Schwann Cell Hamartoma Presenting as a Colonic Polyp: A Rare Case Report With a Literature Review.

Mucosal Schwann cell hamartomas (MSCHs) are non-common noncancerous growths derived from Schwann cells in the peripheral nervous system, often found unexpectedly during routine colonoscopy examinations. These growths primarily occur in the colon, although they can also appear in the esophagus and are not linked to familial cancer syndromes. Diagnosis relies on specific histological characteristics and staining patterns. It is essential to distinguish MSCHs accurately since their appearance can closely resemble that of malignant tumors. Characteristically, these hamartomas test positive for S-100 protein but do not exhibit markers typical of other gastrointestinal growths, such as gastrointestinal stromal tumors (negative for KIT), leiomyomas (negative for smooth muscle actin), neurofibromas (negative for CD34), and perineuromas (negative for epithelial membrane antigen or claudin-1). This report discusses the case of a 48-year-old woman who was diagnosed with MSCH during a screening colonoscopy.

Metabolic Dysfunction-Associated Steatohepatitis and Progression to Hepatocellular Carcinoma: A Literature Review.

The prevalence of metabolic-associated fatty liver disease (MAFLD) is increasing globally due to factors such as urbanization, obesity, poor nutrition, sedentary lifestyles, healthcare accessibility, diagnostic advancements, and genetic influences. Research on MAFLD and HCC risk factors, pathogenesis, and biomarkers has been conducted through a narrative review of relevant studies, with a focus on PubMed and Web of Science databases and exclusion criteria based on article availability and language. Steatosis marks the early stage of MASH advancement, commonly associated with factors of metabolic syndrome such as obesity and type 2 diabetes. Various mechanisms, including heightened lipolysis, hepatic lipogenesis, and consumption of high-calorie diets, contribute to the accumulation of lipids in the liver. Insulin resistance is pivotal in the development of steatosis, as it leads to the release of free fatty acids from adipose tissue. Natural compounds hold promise in regulating lipid metabolism and inflammation to combat these conditions. Liver fibrosis serves as a significant predictor of MASH progression and HCC development, underscoring the need to target fibrosis in treatment approaches. Risk factors for MASH-associated HCC encompass advanced liver fibrosis, older age, male gender, metabolic syndrome, genetic predispositions, and dietary habits, emphasizing the requirement for efficient surveillance and diagnostic measures. Considering these factors, it is important for further studies to determine the biochemical impact of these risk factors in order to establish targeted therapies that can prevent the development of HCC or reduce progression of MASH, indirectly decreasing the risk of HCC.

A Rare Case of Cecal Adenocarcinoma Presenting as Intussusception.

Colorectal cancer is widely recognized as one of the most common types of cancer worldwide. The management and outlook for colorectal cancer depend on its specific characteristics and how it presents clinically. Despite the identification of various risk factors and causes, cecal carcinoma, a type of colorectal cancer, is infrequent in Western populations under 50 years of age, and little research has been conducted on its epidemiology. Additionally, intussusception, a medical condition where one part of the intestine slides into another, is relatively rare among younger individuals. In this case report, we present a 36-year-old male who presented with abdominal pain. A physical exam revealed mild right-sided and peri-umbilical tenderness. A computed tomography scan of the abdomen and pelvis with contrast revealed long segment intussusception involving the terminal ileum and cecum. The patient underwent a reduction of intussusception and hemicolectomy. He was diagnosed with invasive cecal adenocarcinoma with metastasis to lymph nodes. He was started on chemotherapy and has been following as an oncology outpatient.

When Meals Turn Into a Medical Mystery: A Case Report of Sigmoid Colon Impaction by a Chicken Bone.

The presence of foreign objects in the digestive system can lead to various complications within the gastrointestinal (GI) tract. In certain cases, ingesting foreign objects can pose a significant dilemma for surgical teams, primarily because they can lead to blockages or punctures in the upper or lower sections of the GI tract. On occasion, foreign objects located in the lower regions of the digestive tract, such as the colon and rectum, might have entered via the anal pathway, thereby carrying the potential risk of causing perforations in the rectum or sigmoid colon. The other complications encompass the creation of abscesses, blockages in the bowel, fistula, and bleeding. Although these issues associated with foreign objects can arise in a healthy bowel, they can pose challenges in diagnosis when occurring in a bowel that is already affected by inflammation, constrictions, or malignancy. We present a unique case report of a 72-year-old female who presented to the emergency department with left lower quadrant pain associated with nausea and vomiting. Following a detailed clinical evaluation and radiographic imaging, a chicken bone was identified as the culprit, causing an unusual impaction in the sigmoid colon. The patient's medical history revealed no prior GI complications, making this case particularly noteworthy. Timely identification and precise diagnosis of complications arising from foreign bodies are essential to efficiently handle and prevent unfavorable consequences.

