Beyond the norm: Illuminating eosinophilic ascites with 2 rare and intriguing cases.

Eosinophilic ascites (EA) is a rare and enigmatic disorder characterized by elevated eosinophil counts in peritoneal fluid, commonly associated with eosinophilic gastroenteritis (EGE), hypereosinophilic syndrome (HES), and parasitic infections. Here, we present two cases of EA diagnosed and managed in our gastroenterology department. Case 1: A 45-year-old male presented with diffuse abdominal pain and distension. Imaging revealed septate abdominal ascites, prompting exploratory laparoscopy. Ascitic fluid analysis showed eosinophil predominance, leading to an EA diagnosis. The patient was treated with oral Albendazole, resulting in a favorable outcome. Case 2: A 52-year-old female complained of abdominal pain with alternating diarrhea and constipation. Imaging unveiled moderate ascites, pyloro-duodenal inflammation, and wall thickening. Eosinophilic leukocytosis prompted empirical treatment, yielding a positive response. In conclusion, diagnosing EA involves a combination of histological and laboratory methodologies. Corticosteroids emerge as the primary therapeutic avenue, with the imperative of eradicating parasitic infections before initiation. This study underscores the critical role of education in mitigating the risk of parasitic infections.

Ischemic cholangitis: Lethal complication of Osler-Weber-Rendu disease.

Osler-Weber-Rendu disease (OWRD), also known as hereditary haemorrhagic telangiectasia (HHT), is an autosomal dominant genetic disorder characterised by arteriovenous malformations in several organs. Ischemic cholangitis is a rare life-threatening complication of OWRD, with only a few documented cases in the literature. A liver transplant is the main curative treatment. In this paper, we report a case of a 33-year-old woman with a history of recurrent epistaxis, admitted with abdominal pain and fever, physical examination found multiple cutaneous and mucosal telangiectasias and the biological workup showed cholestasis, abdominal imaging identified arterio-venous shunts and multiple cystic hepatic lesions, one of them seemed to communicate with an intrahepatic biliary duct, finally the diagnosis of ischemic cholangitis due to OWRD was retained and antibiotic treatment has been initiated. We review the various therapeutic options available to improve the management of this fatal complication.

Is serum albumin a pivotal biomarker in anticipating acute pancreatitis outcomes?

This study aimed to assess the significance of serum albumin levels within 24 h of patient admission in correlation with the incidence of outcomes and mortality in patients diagnosed with acute pancreatitis. A retrospective study was conducted over a 5-year period, from January 2018 to December 2023, at the Mohammed VI University Hospital in Oujda, Morocco. The study included 371 patients diagnosed with acute pancreatitis. Hypoalbuminemia (≤ 30 g/L) was observed in 124 patients (33.4% of cases), and these patients had a higher mean age compared to those with normal albumin levels (P = 0.003). Hypoalbuminemia was significantly associated with persistent Systemic Inflammatory Response Syndrome (SIRS) (70.8% vs. 29.2%, P = 0.000), a higher BISAP score (66.7% vs. 33.3%, P = 0.000), and a higher CTSI score (51.7% vs. 48.3%, P = 0.000). Hypoalbuminemia was also associated with the presence of pleural effusion (P = 0.000). The mortality in the sample was 4.6%, and it was significantly associated with hypoalbuminemia (76.5%, P = 0.000). In conclusion, serum albumin levels within 24 h of patient admission appear to be a significant prognostic biomarker in acute pancreatitis, particularly in anticipating persistent organ failure and mortality.

Clinical, endoscopic and therapeutic features of bleeding Dieulafoy's lesions: case series and literature review.

