Going Outside the Gut: Immune Thrombocytopenia Presenting as a Rare Extraintestinal Manifestation of Ulcerative Colitis.

A 26-year-old male with no significant medical history presented with hematochezia and was diagnosed with ulcerative colitis (UC) accompanied by immune thrombocytopenia (ITP) as an extraintestinal manifestation (EIM) of UC. This case report delves into the uncommon overlap between UC, a subtype of inflammatory bowel disease primarily affecting the colon and rectum, and ITP, an autoimmune condition leading to platelet destruction. The patient's atypical presentation and subsequent positive response to a treatment regimen targeting both UC and ITP underscores the necessity for a thorough and multifaceted diagnostic approach in individuals with UC, especially when faced with non-gastrointestinal symptoms like unexplained thrombocytopenia. The findings from this study enhance the understanding of UC's diverse manifestations and highlight its potential intersection with other autoimmune diseases, advocating for integrated care strategies in managing such intricate clinical cases.

Germ cell cancer presenting as gastrointestinal bleeding and developing brain metastases: case report and review of the literature.

This paper describes a rare case of germ cell cancer with duodenum, brain and lung metastases. The patient presented with melena and left testicle enlargement. Orchiectomy revealed mixed germ cell cancer, enteroscopy revealed duodenal choriocarcinoma, and chest x-ray and computed tomography (CT) showed bilateral lung metastases. The patient received and tolerated cisplatinum-based chemotherapy, and responded well. However, he developed seizures 3 months later. MRI showed brain metastases and he was treated with whole-brain radiation. One month later, he developed progressive dyspnea. Chest CT showed worsening lung metastases. He received second-line chemotherapy, but died due to multiorgan failure. Germ cell cancer with nonpulmonary metastases has poor prognosis and the management of these patients requires a multimodal approach. Head CT should be considered as routine screening for all germ cell cancer patients on initial diagnosis and brain MRI should be considered for high-risk patients (with an embryo- or choriocarcinoma histology, dramatically elevated ß-human chorionic gonadotropin and lung involvement).

A Comprehensive Analysis of the Impact of Acute Myocardial Infarction in Patients With Celiac Disease.

Background and Aims: We aimed to study the impact of acute myocardial infarction (AMI) in patients with celiac disease (CD). Methods: We used the National Inpatient Sample 2011-2018 to identify patients aged 18 years and older with a history of CD who presented with AMI using International Classification of Disease Nineth and Tenth Revision codes. Primary outcome of interest was mortality differences in AMI patients with and without CD. Secondary outcomes were in-hospital length of stay, hospital costs, and coronary revascularization. Results: A total of 2,287,840 weighted patients were included in this study with a principal diagnosis of AMI. Among this population, 183,027 weighted patients had a history of CD (0.08%), and 2,286,010 weighted patients had AMI without a history of CD (99.92%). Most AMI patients with and without CD were older (69.57 ± 13.21 vs 67.08 ± 13.87 years, respectively) and white (92.55% vs 75.39%, respectively). Patients with AMI and CD were more likely to be female than patients without CD (53.76% vs 38.47%; P < .05). In our study, we found that the difference in hospital charges (adjusted mean difference $2644.7) was lower among AMI and CD; however, length of stay was higher among patients with CD (adjusted mean difference 0.36 day) although they were not statistically significant (P > .05). Both cohorts had higher number of Medicare recipients and lower number of patients who self-pay. Our study also found that smoking was more prevalent among patients with CD, 12.14%, vs patients without CD, 2.51%. Moreover, patients with CD who developed AMI had a lower adjusted odds of mortality than those without CD (adjusted odds ratio [aOR] 0.41; P < .05). Patients with CD and AMI also had lower odds of coronary revascularization (aOR 0.80; P < .05). In addition, we found that adults with CD had a lower odds of developing AMI (aOR 0.78; P < .05). Conclusion: CD is a chronic disease leading to chronic inflammation and various nutrition-related problems which can lead to increased morbid conditions. However, we found lower odds of AMI among patients with CD, as well as lower mortality and comorbidities related to AMI, thus contradicting previous assumptions.

COVID-19 Exposure Unmasking Systemic Amyloidosis With Hepatic Predominance.