Understanding Esophageal Diverticular Bleeding: Causes, Symptoms, and Treatment.

Esophageal diverticulum refers to a sac or protrusion formed by the epithelial-lined tissue of the esophagus. It can exist as either a true diverticulum involving all layers of the esophagus or a false diverticulum. Most cases of esophageal diverticula are acquired conditions that primarily affect older individuals. Typically, patients with a known motility disorder experience dysphagia as a common symptom of esophageal diverticulum; other symptoms include recurrent pneumonia, hoarseness, and halitosis. Failure to diagnose this condition promptly or accurately can result in more severe complications, such as gastrointestinal bleeding, lung abscesses, aspiration pneumonia, and cancer development. In this report, we present the case of a 68-year-old female who arrived at the emergency department with symptoms of epigastric discomfort and hematemesis and was found to have diverticula in the middle portion of the esophagus.

Esophagitis Dissecans Superficialis: Unveiling the Enigmatic Entity of Esophageal Mucosal Sloughing.

Esophagitis dissecans superficialis (EDS), formerly referred to as sloughing esophagitis, is a degenerative condition affecting the squamous epithelium. EDS is known to be a benign condition that resolves on its own. The exact etiology of EDS remains unclear, although associations with medications like bisphosphonates or nonsteroidal anti-inflammatory drugs, skin conditions, heavy smoking, and physical trauma have been reported. The clinical manifestations exhibit a wide range, encompassing both incidental findings and symptomatic presentations related to the esophagus. Here we present an interesting case of a middle-aged female patient with dysphagia who underwent early esophagogastroduodenoscopy (EGD) for timely identification and treatment of EDS, emphasizing the significance of early detection and management.

Novel Therapies for Celiac Disease: A Clinical Review Article.

Celiac disease is emerging as an autoimmune disorder with increasing prevalence and incidence. The mean age of presentation is also increasing with the passage of time. The delay in diagnosis is partly attributable to the asymptomatic state in which most patients present. The diagnosis of the disease is primarily based on biopsy, but serology can also be included for possible screening purposes. Although the primary management strategy is to eliminate gluten from the diet of such patients; however, compliance with the diet and follow-up to detect healing might be difficult to maintain. Therefore, there is a need to investigate further management therapies that can be easily administered and monitored. The aim of the review is to discuss the epidemiology, clinical presentation, and novel therapies being investigated for celiac disease.

Diagnostic Challenge of Small Bowel Neuroendocrine Tumor in a Young Female Patient.

Neuroendocrine tumors (NETs) are rare cancers arising from neuroendocrine cells and are characterized by their ability to secrete functional hormones causing distinctive hormonal syndromes. The incidence of NET has increased over the years, and small bowel neuroendocrine tumor (SBNET) is one of the most challenging to detect due to its varied presentation and poor accessibility with traditional endoscopic methods. Patients with SBNET present with variable hormonal symptoms, such as diarrhea, flushing, and nonspecific abdominal pain, which often delay the diagnosis. We present the case of a young patient who underwent multidisciplinary workups leading to a successful diagnosis of SBNET promptly. The patient was a 31-year-old female who presented to the emergency department with complaints of nausea, vomiting, and sudden-onset, severe, sharp abdominal pain. CT scan of her abdomen showed an area of irregular intraluminal soft tissue density suspicious for a mass in the mid-small bowel. The patient's initial enteroscopy was normal. A video capsule endoscopy showed a small bowel mass, which was consistent with SBNET confirmed by pathology later. This case emphasizes the importance of considering SBNET as a differential diagnosis in young patients with nonspecific symptoms of abdominal pain and highlights the role of multidisciplinary approaches in achieving prompt diagnosis and treatment.

Emphysematous Gastritis: A Case Series on a Rare but Critical Gastrointestinal Condition.

Emphysematous gastritis (EG) is a rare and life-threatening condition characterized by gas-forming microorganisms causing gas to accumulate within the stomach wall. It has a high mortality rate and is associated with risk factors like gastroenteritis, alcohol use disorder, diabetes mellitus, renal failure, recent abdominal surgery, long-term corticosteroid use, and ingestion of corrosive agents. Diagnosis is challenging due to its rarity and nonspecific symptoms, including severe abdominal pain, coffee-ground emesis, fever, and signs of systemic infection. We present two cases of patients with signs and symptoms of EG, where prompt diagnosis and treatment were achieved, avoiding further complications. Surgical intervention was avoided due to the successful response to conservative treatment. These cases highlight the importance of early detection and intervention in improving patient outcomes and preventing complications associated with EG.

