Epidermolysis bullosa acquisita: an uncommon cause of esophageal stricture.

Epidermolysis bullosa acquisita (EBA) encompasses a wide spectrum of rare diseases with a common genetic origin transmitted in an autosomal recessive fashion. Mild forms of non-inflammatory EBA are characterized by skin lesions and have gained great relevance in the literature. However, resistant inflammatory EBA with widespread mucosal involvement remains a rare entity given its low prevalence. It commonly represents a great burden for the patient's quality of life with most cases being resistant to different therapeutic modalities. We present a case of resistant inflammatory EBA with esophageal strictures that improved after therapy with intravenous immunoglobulin and rituximab.

An unusual cause of massive upper gastrointestinal bleeding-gastric mucormycosis.

Mucormycosis of the gastrointestinal tract is a life threatening infection most commonly seen in patients with severe immunosuppression. A 42-year-old male with history of choriocarcinoma was admitted to the intensive care unit with septic shock. He developed massive hematemesis requiring upper endoscopy which showed multiple deep gastric ulcers. Due to uncontrollable bleeding he underwent an emergent gastrectomy which revealed necrotic ulcers with evidence of angioinvasion in the ulcer bed with mucor organisms. The PCR revealed the mucor to be Mycotypha microspora which is extremely rare. We discuss the challenges involved in the diagnosis and treatment of gastric mucormycosis.

Henoch-schonlein purpura-a case report and review of the literature.

We describe a case of an adolescent male with Henoch-Schonlein purpura (HSP), presenting with cutaneous and gastrointestinal manifestations. Endoscopy revealed diffuse ulcerations in the stomach, duodenum, and right colon. Biopsies revealed a leukocytoclastic vasculitis in the skin and gastrointestinal tract. Steroid therapy led to complete resolution of the symptoms. HSP is the most common childhood vasculitis, and is characterized by the classic tetrad of nonthrombocytopenic palpable purpura, arthritis or arthralgias, gastrointestinal and renal involvement. It is a systemic disease where antigen-antibody (IgA) complexes activate the alternate complement pathway, resulting in inflammation and small vessel vasculitis. Mild disease resolves spontaneously, and symptomatic treatment alone is sufficient. Systemic steroids are recommended for moderate to severe HSP. The prognosis depends upon the extent of renal involvement, which requires close followup. Early recognition of multiorgan involvement, especially outside of the typical age group, as in our adolescent patient, and appropriate intervention can mitigate the disease and limit organ damage.

Bile leak after laparoscopic cholecystectomy.

Laparoscopic cholecystectomy is commonly performed as the treatment of choice for symptomatic gallstone diseases. Bile leak is a potential complication of this procedure and the cystic duct stump is the most common site of leakage. Early diagnosis and treatment of bile leak is crucial in decreasing the morbidity and mortality related to this complication. Endoscopic retrograde cholangiopancreatography with stent placement and/or sphincterotomy is highly effective in the diagnosis and treatment of this problem.

Serum and liver micronutrient antioxidants and serum oxidative stress in patients with chronic hepatitis C.

OBJECTIVES: The exact pathogenesis of liver injury and fibrosis in chronic hepatitis C (CHC) is unclear. Free radicals play a role in CHC liver damage. Antioxidants (AO) (enzymatic and nonenzymatic) scavenge free radicals and prevent tissue injury. The aims of our study were to estimate serum levels of malondialdehyde (MDA), serum and liver levels of nonenzymatic fat-soluble AO, and to correlate the liver AO levels with the degree of inflammation and fibrosis on biopsy. METHODS: AO levels were estimated by high-pressure liquid chromatography in the pretreatment serum and liver biopsy specimen of 20 treatment-naïve patients with CHC who were not on vitamin supplements. Serum levels of MDA were measured as a marker of increased oxidative stress. Twenty-two healthy individuals with no history of vitamin supplementation served as controls. AO analyzed were: retinol, alpha- and gamma-tocopherol, lutein, beta-cryptoxanthin, lycopene, and alpha- and beta-carotene. RESULTS: Twenty CHC patients (11 men, nine women, mean age 48.5 +/- 7.9 yr) were studied. Patients and controls were comparable in age and sex. Serum MDA levels were significantly higher in CHC patients compared with controls (1.62 +/- 0.57 vs 0.23 +/- 0.15 micromol/L, p = < 0.0000). Serum levels of all AO except lutein were significantly decreased in CHC patients, and their levels were two to ten times lower than serum levels in controls. Liver levels of alpha-carotene (p = 0.0004), beta-carotene (p = 0.006), and lutein (p = 0.002) correlated with the serum levels, whereas the levels of retinol, alpha-tocopherol, lycopene, and beta-cryptoxanthin showed no correlation. Serum MDA levels were significantly higher in patients with moderate-to-severe inflammation or fibrosis compared with those with mild inflammation or fibrosis. The levels of all liver AO except alpha-carotene were significantly lower in patients with moderate-to-severe fibrosis. The severity of inflammation (portal or lobular) did not affect liver AO levels. CONCLUSIONS: Our findings suggest that increased oxidative stress is present in patients with CHC. Micronutrient AO are severely depleted in serum and liver tissue of patients with CHC, and liver levels of some AO appear to reflect serum levels. Increasing fibrosis is associated with decreased liver AO levels indicating that severe disease may be a consequence of AO depletion or decreased liver storage resulting from fibrosis.