Chameleonic Chloroma: A Case of Myeloid Sarcoma Presenting as a Pancreatic Head Mass.

We report a case of pancreatic myeloid sarcoma (MS), an extremely rare manifestation of acute myeloid leukemia (AML), in a 35-year-old male who presented with epigastric pain and watery stools. Initial diagnostic testing was inconclusive; however, following an extensive evaluation, endoscopic biopsies suggested AML, which was confirmed by a bone marrow biopsy. Given that few cases are documented in the literature, pancreatic MS without a preexisting hematologic malignancy poses a significant diagnostic challenge.

Angiotensin converting enzyme inhibitor-induced gastrointestinal angioedema: a case series and literature review.

GOALS: The objective of this study was to better understand the presenting signs and symptoms of angiotensin converting enzyme (ACE) inhibitor-induced gastrointestinal angioedema, review the medical literature related to this condition, and bring this diagnosis to the attention of clinicians. BACKGROUND: Angioedema occurs in 0.1% to 0.7% of patients treated with ACE inhibitors and ACE inhibitors account for 20% to 30% of all angioedema cases presenting to emergency departments. However, only recently have ACE inhibitors been recognized as a cause of angioedema of the gastrointestinal tract. Patients with this disease present with one or more episodes of abdominal pain associated with nausea, vomiting, and/or diarrhea. STUDY: We present four cases of ACE inhibitor-induced gastrointestinal angioedema seen at a single institution and review the literature of other case reports. RESULTS: Review of the medical literature identified 27 case reports of ACE inhibitor-induced angioedema of the gastrointestinal tract. Multiple ACE inhibitors were implicated in these case reports suggesting that this disease is a class effect of ACE inhibitors. In cases where the race of the patient was stated, 50% were identified as being African American. Ascities was described as a radiographic finding in 16 of 27 cases. There were no reported cases of paracentesis or ascitic fluid analysis described in any of the identified case reports. CONCLUSIONS: This series highlights ascites as a key feature that distinguishes ACE inhibitor-induced gastrointestinal angioedema from infectious enteritis. This series also confirms the increased incidence of this condition among African American women, an unpredictable interval between medication initiation and the development of symptoms, and the heightened probability of symptom recurrence if ACE inhibitors are not discontinued. ACE inhibitor-induced gastrointestinal angioedema is a rare cause of acute abdominal complaints, but is likely underdiagnosed and should be considered in the differential diagnosis of all individuals taking ACE inhibitors with such symptoms. Early recognition of ACE inhibitor-induced gastrointestinal angioedema may avoid recurrent episodes or costly, invasive evaluations.

Bleeding Gastrointestinal Stromal Tumor (GIST) Results in a Sticky Situation: The Good and Bad of Hemostatic Spray.

A 50-year-old female presented with symptomatic anemia and hematemesis due to a 3.3 cm gastric gastrointestinal stromal tumor (GIST), which was located in the fundus. Adequate endoscopic views were only achieved in the retroflexed position and attempts at hemostasis via endoscopic clips were unsuccessful. Subsequently, TC-325 hemostatic powder was sprayed on the bleeding lesion and given retroflexed positioning, the powder also coated the esophagogastroduodenoscopy (EGD) scope where it abutted the gastroesophageal junction (GEJ). Hemostasis was successful, but the scope was unable to be withdrawn due to adherence to the surrounding mucosa. With torque maneuvering and a moderate amount of withdrawal force, the scope was successfully freed. The patient was started on imatinib mesylate and did not experience further bleeding episodes. This case highlights the challenge of achieving hemostasis in a bleeding GIST, the beneficial role of hemostatic powder spray, and the need for caution when utilizing it in a retroflexed manner.

Systems-based Strategies Improve Positive Screening Fecal Immunochemical Testing Follow-up and Reduce Time to Diagnostic Colonoscopy.

INTRODUCTION: Fecal immunochemical testing (FIT) is the most commonly used colorectal cancer (CRC) screening tool worldwide and accounts for 10% of all CRC screening in the United States. Potential vulnerabilities for patients enrolled to facilities within the military health system have recently come to light requiring reassessment of best practices. We studied the impact of a process improvement initiative designed to improve the safety and quality of care for patients after a positive screening FIT given previously published reports of poor organization performance. METHODS: During a time of increased utilization of nonendoscopic means of screening, we assessed rates of colonoscopy completion and time to colonoscopy after positive FIT after a multi-faceted process improvement initiative was implemented, compared against an institutional control period. The interventions included mandatory indication labeling at the time of order entry, as well as utilization of subspecialty nurse navigators to facilitate rapid follow-up even the absence of a referral from primary care. RESULTS: Preintervention, 34.8% of patients did not have appropriate follow-up of a positive FIT. Those that did had a variable and prolonged wait time of 140.1 ± 115.9 days. Postintervention, a standardized order mandating test indication labeling allowed for proactive gastroenterology involvement. Colonoscopy follow-up rate increased to 91.9% with an average interval of 21.9 ± 12.3 days. CONCLUSION: The addition of indication labels and patient navigation after positive screening FIT was associated with 57.1% absolute increase in timely diagnostic colonoscopy. Similar highly reliable systems-based solutions should be adopted for CRC screening, and further implementation for other preventative screening interventions should be pursued.