Diffuse Large B-cell Lymphoma in a Young Patient Presenting as a Cecal Mass.

Colorectal lymphomas are very rare and are usually found in male patients between the fifth and seventh decade of life. Our patient was a 30-year-old male who presented with the complaint of epigastric pain and abdominal mass for the past three months. Physical examination was remarkable for soft solid abdominal mass extending from the right side of the abdomen toward the left side. Computed tomography showed a large lobulated mass in the right lower quadrant involving multiple loops of bowel. The mass measured 15.1 x 12.5 cm in transverse dimension and 16.2 cm in craniocaudal dimension. Colonoscopy showed a villous and fungating mass occupying the whole cecum and extending into the ascending colon. Pathology from the colonoscopy mass revealed diffuse large B-cell lymphoma, which was CD20 (cluster of differentiation 20) positive. He was started on rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) chemotherapy regimen and is following at the oncology outpatient department. A combination of surgical resection and chemotherapy is used in treating patients with colorectal lymphoma.

Kikuchi-Fujimoto Disease in a Crohn's Patient.

Kikuchi-Fujimoto disease (KFD), also known as histiocytic necrotizing lymphadenitis, is a rare, benign, focal, self-limiting disease. We report a unique case of KFD in a patient with coexisting Crohn's disease. Our patient is a 23-year-old African American female with a past medical history significant for Crohn's disease who presented to the clinic because of a painless lump over the right side of the neck for the past 3 weeks. On physical examination, the patient was found to have enlarged nontender right cervical lymph nodes from levels 2 to 4. An excisional biopsy of the right neck lymph node was done which revealed necrotizing histiocytic lymphadenitis, favoring a diagnosis of KFD. Over the course of the next 2 months, her lymphadenopathy got resolved. This is the first case of KFD in a patient with Crohn's Disease. Lymphoma remains a feared adverse outcome for immunomodulatory drugs, thus necessitating their cessation upon signs of lymphadenopathy. Our case highlights the importance of a detailed workup in order to access the underlying cause of the lymphadenopathy so that the immunomodulatory drugs can be resumed in these patients.

Hepatic Amyloidosis as a Rare Cause of Liver Failure: A Case Report.

Amyloidosis is a systemic disease that results from the extracellular deposition of an abnormal protein called amyloid. The kidney and the heart are the most common organ affected by amyloidosis while in some cases liver involvement can be seen. Our patient is a 60-year-old African American male who presented to the emergency department because of multiple episodes of syncope over the past day. Chest x-ray and ultrasound chest were suggestive of pleural effusion for which thoracentesis was done. His hospital course was complicated with renal and liver failure. Computed tomography (CT) abdomen and pelvis was done which showed mild hepatomegaly. Liver biopsy was done which showed congo red stain positive for amyloid. The patient's clinical condition continued to worsen and he was started on hemodialysis. During hospital course, the patient developed liver failure. His family members opted for palliative care and the patient passed away during the same admission. Physicians need to be aware of the detrimental course and poor prognosis associated with hepatic and renal amyloidosis. High clinical suspicion is needed to make an early diagnosis and initiate prompt treatment. Although clinical, laboratory and radiological findings can help in suggesting amyloidosis, a tissue biopsy is needed to confirm the diagnosis of amyloidosis.

A Case of Severe Epstein-Barr Virus-Associated Hemophagocytic Lymphohistiocytosis Successfully Treated With High Dose Steroids and Ganciclovir.

Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening hematological disorder characterized by immune dysregulation with multiple organ involvement and carries a poor prognosis. The occurrence of HLH can be familial or sporadic, which is triggered by causes like infection or malignancy. This case report is about a 47-year-old male who presented to the hospital with a fever, chills, night sweats, and unintentional weight loss. He was found to have severely elevated ferritin, and computed tomography showed cirrhosis, a normal sized spleen, and retroperitoneal lymphadenopathy. He underwent an extensive battery of tests to identify the etiology. Meanwhile, he had recurrent fevers with worsening transaminitis and septic shock, requiring admission to the ICU. Blood tests for Epstein-Barr virus (EBV) deoxyribonucleic acid (DNA) and immunoglobulin G (IgG) were positive. Due to high suspicion of HLH, he was started on intravenous methylprednisone 1000 mg daily for three days with clinical improvement. A bone marrow biopsy showed hemophagocytosis and he was diagnosed with EBV-associated HLH. He was continued on steroids with oral prednisone and continued to clinically improve. He was later tapered off steroids over the course of five months. HLH is a rapidly progressive and fatal condition that requires prompt treatment, and thus a high index of suspicion is needed to make a timely diagnosis.