OBJECTIVE: Dieulafoy's lesions (DLs) are a rare but potentially life-threatening source of gastrointestinal (GI) haemorrhage. They are responsible for roughly 1%-6.5% of all cases of acute non-variceal GI bleeding.Here, we describe retrospectively the clinical and endoscopic features, review the short-term and long-term outcomes of endoscopic management of bleeding DLs and we identify rate and risk factors, of recurrence and mortality in our endoscopic unit. DESIGN: Data were collected from patients presenting with GI haemorrhagic secondary to DLs between January 2018 and August 2023. Patients' medical records as well as endoscopic databases were retrospectively reviewed. Demographic data, risk factors, bleeding site, outcomes of endoscopy techniques, recurrence and mortality rate were taken into account. RESULTS: Among 1170 cases of GI bleeding, we identified only seven cases involving DLs. Median age was 74 years, with a male-to-female ratio of 2.5. 75% of patients had significant comorbidities, mainly cardiovascular diseases. Only anticoagulant and antiplatelet agents were significantly associated with DLs. All patients were presented with GI bleeding as their initial symptom. The initial endoscopy led to a diagnosis in 85% of the cases. Initial haemostasis was obtained in all patients treated endoscopically. Nevertheless, the study revealed early recurrence in two out of three patients treated solely with epinephrine injection or argon plasma coagulation. In contrast, one of three patients who received combined therapy, experienced late recurrence (average follow-up of 1 year). Pathological diagnosis was necessary in one case. One patient (14%) died of haemorrhagic shock. Average length of hospital stay was 3 days. CONCLUSION: Although rare, DLs may be responsible for active, recurrent and unexplained GI bleeding. Thanks to the emergence of endoscopic therapies, the recurrence rate has decreased and the prognosis has highly improved. Therefore, the endoscopic approach remains the first choice to manage bleeding DLs.

Two cases of Dieulafoy's lesion in unusual sites: A rare case reports of gastrointestinal bleeding.

INTRODUCTION: Dieulafoy's lesion (DL) is a vascular malformation that can lead to massive gastrointestinal bleeding. It's usually found in the stomach. However, DL's occurrence in atypical sites such as the small bowel and colon is exceptionally rare, posing significant management challenges. CASE PRESENTATION: In this report, we present two cases of DL occurring in uncommon sites, each managed with distinct approaches. Case 1 is a 50-year-old man admitted to the emergency department due to massive GI bleeding and hemodynamic instability. The diagnosis of DL was established through computed tomography angiography and confirmed by histopathological examination after emergency surgery. Case 2 involves a 68-year-old woman presented with melena due to a colonic DL. This case was successfully managed through an endoscopic hemostasis approach. DISCUSSION: Dieulafoy's lesions (DL) were first identified as a large submucosal artery lacking typical gastric ulcer characteristics in three of Paul Georges Dieulafoy's patients. This lesion is responsible for approximately 1-2 % of all cases of gastrointestinal bleeding. Endoscopy is the preferred method for diagnosing and managing DL lesions, especially in cases of active bleeding that is accessible. However, if endoscopic treatment or angiographic embolization fails, a surgical approach may be needed. CONCLUSION: DL presents a diagnostic challenge due to its rarity and is not usually included in the differential diagnosis of gastrointestinal bleeding, particularly when occurring in unusual sites. Endoscopy is the preferred method to identify DL and a possible therapeutic approach in active bleeding. However, if endoscopy hemostasis fails, angiographic embolization or surgical intervention may be required.

A rare cause of acute esophageal necrosis: A case report.

Acute esophageal necrosis (AEN) or black esophagus is a rare entity characterized by diffuse circumferential black pigmentation of the esophageal mucosa due to ischemic necrosis. It may be lethal, especially among elderly patients with multiple comorbidities and hemodynamic instability. Diagnosis is based on gastroscopy. Treatment consists of intravenous fluids, proton pump inhibitors, and additional therapies to treat the underlying illness. We report a rare case of a woman in her 50s with cervical cancer who presented with hematemesis and sepsis. Upper gastrointestinal endoscopy showed a black esophagus and an ulcerobudding duodenal process. Few days later, she developed abdominal distension with diffuse pain. Abdominal CT scan demonstrated perforation of gastroduodenal tumor. The treatment was based on resuscitation, proton pump inhibitors, antibiotics, and surgery of the perforated tumor. Unfortunately, the patient died 2 days later because of septic shock. The black esophagus is a fatal complication, thus diagnosis at an early stage and timely management may improve survival. This is the first case reported of AEN due to perforated duodenal tumor explained by septic shock leading to an ischemic esophageal injury.

