves the right-sided tricuspid valve. However, having a secondary condition that increases risk for hypercoagulability can potentiate the severity and frequency of cardiac valvular disease in SLE. In this report, the authors describe a rare case of a patient who presented with clinically symptomatic isolated-sterile tricuspid valve vegetations likely due to antiphospholipid syndrome (APLS) on top of SLE. Optimal medical and surgical managements of these vegetations are not well defined. Criteria call for surgical intervention in infective endocarditis when there are severe heart failure or valve dysfunction, prosthetic valve infection, recurrent systemic emboli, large mobile vegetations, and other detrimental complications. However, intervention for sterile vegetations should also be discussed if the patient can benefit from it clinically and if it can improve quality of life. The authors discuss this case in the context of the relevant medical and surgical literature.