Necrotizing Fasciitis In A Patient with Metastatic Clear Cell Ovarian Carcinoma Treated with Bevacizumab.

BACKGROUND Necrotizing fasciitis is a life-threatening infection of the deep soft tissues that leads to progressive destruction of the fascia and subcutaneous fat. It typically spreads along the muscle fascia planes because of the relatively poor blood supply. Muscle tissue is usually spared because of its better blood supply. The usual risk factors for necrotizing fasciitis include trauma, malnutrition, obesity, uncontrolled diabetes mellitus, alcoholism, cirrhosis, neutropenia, and recent surgery. CASE REPORT We present a case of a middle-aged female who presented with necrotizing fasciitis of the right gluteal region. Her medical history was significant for well-controlled diabetes mellitus (hemoglobin A1c: 6.6), and clear cell carcinoma of ovaries (stage IV). She was on active chemotherapy with bevacizumab, paclitaxel, and carboplatin. She underwent incision and debridement of right gluteal abscess with drainage of 200 ml of foul-smelling pus and was started on intravenous antibiotics. Her blood cultures were negative, but the cultures taken from the right gluteal abscess showed moderate growth of Escherichia coli. The antibiotics were de-escalated and the patient was discharged with outpatient follow-up. CONCLUSIONS Bevacizumab, a humanized monoclonal IgG antibody, is a novel treatment for metastatic ovarian cancer. It is associated with necrotizing fasciitis due to anti-angiogenic, pro-thrombotic, and poor wound healing properties. It should be stopped in the patients presenting with necrotizing fasciitis.

Penile Necrosis Associated with Local Intravenous Injection of Cocaine.

BACKGROUND Cocaine is a highly addictive drug and its use has increased in recent years. It is the second most popular illicit drug in the United States and is the second most trafficked illicit drug in the world. Intravenous (i.v.) drug use leads to severe injury to the veins, including erythema, thrombophlebitis, vasoconstriction, necrosis, development of venous ulceration, and vein occlusion. CASE REPORT A 35-year-old man presented to our Emergency Department with a 3-day history of excruciating and progressive penile and scrotal pain after having injected cocaine in the dorsal vein of the penis. A genital examination revealed ulcerations and swelling on the ventral proximal penis and scrotum junction, with foul-smelling serous discharge. There was no crepitus. He also had stellate purpura with necrosis of the dorsum of the penis and tender bilateral inguinal lymphadenopathy. Computed tomography of the pelvis, with contrast, showed subcutaneous edema of the penis with ulceration of the penile tip on the right. It also revealed left inguinal adenopathy. Vasculitis and concomitant sexually transmitted disease were ruled out as well as Fournier gangrene, and he was started on i.v. broad-spectrum antibiotics. The patient's clinical condition improved with antibiotics and local wound care. CONCLUSIONS Our case highlights the importance of taking a thorough history from i.v. drug users, as they are at risk of injecting drugs into unusual sites, such as the dorsal penile vein. It is important for the physician to counsel active i.v. drug users regarding possible complications of injecting drug into unusual sites.

Apixaban Causing Hepatic Cystic Bleeding: A Rare but a Life-Threatening Complication.

Cystic lesions of the liver are a heterogeneous group of disorders with varied etiology, prevalence, and clinical manifestations. Fibropolycystic liver disease encompasses a spectrum of related liver and biliary tract lesions caused by abnormal embryologic development of the ductal plates. These disorders include congenital hepatic fibrosis, biliary hamartomas, polycystic liver disease (PCLD), choledochal cysts, and Carolis disease. PCLD is arbitrarily defined as a liver that contains >20 cysts. Most liver cysts are incidentally found on imaging studies, and the majority of the patients with liver cysts are asymptomatic. Rarely, complications such as compression, infection, and bleeding within the cyst can occur. Under the effect of the increased pressure, the epithelial lining of the cyst undergoes necrosis and sloughing, causing injury of the fragile blood vessels, leading to intracystic bleeding. The bleeding within or from the cyst can be precipitated by anticoagulation. We present a patient with PCLD who developed intracystic bleeding after he was started on apixaban for the prevention of thromboembolism.

Atypical Presentation of Esophageal Squamous Cell Carcinoma Masquerading as Diffuse Severe Esophagitis.