Acute pancreatitis related to hypercalcemia as initial manifestation of cancer: About 4 cases.

Acute pancreatitis is a frequent gastrointestinal emergency seen in tertiary care hospitals. While gallstones and chronic alcohol consumption remain the most common causes, other etiologies can also be identified, notably hypercalcemia, which constitutes a rare yet deadly cause of acute pancreatitis. Herein, we report 4 cases of AP related to hypercalcemia from malignancies: 2 cases of multiple myeloma, one case of rectal malignancy, and 1 case of medullary thyroid carcinoma associated with a parathyroid adenoma. Among these cases, one patient died, one developed exocrine and endocrine pancreatic insufficiency, and another progressed to end-stage chronic renal failure. Awareness of hypercalcemia of malignancy as an exceptional etiology of AP is crucial for timely diagnosis and appropriate management of these cases.

Spontaneous Rupture of Hepatocellular Carcinoma With Fatal Outcome in a Patient Taking Direct-Acting Antivirals.

Hepatocellular carcinoma (HCC) is one of the most common malignant tumors globally. Many complications are attributed to it, including spontaneous rupture, which is a serious and rare complication that can be life-threatening. Managing and detecting this condition might pose challenges, especially when there is no prior history of liver cirrhosis or tumor. We report on a 57-year-old man followed as an outpatient for chronic hepatitis C who presented to the emergency department for abdominal pain with abdominal distention and jaundice, occurring two months after treatment by direct-acting antiviral (DAA). He was not known to have a liver tumor on the ultrasound performed before the start of treatment. Therefore, the diagnosis of tumor rupture was not very clear. The evolution was fatal, and death occurred quickly. Although the association between DAA treatment and hepatocarcinogenesis and its possible complications is unknown, close monitoring by high-performance imaging is probably required in patients under DAA.

Upper gastrointestinal bleeding revealing a Bouveret syndrome: A case report.

Bouveret's syndrome is an uncommon cause of gastrointestinal obstruction. It's a result of the passage of a gallstone through a fistula connecting the gallbladder with the duodenum or stomach. The diagnosis is challenging due to its atypical clinical manifestations. There have been a few reported cases of Bouveret syndrome presenting with gastrointestinal bleeding. Treatment options include both endoscopic and surgical approaches. We present the case of a 92-year-old woman admitted to the emergency department for upper gastrointestinal bleeding. Gastroscopy revealed gastric stasis upstream of a calculus inducing an obstruction of the bulb. The computed tomography (CT) scan showed a cholecystoduodenal fistula with a calculus lodged in the bulb. The patient underwent a gastrostomy with extraction of the calculus. Postoperative course was uneventful and the patient was discharged home. In the majority of cases, Bouveret's syndrome is revealed by an upper gastrointestinal obstruction, but other signs, such as gastrointestinal bleeding, can be seen. The diagnosis is confirmed by an imaging method that highlights Rigler's triad. The management can be either endoscopic or surgical depending on the patient's general condition. The diagnosis is often difficult due to the lack of specificity in the symptoms. Presently, there exists no consensus concerning the appropriate approach for its management.

Association between pancreatic cancer and diabetes: insights from a retrospective cohort study.