Amyloidosis is characterized by depositing insoluble fibrillar proteins that misfold into beta-pleated sheets. This phenomenon occurs on a systemic or local level and may interfere with the function of various organs, including the heart, kidneys, and liver. Among those presenting with amyloidosis, hepatic, gastrointestinal, renal, cardiac, vitreous, and immunological involvement may occur. These manifestations are linked to several clinical presentations, varying from abdominal pain and hepatomegaly to restrictive cardiomyopathy and chronic renal failure. The two most common types of amyloid proteins are amyloid light chain (AL) and serum amyloid A (AA) proteins. AL produced by immunoglobulin light chains kappa and lambda (κ, λ) circulate systemically and accumulate in organs. At the same time, serum AA proteins are acute-phase reactants seen in infectious, chronic inflammatory states. In an immune-mediated infection such as COVID-19, serum AA levels may be a predictive factor of disease severity and a valuable biomarker to monitor the clinical course of COVID-19 patients. This report highlights a case in which infection with COVID-19 provoked an effective immune response that may have contributed to the accelerated progression of systemic amyloidosis with hepatic involvement. The study further investigates the involvement of AL and AA proteins in COVID-19 infections, including their role in synergistically exacerbating an already grueling clinical course.

Abdominal Pain: A Silent and Unlikely Cause.

While diverticulosis is a common phenomenon in the large intestine, it is a rare disease found in the small intestine accounting for only 0.06% to 1.3% of cases. Although most cases are asymptomatic, roughly 30% to 40%, it is crucial that it is on the differential of acute abdominal pain as it can be life-threatening and potentially require surgical management. Here, we describe a case of a 61-year-old Hispanic man who was found to have a perforated jejunal diverticula after initially presenting with left upper quadrant abdominal pain.

Intra-gastric band erosion from an un-inflated Lap-Band: a case report.

The increasing prevalence of morbid obesity is of public health concern throughout the world, and surgical intervention seems to offer the only long-term solution to the problem. Gastric banding is one of the available options in the bariatric armamentarium. As more Lap-Bands are being inserted, intragastric erosion is increasingly being encountered as a major complication. The case of a 40-year-old man with intra-gastric band erosion is presented with the band never having been inflated, suggesting that additional factors may play a role in the development of erosions. The presentation, diagnostic modalities, and pathognomomic findings are discussed.

Jejunal diverticulitis in a healthy 91-year-old man.

A 91-year-old African American man was admitted with sudden onset diffuse abdominal pain which radiated to the right flank. CT of the abdomen with contrast showed diverticula in the jejunum with adjacent inflammation and microperforation that was contained. Conservative therapy similar to colonic diverticulitis was effective. Although rare, our case highlights the importance of having an early and high suspicion for jejunal diverticulitis when patients present with non-specific abdominal symptoms in order to avoid perforation.

Rectal ulcers and massive bleeding after hemorrhoidal band ligation while on aspirin.

Endoscopic hemorrhoidal band ligation is a well-established nonoperative method for treatment of bleeding internal hemorrhoids (grade 1 to 3). It is a safe and effective technique with a high success rate. Complications with this procedure are uncommon. Although rectal ulceration due to band ligation is a rare complication, it can cause life-threatening hemorrhage especially when patients are on medications which impair hemostasis like aspirin or non steroidal anti-inflammatory drugs. We present 2 cases of massive lower gastro-intestinal bleeding in patients who had a band ligation procedure performed 2 wk prior to the presentation and were on aspirin at home. Both the patients were hemodynamically unstable requiring resuscitation. They required platelet and blood transfusions and were found to have rectal ulcers on colonoscopy done subsequently. The rectal ulcers corresponded to the site of band ligation. The use of aspirin by these patients would have caused defects in the hemostasis and may have predisposed them to massive bleeding in the presence of rectal ulcers occurring after the band ligation procedure. Managing aspirin before and after the ligation may be difficult especially since adequate guidelines are unavailable. Stopping aspirin in all the cases might not be safe and the decision should be individualized.

Synchronous Small Cell Neuroendocrine Carcinoma and Adenocarcinoma of the Colon: A Link for Common Stem Cell Origin?