Two cases of Klebsiella pneumoniae primary liver abscesses; an emerging clinical entity among diabetics.

Klebsiella pneumoniae liver abscesses with limited antibiotic resistance have been increasing among diabetics in various geographic regions, most notably in Taiwan. Two cases of Hawaiian diabetic men with Klebsiella pneumoniae primary liver abscesses are presented as well as a brief review of the literature.

Medical evacuation for unrecognized abdominal wall pain: a case series.

BACKGROUND: Chronic abdominal pain is a frequently encountered complaint in the primary care setting. The abdominal wall is the etiology of this pain in 10 to 30% of all cases of chronic abdominal pain. Abdominal cutaneous nerve entrapment at the lateral border of the rectus abdominis muscle has been attributed as a cause of this pain. In the military health care system, patients with unexplained abdominal pain are often transferred to military treatment facilities via the Military Medical Evacuation (MEDEVAC) system. CASE SERIES: We present two cases of patients who transferred via MEDEVAC to our facility for evaluation and treatment of chronic abdominal pain. Both patients had previously undergone extensive laboratory evaluation, imaging, and invasive procedures, such as esophagogastroduodenoscopy before transfer. Upon arrival, history and physical examinations suggested an abdominal wall source to their pain, and both patients experienced alleviation of their abdominal wall pain with lidocaine and corticosteroid injection. CONCLUSION: This case series highlights the need for military physicians to be aware of abdominal wall pain. Early diagnosis of abdominal cutaneous nerve entrapment syndrome by eliciting Carnett's sign will limit symptom chronicity, avoid unnecessary testing, and even prevent medical evacuation.

Hemorrhagic fever with renal syndrome.

Hemorrhagic fever with renal syndrome (HFRS) is caused by the Hantaviruses, a group enveloped RNA viruses transmitted through contact with infected rodent urine or feces. Although distributed widely through Europe, Asia, and the New World, infections acquired in Korea, China, and Russia tend to be among the most severe. The initial presentation of HFRS is extremely variable, but generally includes fever, malaise, headache and abdominal pain. Laboratory findings that may lead to the diagnosis include thrombocytopenia, azotemia, elevated serum creatinine, or proteinuria. We present the case of a patient that acquired hemorrhagic fever with renal syndrome in South Korea.

Postpolypectomy electrocoagulation syndrome: a mimicker of colonic perforation.

Postpolypectomy electrocoagulation syndrome is a rare complication of polypectomy with electrocautery and is characterized by a transmural burn of the colon wall. Patients typically present within 12 hours after the procedure with symptoms mimicking colonic perforation. Presented is the case of a 56-year-old man who developed abdominal pain six hours after colonoscopy during which polypectomy was performed using snare cautery. CT imaging of the abdomen revealed circumferential thickening of the wall of the transverse colon without evidence of free air. The patient was treated conservatively as an outpatient and had resolution of his pain over the following four days. Recognition of the diagnosis and understanding of the treatment are important to avoid unnecessary exploratory laparotomy or hospitalization.

Anti-gliadin antibodies identify celiac patients overlooked by tissue transglutaminase antibodies.

For patients with suspected celiac disease, the American Gastroenterological Association recommends initial screening with anti-tissue transglutaminase antibody (tTG) and confirmation testing with small bowel biopsy. However, at Tripler Army Medical Center we routinely screen patients with both tTG and anti-gliadin antibodies (AGA) in combination. The purpose of this study was to evaluate whether this dual screening method adds to the evaluation of patients with suspected celiac disease or results in more false-positive results than tTG screening alone. A retrospective chart review of all tTG and AGA screening serologies at Tripler Army Medical Center between September 2008 and March 2012 was performed. For patients with positive serologic testing, small bowel biopsy results or reasoning for deferring biopsy were investigated. tTG was found to have a higher positive predictive value for celiac disease than AGA, however AGA identified 5 patients (19% of biopsy confirmed celiac disease) that had a negative tTG and would not have been identified by tTG screening alone. Using AGA in combination with tTG should be considered if the goal of screening is to identify all patients with celiac disease, with the understanding that this strategy will generate more false positive tests and result in additional patients undergoing small bowel biopsy.