BACKGROUND: Studies investigating the prevalence of pancreatic cancer have revealed a heightened risk of 1.5 to 2.0 times among individuals with long-standing type 2 diabetes mellitus. AIMS: We aimed to estimate the prevalence of diabetes among patients with pancreatic cancer, and identify the factors associated with type 2 diabetes mellitus in this population. METHODS: This retrospective observational and analytical study was carried out in the Department of Gastroenterology of the Mohammed VI University Hospital over a period of 5 years, between 2018 and 2022, including all patients with confirmed cases of pancreatic adenocarcinoma. RESULTS: Out of the 197 patients, 38.1% had a history of diabetes, among them, 42.7% had new-onset diabetes, while the remaining 57.3% had long-standing diabetes. Diabetic patients were significantly older than nondiabetic patients (mean age of 67.2 vs. 63, P = 0.009). Diabetes was more prevalent among obese patients (66.7%, P = 0.01), and less frequent among individuals with chronic alcohol consumption (20% vs. 80%, P = 0.04), and tobacco smokers (24.4% vs75.6%, P = 0.03). Among patients with an ECOG score ≥ 3, DM, 54.5% were DM-patients (P = 0.033). The same significant association was found for the Nutritional Risk Index, Patients who had moderate or severe malnutrition were more likely to be diabetic 74.7% (P = 0.004). Diabetic patients were less likely to undergo surgery due to comorbidities and general health deterioration. However, no significant differences were observed in sex, tumor stage or location. CONCLUSION: Our study has shown an increased prevalence of diabetes in pancreatic cancer and highlights the importance of considering this cancer in cases of recent onset or uncontrolled diabetes, especially in elderly individuals.

Abdominal Inflammatory Myofibroblastic Tumour Presenting as a Pancreatic Mass: A Case Report.

An abdominal inflammatory myofibroblastic tumor (AIMT), is a rare benign tumor composed of inflammatory and other mesenchymal cells. It can affect the entire body, predominantly in children and young adults. The diagnosis is challenging considering the wide clinical presentation and can often be mistaken for malignant tumors. We report a rare case of a 46-year-old female patient, who presented with intermittent abdominal pain weight loss, and an abdominal palpable mass. Abdominal ultrasound found a well-defined 18 cm, rounded mass, with solid and cystic components. Abdominal CT demonstrated a well-defined, hypodense, retro gastric mass of 20 cm, with thickened wall and heterogenous enhancement. The mass had contact with the pancreatic tail, transverse colon, spleen, left kidney pedicles, abdominal aorta, superior mesenteric vein, and mesaraic trunk with no invasion signs. The mass was initially thought to be pancreatic cancer, but given the large size, other diagnoses like sarcoma, lymphoma, or abdominal hydatid cyst were suggested. Endoscopic ultrasound found a rounded retro gastric mass of 18/12 cm, with a thickened wall and well-limited calcifications. The content was both cystic and solid with mobile vegetations, with no visible Doppler flow. The mass had contact with the body and tail of the pancreas, spleen hilum, the upper pole of the spleen, and the hepatic pedicle behind, with no invasion sign. After a multidisciplinary team meeting, a decision was taken to perform surgical resection with mass resection, distal splenopancreatectomy, and transverse and sigmoid colectomy. Pathological and immunostaining results were consistent with inflammatory pseudotumor. The postoperative recovery was uncomplicated. The patient remains asymptomatic with no obvious signs of metastasis or recurrence. AIMT represents a reel diagnostic challenge. Clinical symptoms are unspecific. Radiological and endoscopic features can often be mistaken for malignant tumors. Surgical management remains to be the best therapeutic option. We report a rare case of AIMT treated by surgery with complete resection. We suggested a long-term follow-up given the local recurrence risk.

Pancreatic cancer: experience from an emerging country in North Africa.

PURPOSE: Pancreatic cancer is a major global health problem, it's a highly aggressive and often has a poor prognosis. The aim of this work is to carry out a retrospective epidemiological study on pancreatic cancer in a university hospital in a North African country. METHODS: This is a monocentric, descriptive and analytical retrospective cohort study carried out in the Gastroenterology department of the Mohammed VI University Hospital of Oujda, Morocco, between January 2018 and December 2022. Analysis were performed using IBM SPSS Version 21.0 RESULTS: During this period, 197 cases of pancreatic cancers were collected, the median age was 64.6 years, the majority of patients (90.9%) were over 50 year's old. and there was no significant difference in gender distribution. Among the patients, several risk factors were prevalent, including chronic tobacco smoking (22.8%), alcohol consumption (12.7%), diabetes (38.1%), obesity (7.6%), and a family history of pancreatic cancer (3%). The most common symptoms at presentation were abdominal pain and obstructive jaundice. Imaging revealed that the majority of cases were located in the head of the pancreas (80.7%). Only 19.8% of the cancers were diagnosed at a resectable stage and adenocarcinoma was the predominant histological type (96.4%). Patients with advanced cancer stages showed higher levels of CA 19-9 and hypoalbuminemia. CONCLUSION: Our study aligns with previous research, indicating an increased incidence of pancreatic cancer among elderly individuals, particularly those with several risk factors such as chronic tobacco smoking, alcohol consumption, diabetes. A small proportion of cancer cases are deemed resectable at the time of diagnosis.

