Complex Antiplatelet Therapy Management in Patients Requiring Urgent Interventions for Pseudoachalasia and Esophageal Obstruction.

This case report describes the use of intravenous (IV) cangrelor as a transient tool for antiplatelet bridging therapy in a 70-year-old male with coronary artery disease and esophageal strictures who underwent recent percutaneous coronary intervention (PCI) and subsequently required a pre-oral endoscopic myomectomy (POEM) procedure. The patient was switched from oral clopidogrel to IV cangrelor drip prior to the procedure, which was successful in preventing stent thrombosis. The case highlights the potential benefits of IV antiplatelet therapy in patients unable to tolerate oral medications in the setting of esophageal obstructions following recent coronary stent placement in a critical care setting.

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.

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.

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.

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.

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.

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.

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.