Synchronous carcinomas have been recognized for over a century, with synchronous primary adenocarcinoma of the colon reported to range from 2-11% of cases involving this type of malignancy. Small cell carcinomas occur frequently with colorectal adenomas; however, despite these reports and a known adenoma-to-carcinoma sequence, scarce literature exists on synchronous colorectal adenocarcinoma and small cell carcinomas. We present a rare cancer of synchronous small cell neuroendocrine carcinomas and discuss a possible link between these two cancers.

Obesity, metabolic factors, and colorectal adenomas: a retrospective study in a racially diverse New York State Hospital.

OBJECTIVE: We studied a racially diverse population and the relationship with colorectal adenomas (CA) further looking for risks related to BMI and metabolic factors. DESIGNS: Seven hundred seventy-nine patients who underwent screening colonoscopies between 2007 and 2009 meeting exclusion criteria were included. To evaluate the association between race, BMI, and other metabolic factors with having one or more CA detected at colonoscopy, adjusted odds ratios and 95 % CI were estimated using unconditional logistic regression models. OUTCOMES: CA were detected in 167 out of 779 (21.4 %) patients. Compared to Whites, Hispanics were less likely to have one or more adenomas detected during a screening colonoscopy (OR = 0.52, 95 % CI, 0.31-0.88; p = 0.01). There was no significant statistical difference between Blacks and Whites, or other races and Whites. There was an association between the presence of CA and smoking (OR = 1.57, 95 % CI, 1.02-2.43; p = 0.04). CONCLUSION: Our results showed that Hispanics were less likely to have an adenoma detected during a screening colonoscopy than Whites. No statistical significant difference was found between patients with metabolic factors and the presence of colorectal adenoma.

Endoscopic Evaluation of Symptomatic Patients following Bariatric Surgery: A Literature Review.

Obesity is an epidemic in our society, and rates continue to rise, along with comorbid conditions associated with obesity. Unfortunately, obesity remains refractory to behavioral and drug therapy but has shown response to bariatric surgery. Not only can long-term weight loss be achieved, but a majority of patients have also shown improvement of the comorbid conditions associated with obesity. A rise in the use of surgical therapy for management of obesity presents a challenge with an increased number of patients with problems after bariatric surgery. It is important to be familiar with symptoms following bariatric surgery, such as nausea/vomiting, abdominal pain, dysphagia, and upper gastrointestinal bleeding and to utilize appropriate available tests for upper gastrointestinal tract pathology in the postoperative period.

Transient Psychotic Episode Induced by Helicobacter pylori Triple Therapy Treatment.

The term 'antibiomania' refers to manic episodes that occur after a patient starts taking antibiotics. We report the case of a 49-year-old male who developed acute psychosis secondary to initiation of triple therapy for Helicobacter pylori eradication. Unlike with proton pump inhibitors, there have been several reported cases of central nervous system side effects and psychiatric consequences due to amoxicillin, however evidence points to clarithromycin as the likely culprit. On average onset of symptoms occurred within 1-5 days of initiating therapy. In all cases, symptoms resolved upon cessation of clarithromycin, mostly within 1-3 days. Unfortunately, the mechanism through which clarithromycin causes neurotoxicity remains unclear. Clinicians should be cognizant of psychiatric side effects secondary to clarithromycin, and discontinuation should be prompt for rapid recovery of mental status.

A case report of eosinophilic esophagitis accompanying hypereosinophilic syndrome.

Hypereosinophilic syndrome is a blood disorder characterized by the overproduction of eosinophils in the bone marrow with persistent peripheral eosinophilia, associated with organ damage by the release of eosinophilic mediators. Although HES can involve multiple organ systems, GI tract involvement is very rare. Few cases of HES presenting with gastritis or enteritis have been reported worldwide. To date, HES presenting with esophagus involvement has only been reported once. Here, we present a 39-year-old Hispanic female patient with history of HES presenting with complaints of dysphagia and generalized pruritus.

Pain from a Bullet Lingers on: An Uncommon Case of Lead Toxicity.

