Unresolved Chronic Diarrhea: A Case of Angiotensin-Converting Enzyme Inhibitor-Induced Mesenteric Angioedema.

Angiotensin-converting enzyme inhibitors (ACEI) are frequently prescribed for cardiovascular and renal diseases. However, ACEI-induced visceral angioedema is a rare occurrence that often goes unnoticed and poses a diagnostic challenge due to its non-specific and diverse symptoms. Key diagnostic indicators on a CT scan include the 'target' sign, elongation of bowel loops, enlarged mesenteric vessels, mesenteric edema with or without ascites, thickened omentum, and the absence of vascular compromise or adenopathy. Discontinuation of ACEI usually results in symptom resolution within 48 hours. While this phenomenon is more commonly observed in females and African Americans, we present a case of a Caucasian male who underwent an extensive diagnostic evaluation, including exploratory surgery, before ACEI-induced angioedema was considered. LEARNING POINTS: The occurrence of angiotensin-converting enzyme inhibitors (ACEI)-induced visceral angioedema is infrequent, frequently overlooked, and presents a diagnostic challenge due to its wide range of non-specific symptoms.While ACEI-induced visceral angioedema is more frequently observed in females and African Americans, it is crucial not to overlook the possibility of this phenomenon in other demographic groups as well.Its rarity emphasizes the importance of including it in the list of potential conditions to be considered, thus preventing unnecessary tests and procedures.

Acute Colonic Pseudo-Obstruction in a Patient With COVID-19 Pneumonia: A Case Report.

Coronavirus disease (COVID-19) is primarily a respiratory illness caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus. However, the disease is also known to cause a range of extrapulmonary manifestations, including gastrointestinal (GI) symptoms such as nausea, vomiting, and diarrhea. The exact mechanisms by which the virus causes extrapulmonary manifestations are not fully understood, but it is theorized that the virus can enter cells in other organs including the GI tract, through the angiotensin-converting enzyme 2 (ACE2) receptor. This can result in inflammation and damage to the affected organs. In rare cases, COVID-19 can also cause acute colonic pseudo-obstruction (ACPO), a condition characterized by symptoms of bowel obstruction but without a physical obstruction present. Acute colonic pseudo-obstruction is a serious and potentially life-threatening complication of COVID-19 that requires prompt recognition and treatment to prevent further complications such as bowel ischemia and perforation. We hereby present a case report of a patient with COVID-19 pneumonia developing ACPO and discuss the suggested pathophysiology, diagnostic approach, and treatment options.

Vasoactive intestinal peptide-oma causing refractory diarrhea in a young woman.

Vasoactive intestinal peptide (VIP)-secreting neuroendocrine tumors are an exceptionally rare cause of chronic diarrhea. We describe a 36-year-old woman presenting with a 2-year history of severe diarrhea and electrolyte derangements ultimately diagnosed with VIPoma.

Ileostomy diarrhea: Pathophysiology and management.

Ileostomy is a common component of surgical treatments for various gastrointestinal conditions. Loss of the fluid absorptive capacity of the colon results in increased fluid and electrolyte losses, which causes a state of relative fluid depletion. These losses can be offset in part by increased oral intake, but the remaining small intestine also compensates by increasing the efficiency of fluid and electrolyte absorption, a process termed adaptation, which occurs within weeks to months of ileostomy creation. Some patients fail to adapt adequately and have high ileostomy outputs from the time of surgery. Others with a previously well-adapted ileostomy may encounter periods of sustained high output when some additional process causes diarrhea. Many patients experience periods of high output after ileostomy creation and often require hospital readmission for this reason. Any patient with an ileostomy is at great risk of dehydration and electrolyte depletion should output rise dramatically. Prompt attention should be given to rehydration and identification of the underlying cause so that directed therapies may be implemented. This review discusses the alteration of normal intestinal fluid balance from colectomy with ileostomy, proposed mechanisms for adaptation, the differential diagnosis of ileostomy diarrhea, the evaluation of ileostomy diarrhea, and current treatment options.

Autoimmune metaplastic atrophic gastritis and association with neuroendocrine tumors of the stomach.

