Endoscopic Ultrasound-Guided Choledochoduodenostomy With Lumen-Apposing Metal Stent Through Duodenal Stent, a Success Case, and a Salvage Case.

Endoscopic ultrasound-guided choledochoduodenostomy (EUS-CD) has become a feasible alternative technique in cases of malignant bile duct obstruction, especially when the endoscopic retrograde cholangiopancreatography is not feasible or has failed. In the case of duodenal obstruction, when a duodenal stent has been initially placed, performing endoscopic retrograde cholangiopancreatography could be quite difficult with a low success rate. Thus, EUS-CD could be a good alternative. In this study, we present 2 particularly challenging endoscopic cases in which EUS-CD was performed with a lumen-apposing metal stent inserted through a previously placed duodenal stent.

Pemphigus vulgaris presenting with epigastric pain.

Pemphigus vulgaris is an autoimmune mucocutaneous disease with an involvement in gastrointestinal tract especially in oral cavity and esophagus. Ulcers can be the initial presentation even before visible mucosal or cutaneous lesions. The presenting symptoms will be in accordance with the affected organ such as throat pain, hoarseness, dysphagia, odynophagia, or even bleeding. Here, we report a case of undiagnosed pemphigus vulgaris presenting with epigastric pain whose endoscopy showed oropharyngeal involvement and isolate esophageal ulcer, which failed proton pump inhibitor treatment.

Gallbladder containing incisional hernia in an elderly woman.

Gallbladder herniation is a rare phenomenon with risk factors of being female, older age, and previous history of hernias. Imaging modalities can confirm the diagnosis. Cholecystectomy and hernia repair to prevent strangulation may be warranted.

Chronic diarrhea as a presentation of Behçet's disease.

Key Clinical Messages: Behçet's disease (BD) or syndrome is a chronic, recurrent, multisystem, inflammatory vasculitis disorder with findings of oral aphthous ulcers, genital ulcers, and uveitis. Gastrointestinal (GI) involvement can be the initial presentation as presented in this case. Abstract: Behçet's disease (BD) or syndrome is a chronic, recurrent, multisystem, inflammatory vasculitis disorder of unknown etiology with classical findings of oral aphthous ulcers, genital ulcers, and ocular involvements including chronic anterior, intermediate, posterior, and even panuveitis. Gastrointestinal involvement in BD usually presents with chronic diarrhea, hematochezia as the disease affects ileocecal area which might be similar to presentation of inflammatory bowel diseases. Here, we report a case of undiagnosed BD who presented with chronic diarrhea for 4 months, leading to the diagnosis of BD and responded well to corticosteroid therapy.

Transient diabetes insipidus after vasopressin discontinuation in cystic fibrosis with septic shock.

Central diabetes insipidus (DI) is an uncommon condition caused by reduced or lack of vasopressin secretion from the posterior pituitary gland, typically caused by gland destruction. Several other causes for central DI have also been proposed. Here we present a case of transient central DI after discontinuation of vasopressin used for septic shock without evidence of overt pituitary damage in a cystic fibrosis patient. The serum sodium concentration peaked at 137 mmol/L in the setting of polyuria within 3 days of vasopressin discontinuation without other identified alternative etiologies. Sodium levels and urine output trended down dramatically with desmopressin administration.

Spontaneous peritoneal drainage following paracentesis in a hospitalized patient with resolution of type 1 hepatorenal syndrome.

The hepatorenal syndrome develops in a small percentage of patients with advanced liver disease. The pathogenesis involves intravascular volume contraction secondary to pooling of blood in the splanchnic vessels, stimulation of the sympathetic nervous system and the renin-angiotensin-aldosterone pathway, and increased intra-abdominal pressure secondary to the formation of large volumes of ascitic fluid. The treatment options are limited, and liver transplant is the only definitive form of management. Here we suggest an alternative approach to treating hepatorenal syndrome based on the unexpected continuous peritoneal drainage in a 36-year-old man hospitalized with hepatic encephalopathy and hepatorenal syndrome. A total of 11.2 L ascitic fluid drained over 5 days from a paracentesis puncture site with marked improvement in renal function; the creatinine decreased from 3.3 mg/dL to 0.7 mg/dL and the BUN decreased from 42 mg/dL to 10 mg/dL. The discussion with this case report summarizes the pathogenesis, including the effect of intra-abdominal pressure, of the hepatorenal syndrome, outlines medical management, and makes a proposal for clinical study based on this case.