Lead toxicity from a retained bullet as a cause for abdominal pain is rarely considered. Given its unpredictable latent period and nonspecific clinical symptoms, such cases are difficult to diagnose but may be fatal if unrecognized. We present the case of a 48-year-old man who presented with complaints of abdominal pain, weight loss and constipation. His past history was significant for a gunshot wound to the left hip about 20 years before. Radiographic studies confirmed the same with the presence of numerous intra-articular bullet fragments and a calcified hemarthrosis surrounding the left femoral head. Blood lead levels were elevated following which the patient was started on chelation therapy with succimer which resulted in symptomatic improvement. The aim of this paper is to highlight the importance of considering lead toxicity from a retained bullet as a cause of abdominal pain and to review the relevant literature.

Unexplained findings of kayser-fleischer-like rings in a patient with cryptogenic cirrhosis.

Cryptogenic cirrhosis (CC) is defined as cirrhosis occurring in an individual without an identifiable cause of liver disease, such as excessive alcohol consumption, viral hepatitis infection, hemochromatosis, autoimmune hepatitis, primary biliary cirrhosis, primary sclerosing cholangitis, chronic intake of medications that could induce cirrhosis, alpha-1-antitrypsin deficiency, Wilson's disease, or any other rare cause of cirrhosis according to the clinical context. Cryptogenic cirrhosis is a common cause of liver-related morbidity and mortality in the United States. Nonalcoholic fatty liver disease is now recognized as the most common cause of cryptogenic cirrhosis. A biopsy specimen is also important for detecting histological advanced disease, which may be clinically silent and undetected by liver-related tests or diagnostic imaging. We are presenting an unusual case of a patient with cryptogenic cirrhosis found to have Kayser-Fleischer-like rings without evidence of Wilson's disease.

Diffuse nodular lymphoid hyperplasia of intestine in selective IgG 2 subclass deficiency, autoimmune thyroiditis, and autoimmune hemolytic anemia: case report and literature review.

Diffuse Nodular Lymphoid Hyperplasia (DNLH) of the intestine is a rare lymphoproliferative disorder of uncertain etiology, which is characterized by the presence of multiple nodular lesions. It can present as an asymptomatic disease or manifest with gastrointestinal symptoms like abdominal pain, chronic diarrhea, occult bleeding or rarely intestinal obstruction. DNLH has been seen in association with common variable immunodeficiency (CVID) where it poses a risk of malignant transformation. We present a case of diffuse lymphoid nodular lymphoid hyperplasia in a patient who was presented with abdominal pain and diarrhea, and was later found to have IgG2 subclass immunodeficieny, autoimmune hemolytic anemia and Hashimoto's (autoimmune) thyroiditis. Through this report, we wish to review current literature as well as share our clinical experience in managing this rare entity.

A solid organising cryptogenic liver abscess and its association with a colonic tubullovillous adenoma.

Cryptogenic liver abscess (CLA) is a well-known disease entity that has puzzled clinicians for centuries. With the advancement of diagnostic modalities, comes the decreasing incidence of liver abscess labelled as 'cryptogenic' in nature. Colonic diseases have been identified as a possible underlying condition found in patients with liver abscesses. Although rare, tubullovillous adenomas have been implicated as one of the colonic causes of a CLA. We present a case of a CLA in a 53-year-old man with a potentially associated tubullovillous adenoma found via colonoscopy.

Blastocystis hominis and Endolimax nana Co-Infection Resulting in Chronic Diarrhea in an Immunocompetent Male.

Blastocystis hominis and Endolimax nana exist as two separate parasitic organisms; however co-infection with the two individual parasites has been well documented. Although often symptomatic in immunocompromised individuals, the pathogenicity of the organisms in immunocompetent subjects causing gastrointestinal symptoms has been debated, with studies revealing mixed results. Clinically, both B. hominis and E. nana infection may result in acute or chronic diarrhea, generalized abdominal pain, nausea, vomiting, flatulence and anorexia. We report the case of a 24-year-old immunocompetent male presenting with chronic diarrhea and abdominal pain secondary to B. hominis and E. nana treated with metronidazole, resulting in symptom resolution and eradication of the organisms. Our case illustrates that clinicians should be cognizant of both B. hominis and E. nana infection as a cause of chronic diarrhea in an immunocompetent host. Such awareness will aid in a timely diagnosis and possible parasitic eradication with resolution of gastrointestinal symptoms.