Esophagitis is described as an inflammation of the esophagus and can result from multiple etiologies. Esophageal squamous cell carcinoma (ESCC), presenting as diffuse esophagitis in the absence of a mass or lesion, is rare. We present a case of a 61-year-old man who presented to the gastroenterology clinic for dysphagia and heartburn of 3 months duration. The patient had lost about 15 pounds unintentionally over 6 months. The patient underwent esophagogastroduodenoscopy, which revealed significant diffuse Grade 4 esophagitis without any overt bleeding. Random biopsies were taken with cold forceps from proximal, middle, and distal esophageal segments because of the striking endoscopic appearance. Histopathology revealed high-grade dysplasia and carcinoma in situ. The patient underwent endoscopic ultrasound (EUS) of the esophagus, which revealed a focal lesion. EUS-guided fine-needle aspiration showed squamous cell carcinoma of the esophagus. ESCC usually presents as a mass or a gross lesion seen on endoscopy. However, it rarely presents as severe diffuse esophagitis seen on routine endoscopy. From our observation, it would be reasonable for physicians to bear this unusual endoscopic presentation in mind and perform multiple random biopsies if encountered with such a case to rule out the possibility of any underlying malignancy.

Colitis Induced by Colon-Cleansing Agent.

Constipation is one of the most common functional gastrointestinal disorders and affects 20% of the general population. Irritable bowel syndrome (IBS) is a functional disorder of the gastrointestinal tract that affects the large intestine and is characterized by chronic abdominal pain and altered bowel habits. We report a case of a 35-year-old African American man with a past medical history of IBS who presented to the clinic with a chief complaint of abdominal pain and bloody diarrhea for 1 week. The patient stated that he used a colon-cleansing agent because of persistent constipation. Computed tomography scan of the patient's abdomen and pelvis with contrast was performed which showed diffuse contiguous segmental mural thickening and nodularity seen along the distal transverse, descending, and sigmoid colon. Colonoscopy showed moderate diffuse inflammation characterized by altered vascularity, erythema, and granularity from the rectum to the descending colon, and localized mild inflammation characterized by erythema was found at the ileocecal valve. The patient's clinical condition improved with symptomatic management over 10 days. Patients with IBS should be advised to restrain from using a colon-cleansing agent without advice from their primary doctor as it can lead to various complications.

The Role of Imaging Modalities in Diagnosing Dysphagia: A Clinical Review.

Dysphagia, which is characterized by difficulty in oro-gastric bolus transit, is a common condition. It is broadly classified into oropharyngeal or esophageal pathology. A wide array of differentials for dysphagia and initial clinical suspicion of oropharyngeal or esophagus etiology can assist in further evaluation. Fiberoptic endoscopic evaluation of swallowing (FEES) and videofluoroscopic swallow study (VFSS) are the preferred modalities for assessing oropharyngeal bolus transit, residual, as well as determining the risk of laryngeal aspiration. High-resolution pharyngeal manometry (HRPM) is an emerging modality for optimal topographical and pressure assessment of pharyngeal anatomy. HRPM provides improved assistance in evaluating the strength of the pharyngeal muscular contraction. Esophagogastroduodenoscopy (EGD) is the preferred exam for patients with suspected esophageal etiology of dysphagia. Barium swallow provides luminal assessment and assists in evaluating esophageal motility; it is non-invasive, but therapeutic interventions like biopsy cannot be performed. High-resolution esophageal manometry (HREM) has added another dimension in the diagnosis of esophageal motility disorders. The purpose of this review article is to help internists and primary care providers get a better understanding of the role of various imaging modalities in diagnosing dysphagia in the elderly population. This article also provides a comprehensive review and detailed comparison of these imaging modalities based on the latest evidence.

Lupus-Mediated Kidney Damage: Lupus Nephritis or Collapsing Glomerulopathy?

Systemic lupus erythematosus (SLE) is a systemic autoimmune disease. It has a myriad of presentations and can involve almost every organ. Its effects on the kidney hold critical importance because patients can ultimately progress to end-stage renal disease (ESRD) if inadequately treated. There are many published cases of collapsing glomerulopathy (CG) in patients with SLE. However, there are not many cases reported of both SLE-related CG and lupus nephritis. Based on our review of the medical literature, fewer than 25 cases have been written about this finding. There are no guidelines to manage these types of patients. Lupus causing CG poses particular challenges in terms of management, particularly treatment options. We present a case of a 47-year-old female who was found to have biopsy findings of both CG and lupus nephritis.