Autoimmune metaplastic atrophic gastritis (AMAG) previously called type A chronic gastritis is an immune-mediated chronic inflammatory disease characterized by the immune-mediated destruction of gastric parietal cells in the fundus and body of the stomach. AMAG is an uncommon disease that often presents with hematological manifestations and may lead to the development of gastric carcinoids. AMAG can be reliably diagnosed by antibody assays, functional serology, and histology. The understanding of the disease process is essential for the detection and management of hematological complications and gastric lesions. The prevalence of AMAG is on the rise and subsequently gastric carcinoids. However, this association is not well recognized in clinical practice, and management and diagnosis of AMAG and gastric carcinoids remain suboptimal. In the current review, we will discuss the pathophysiology, diagnosis and management of AMAG. A special focus is given to the association between AMAG and gastric carcinoids. We will also review the management options of type 1 gastric carcinoids.

Gastrointestinal histoplasmosis ileal stricture successfully treated with through-the-scope balloon dilation in a patient with hyperimmunoglobulin M syndrome.

Gastrointestinal histoplasmosis is common in patients with disseminated disease affecting both immunocompetent and immunocompromised patients. However, it is often unrecognized due to a lack of specific signs and symptoms. It has only rarely been reported to cause small bowel obstruction, during which surgical treatment was nearly always necessary. Little is known about the usefulness of endoscopic therapy in gastrointestinal histoplasmosis associated strictures. We report the case of a 32-year-old man with a history of hyperimmunoglobulin M syndrome who presented with small bowel obstruction secondary to disseminated gastrointestinal histoplasmosis. Treatment was successful with a through-the-scope balloon dilator in combination with medical therapy. This report adds to the limited data available on the benefit of endoscopic therapy in infectious strictures, particularly gastrointestinal histoplasmosis.

Primary duodenal follicular lymphoma with late disseminated nodal relapse responsive to rituximab monotherapy: A case report.

Gastrointestinal follicular lymphoma is a rare malignancy accounting for only 1-3.6% of primary non-Hodgkin lymphomas of the gastrointestinal tract and it is a relatively new clinical entity that was recently classified as a distinct variant of systemic follicular lymphoma. Therefore, data regarding long-term outcome are currently lacking. In addition, a consensus on the management of this disease has not been established and treatment strategies are derived from systemic follicular lymphoma. We herein report the case of a 51-year-old female patient diagnosed with duodenal follicular lymphoma who had nodal relapse nearly 5 years after complete remission. The patient was successfully treated with a 4-week course of rituximab during the initial diagnosis and relapse. To the best of our knowledge, this is the first case report to demonstrate the efficacy of a 4-week course of rituximab during both the initial diagnosis and nodal relapse. The aim of this report was to add to the limited available data on the treatment of gastrointestinal follicular lymphoma.

Primary Hepatic Angiosarcoma Mimicking Multifocal Liver Abscess with Disseminated Intravascular Coagulation and Hemoperitoneum.

Primary hepatic angiosarcoma (PHA), a rare and aggressive malignancy, has rarely been reported to present with disseminated intravascular coagulation with liver hemorrhage. Incidence is estimated at 0.5-2.5 cases per 10,000,000. To our knowledge, it has not been reported to mimic liver abscess with a septic presentation. Advanced imaging techniques may aid in the diagnosis, though biopsy with microscopy and immunohistochemistry is the mainstay. Prognosis is very poor, with a 5-year survival rate estimated at 6.4%. We present the case of a 70-year-old man who presented with sepsis thought to be due to a multifocal liver abscess, who did not respond to drainage and antibiotics. This atypical course led to further workup which subsequently revealed a diagnosis of PHA.

Gastrointestinal Amyloidosis: Review of the Literature.

Gastrointestinal amyloidosis (GIA), a protein deposition disorder, represents a complex common pathway that encompasses multiple etiologies and presentations. It represents a significant diagnostic and treatment challenge. The disease results from the deposition of insoluble extracellular protein fragments that have been rendered resistant to digestion. GIA can be acquired or genetic, and most commonly results from chronic inflammatory disorders (AA amyloidosis), hematologic malignancy (AL amyloidosis), and end-stage renal disease (Beta-2 amyloidosis). The deposition of these abnormal proteins interferes with gastrointestinal tract (GI) organ structure and function, most notably in the liver and small bowel. Presentation from GI involvement includes cirrhotic sequelae, abdominal pain, malabsorption, and GI bleeding. Diagnosis hinges on pathologic examination of affected tissue, with classic green birefringence under polarized light. Abdominal fat pad and rectal mucosal biopsy have been described as sites of higher sensitivity for diagnosis. Serum amyloid P scintigraphy is near 90% sensitive for diagnosis of AA amyloidosis. Patients should be considered for further evaluation to rule out additional organ involvement, notably cardiac and renal. Treatment hinges on an adequate suppression of the predisposing inflammatory disorder, or malignancy, followed by supportive therapy. Prognosis varies depending on the etiology of the disease, with the AL subtype showing worse outcomes, as well as those with hepatic involvement.