Primary Gastric Signet Ring Cell Carcinoma or Metastatic Lobular Carcinoma With Signet Ring Cells: A Diagnostic Challenge.

Histologically, cells having vacuolated cytoplasm rich in mucin and pushing the nucleus to the periphery are indicative of signet ring cell carcinoma. This condition often affects the digestive system. On the other hand, it is a very uncommon subtype of invasive lobular breast carcinoma, with a higher probability (more than invasive breast carcinoma of no special type {IBC-NST}) to migrate to the stomach, spleen, urinary tract, and uterus. As with other metastatic carcinomas of breast origin, metastatic signet ring cell carcinoma of the breast is often treated with systemic therapies such as chemotherapy or hormonal therapy. However, surgical resection and eventual perioperative chemotherapy are usually recommended in case of primary gastric ring cell carcinomas that are non-metastatic. As a result, misdiagnosis might result in unneeded gastrectomy and chemotherapy, which would result in considerable mortality and morbidity. We report a case of mammary lobular carcinoma with signet ring cells metastatic to the stomach, a variant rarely described and challenging to distinguish from primary gastric signet ring carcinoma.

Colonic schistosomiasis: A case report.

BACKGROUND: Schistosomiasis is a chronic parasitic infection endemic in many countries. Colonic schistosomiasis is a rare entity with no specific clinical manifestations or endoscopic aspects, which delays the diagnosis. Diagnosis is primarily dependent on histopathological analysis, and treatment with antihelminthics typically resolves the infection. CASE SUMMARY: We present the case of a 21-year-old male who suffered from chronic diarrhea and abdominal pain. Physical examination found no abnormalities, blood tests were normal, and stool examination was negative. A colonoscopy revealed a nodular terminal ileal mucosa, two cecal polypoid lesions with no particular surface pattern, and millimetric erosions in the rectum. The presence of Schistosoma eggs with thick peripheral capsules and viable embryos inside and numerous eosinophils surrounding the egg capsule were observed on histopathological examination. The patient received praziquantel, and his symptoms were resolved. CONCLUSION: Colonic schistosomiasis should be considered as a differential diagnosis, especially in endemic countries. Endoscopy and histopathological examination can confirm the diagnosis, and antihelminthics are an effective treatment.

Solitary pancreatic metastasis from squamous cell lung carcinoma: A case report and review of literature.

BACKGROUND: Pancreatic metastases from squamous cell lung carcinoma (SCLC) are unusual. These lesions are often asymptomatic and detected incidentally or during follow-up investigations, occasionally several years after removal of the primary tumor. CASE SUMMARY: A 56-year-old male with SCLC developed jaundice 1 mo after the cancer diagnosis. An abdominal computed tomography (CT) scan showed a mass in the pancreatic head with distention of both intra- and extrahepatic biliary ducts. Endoscopic retrograde cholangiopancreatography and sphincterotomy were performed first, culminating with plastic biliary stent placement. Cytological examination of the pancreatic mass sample collected by fine-needle aspiration (FNA) under endoscopic ultrasound (EUS) guidance revealed the presence of malignant cells compatible with well-differentiated squamous cell carcinoma. After liver function normalized, chemotherapy was initiated with carboplatin and paclitaxel; however, 4 d later, the patient presented dysphagia. Cervico-thoraco-abdominal CT showed tracheoesophageal fistula and stent migration. After replacement with a 10 cm/10 mm uncovered metallic biliary stent and treatment of the tracheoesophageal fistula with a fully covered esophageal stent, the patient was able to start oral feeding progressively. He died 9 mo after the initial diagnosis. CONCLUSION: The diagnosis of pancreatic metastasis from SCLC is challenging for clinicians. EUS-FNA is the primary exam for confirmatory diagnosis.

