Jejunal lipoma: A rare cause of small bowel bleeding.

Prompt endoscopic recognition as well as histopathological examination are crucial for establishing the diagnosis and management of small bowel lipomas complicated by bleeding.

Transcolonic misplacement as a rare complication associated with PEG tube.

PEG tube placement is a relatively safe procedure; however, complications sometimes occur. Our article will allow readers to visualize the uncommon complication of PEG - a transcolonic misplacement.

Esophageal Stricture Caused by CMV in a Non-HIV-Infected Renal Transplant Patient.

Esophageal stricture due to cytomegalovirus (CMV) infection is an uncommon pathology, with most reported cases occurring in patients infected with human immunodeficiency virus. We report a renal transplant patient who presented with progressive dysphagia and weight loss for 2 years. Endoscopic examination revealed a long esophageal stricture with a necrotic lesion but no typical CMV esophageal ulcers; immunostains were positive for CMV. Dysphagia resolved after treatment with ganciclovir and serial esophageal dilations. We are presenting the first case of esophageal stricture due to CMV esophagitis in a renal transplant patient without human immunodeficiency virus infection and are reviewing current literature.

Two case reports of acute upper gastrointestinal bleeding from duodenal ulcers after Roux-en-Y gastric bypass surgery: Endoscopic diagnosis and therapy by single balloon or push enteroscopy after missed diagnosis by standard esophagogastroduodenoscopy.

The diagnosis and opportunity for endoscopic therapy of gastric or duodenal lesions may be missed at esophagogastroduodenoscopy (EGD) because of technical difficulty in intubating at EGD the postoperatively excluded stomach and proximal duodenum in patients status post Roux-en-Y gastric bypass (RYGB). Two cases are reported of acute upper gastrointestinal bleeding 10 or 11 years status post RYGB, performed for morbid obesity, in which the EGD was non-diagnostic due to failure to intubate the excluded stomach and proximal duodenum, whereas subsequent push enteroscopy or single balloon enteroscopy were diagnostic and revealed 4-cm-wide or 5-mm-wide bulbar ulcers and even permitted application of endoscopic therapy. These case reports suggest consideration of push enteroscopy, or single balloon enteroscopy, where available, in the endoscopic evaluation of acute UGI bleeding in patients status post RYGB surgery when the EGD was non-diagnostic because of failure to intubate these excluded segments.

Invasive cancer in a diminutive rectal polyp amidst internal hemorrhoids detected by rectal retroflexion.

A diminutive rectal polyp amidst internal hemorrhoids, detected by rectal retroflexion during colonoscopy, was shown to harbor invasive rectal adenocarcinoma by colonoscopic biopsy. Initially this lesion had appeared to be a relatively innocuous prominent anorectal mucosal fold and was recognized as a diminutive polyp only after careful rectal retroflexion during colonoscopy. This report emphasizes that lesions just above the anorectal junction with atypical endoscopic features for internal hemorrhoids should be carefully examined at rectal retroflexion and that polyps or suspicious lesions amidst internal hemorrhoids identified during colonoscopy should be snared or at least biopsied, even if small. This case report also illustrates how easily an early cancer in a diminutive colonic polyp can be missed when in difficult areas of colonoscopic inspection, such as behind a colonic fold or immediately above the anus.

The cannabis hyperemesis syndrome characterized by persistent nausea and vomiting, abdominal pain, and compulsive bathing associated with chronic marijuana use: a report of eight cases in the United States.

GOALS/BACKGROUND: The cannabis hyperemesis syndrome, which is associated with chronic cannabis use, was recently reported in seven case reports and one clinical series of ten patients from Australia. We further characterize this syndrome with eight well-documented cases in the United States and report results of cannabis discontinuation and cannabis rechallenge. STUDY METHODS: Patients were identified by the three investigators in gastroenterology clinic or inpatient wards at William Beaumont Hospital from January to August 2009 based on chronic cannabis use; otherwise unexplained refractory, recurrent vomiting; and compulsive bathing. Charts were retrospectively analyzed with follow-up data obtained from subsequent physician visits and patient interviews. RESULTS: The eight patients on average were 32.4 ± 4.1 years old. Five were male. The mean interval between the onset of cannabis use and development of recurrent vomiting was 19.0 ± 3.7 years. Patients had a mean of 7.1 ± 4.3 emergency room visits, 5.0 ± 2.7 clinic visits, and 3.1 ± 1.9 admissions for this syndrome. All patients had visited at least one other hospital in addition to Beaumont Hospital. All patients had vomiting (mean vomiting episodes every 3.0 ± 1.7 h), compulsive bathing (mean = 5.0 ± 2.0 baths or showers/day; mean total bathing time = 5.0 ± 5.1 h/day), and abdominal pain. Seven patients took hot baths or showers, and seven patients experienced polydipsia. Four out of five patients who discontinued cannabis use recovered from the syndrome, while the other three patients who continued cannabis use, despite recommendations for cessation, continued to have this syndrome. Among those four who recovered, one patient had recurrence of vomiting and compulsive bathing with cannabis resumption. CONCLUSIONS: Cannabis hyperemesis is characterized by otherwise unexplained recurrent nausea and vomiting, compulsive bathing, abdominal pain, and polydipsia associated with chronic cannabis use. This syndrome can occur in the United States as well as in Australia. Cannabis cessation may result in complete symptomatic recovery.

Mechanical obstruction of the small bowel and colon.

Mechanical obstruction of the small bowel and colon is moderately common, accounting for several hundred thousand admissions per year in the United States. Patients generally present with abdominal pain, nausea and emesis, abdominal distention, and progressive obstipation. Clinical findings of high fever, localized severe abdominal tenderness, rebound tenderness, severe leukocytosis, or metabolic acidosis suggest possible complications of bowel necrosis, bowel perforation, or generalized peritonitis. Differentiation of total mechanical obstruction from partial mechanical obstruction and pseudo-obstruction is important because total mechanical obstruction is generally treated surgically,whereas the other two entities are usually treated medically. Mechanical obstruction is usually suggested by plain abdominal radiographs, and confirmed by small bowel follow through,abdominal CT, or CT enteroclysis.

Adynamic ileus and acute colonic pseudo-obstruction.

Ileus and colonic pseudo-obstruction cause functional obstruction of intestinal transit, without mechanical obstruction, because of uncoordinated or attenuated intestinal muscle contractions. Ileus usually arises from an exaggerated intestinal reaction to abdominal surgery that is often exacerbated by numerous other conditions. Colonic pseudo-obstruction is induced by numerous metabolic disorders, drugs that inhibit intestinal motility, severe illnesses, and extensive surgery. It presents with massive colonic dilatation with variable, moderate small bowel dilatation. Both conditions are initially treated with supportive measures that include intravenous rehydration, correction of electrolyte abnormalities, discontinuation of antikinetic drugs, and treatment of other contributing disorders. Specific therapies for colonic pseudo-obstruction include neostigmine (an anticholinesterase) for pharmacologic colonic decompression and colonoscopic decompression.