A Rare Cause of Primary Aortoenteric Fistula: Streptococcus parasanguinis Aortitis.

Primary aortoenteric fistula is a rare cause of upper gastrointestinal bleed but can lead to significant mortality if the diagnosis is delayed. Aortitis, characterized by inflammation of the aortic wall, is a rare cause of aortoenteric fistula. We present a case report of a 72-year-old male patient with infectious aortoenteric fistula secondary to Streptococcus parasanguinis, along with a review of the literature. This case demonstrates the importance of early diagnosis and aggressive surgical treatment of aortoenteric fistulae and recognizing infectious aortitis as a potential etiology.

Isolated Ileal Stricture Secondary to Antigen-Negative GI Histoplasmosis in a Patient on Immunosuppressive Therapy.

We present a case of antigen-negative disseminated histoplasmosis manifesting as an isolated ileal stricture in a patient on chronic infliximab and methotrexate. Diagnosis can be challenging due to imperfect tests, and this condition should remain in the differential, even with negative testing. Mortality of untreated disseminated histoplasmosis can be as high as 80%.

Spontaneous Splenic Infarcts in a Cirrhotic Patient with Primary Biliary Cirrhosis.

Spontaneous splenic infarction has been rarely reported as a complication of cirrhosis and portal hypertension. We describe the case of a 67-year-old female with past medical history of primary biliary cirrhosis presenting for a 1-day history of left upper quadrant pain. Investigations were in favor of splenic infarcts secondary to portal hypertension. The patient improved with conservative management and no recurrence was noted on further follow-up. Splenic infarction must be kept in mind when a patient with cirrhosis presents with left upper quadrant abdominal pain without a clear source.

Direct Primary Care in 2015: A Survey with Selected Comparisons to 2005 Survey Data.

INTRODUCTION: Direct primary care (DPC), a fee for membership type of practice, is an evolving innovative primary care delivery model. Little is known about current membership fees, insurance billing status, physician training, and patient panel size in DPC practices. This study aimed to obtain current data for these variables, as well as additional demographic and financial indicators, and relate the findings to the Healthy People 2020 goals. It was predicted that DPC practices would (1) submit fewer claims to insurance, (2) have decreased membership fees, (3) be primarily family medicine trained, and (4) have increased the projected patient panel size since 2005. METHODS: An electronic survey was sent to DPC practices (n = 65) requesting location, membership fees, projected patient panel size, insurance billing status, training, and other demographic and financial indicators. Data were aggregated, reported anonymously, and compared to two prior characterizations of DPC practices done in 2005. RESULTS: Thirty-eight of 65 (59%) practices responded to the 2015 survey. The majority of respondents (84%) reported using an EMR, offering physician email access (82%), 24-hour access (76%), same day appointments (92%), and wholesale labs (74%). Few respondents offered inpatient care (16%), obstetrics (3%), or financial/insurance consultant services. Eighty-eight percent (88%) of practices reported annual individual adult membership rates between $500 and $1,499, decreased from 2005 where 81% reported greater than a $1,500 annual fee. The proportion of practices who submit bills to insurance decreased from 75% in 2005 to 11% in 2015. Fifty-six percent (56%) of practices reported projected patient panel size to be greater than 600, increased from 40% in 2005. Family medicine physicians represented 87% of respondents, markedly different from 2005 when 62 - 77% of DPC respondents were general internal medicine physicians. CONCLUSIONS: Most DPC practices no longer submit to insurance and are family medicine trained. Compared with the previous sampling, DPC practices report decreased membership fees and increased projected panel size. These trends may signify the DPC movement's growth in application and scope.