A rare case report of an adult with down syndrome and gallbladder cancer.

Introduction: The most frequent malignancies observed on adult with Down syndrome are lymphoblastic and myeloblastic leukemia. The incidence and the relationship between gallbladder cancer and Down syndrome is unknown. Case presentation: We report a rare case of a 25-year-old male with Down syndrome who consulted to the emergency because of deterioration in overall health associated with post-meal food vomiting, abdominal distension and diffuse abdominal pain. CECT scan reveal suspicious locally advanced parietal tissue thickening of the gallbladder, associated with peritoneal carcinosis, and a bilateral massive pulmonary embolism, in addition to a large bilateral pleurisy and moderate pericardial effusion. The patient died three weeks later. Discussion: Solid tumors are rare among population with Down syndrome, especially gallbladder cancer. Main risk factors are: cholelithiasis and gallbladder abnormalities, which are frequent in these patients. Management of this lethal disease depends on precocity of diagnosis. For this we suggest an abdominal ultrasound in children with DS to screen previously cholelithiasis and prevent this fatal cancer. Conclusion: Some Authors found that the rate of gallbladder disease especially cholelithiasis, was 25% among Down syndrome group, compared to 4.5% among the control group (p = 0.002). We suggest that cholelithiasis is the main risk factor of gallbladder cancer in this population. However, other prospective studies should be accomplished so as to confirm this outcome.

Non-Bismuth Quadruple Therapy, Sequential Therapy or High-Dose Esomeprazole and Amoxicillin Dual Therapy for First-Line Helicobacter pylori Eradication: A Prospective Randomized Study.

AIM: The study aims were to evaluate and compare the effectiveness and safety of non-bismuth quadruple therapy with sequential therapy and dual therapy with high dose esomeprazole and amoxicillin as an empirical first-line approach to eradicate Helicobacter pylori infection. PATIENTS AND METHODS: Prospective randomized trial included 393 patients infected with H. pylori naïve to eradication therapy, randomized to receive a 10-day non-bismuth quadruple or concomitant (CT) therapy, 10-day sequential therapy (SQ), or 14-day high-dose esomeprazole and amoxicillin (BT). Treatment outcome was assessed by C13-urea breath test at least six weeks after therapy. Adverse events and compliance were assessed with questionnaires and residual medication count. RESULTS: The baseline demographic clinical and endoscopic characteristics were similar among the three groups. The intention to treat (ITT) analysis was performed in 130, 132, and 131 patients in the BT, SQ, and CT groups, respectively. The eradication rates in ITT were 64.6%, 83.1%, and 92.3%, respectively, in the BT, SQ and CT groups (p = 0.0001). The eradication rates per protocol were 67.7%, 88.5%, and 95.3% (p = 0.0001), respectively, in the BT, SQ, and CT groups. The CT and SQ groups were higher than the BT group (p = 0,0001) but no significant results were seen in the eradication rate between CT and SQ, both in PP analysis and in ITT analysis (p = 0.09). The prevalence of the side effects following the non-bismuth quadruple therapy was 38.2%, significantly higher (p = 0.001) than the BT group (13.80%) and SQ group (22%). There were no significant differences in compliance among the three therapies (p = 0.16). CONCLUSION: This study found that non-bismuth quadruple therapy yielded a higher H. pylori eradication rate over sequential regimen as a first-line treatment in Morocco, with no statistical difference between the two protocols studied, while the eradication rate of dual high-dose of esomeprazole and amoxicillin did not exceed 60%. All three therapy schemes showed excellent compliance. However, the prevalence of side events was more important and significantly higher with non-bismuth quadruple therapy.