Dialysis Disequilibrium Syndrome With Cerebral Edema in an Adult Patient Following the Initial Dialysis Session.

Dialysis is a common treatment for removing toxins, electrolytes, and excess fluids due to impaired kidney function. A rare but life-threatening complication that can arise is dialysis disequilibrium syndrome (DDS) with cerebral edema. DDS is characterized by a range of neurological symptoms that may occur following dialysis. Its incidence is not well-established because it often presents with nonspecific symptoms, making diagnosis challenging. Here, we present a case of a 64-year-old female with a history of hypertension and chronic kidney disease stage 5, who sought evaluation for nausea and vomiting with coffee-ground emesis that began three weeks prior. Despite an initial blood transfusion stabilizing her hemoglobin with no further hematemesis, she developed DDS with cerebral edema after her first dialysis session. The condition was managed with 3% hypertonic saline, which quickly resolved both her cerebral edema and neurological symptoms. She tolerated subsequent dialysis sessions without complications and was discharged with a follow-up arranged with nephrology and an outpatient dialysis chair. This case report reviews the clinical features, risk factors, pathophysiology, management, and treatment goals for DDS. In patients commencing dialysis, particular attention should be given to preventing DDS, especially in those with elevated blood urea nitrogen levels above 100 mg/dL. Prompt recognition and treatment are crucial to balance the osmotic gradient and prevent severe outcomes, such as cerebral edema and death.

Type Vb Double Common Bile Duct: A Rare Case Associated With Cholangiocarcinoma.

Double common bile duct (DCBD), also called extrahepatic biliary duct duplication, is a rare anatomical variation of the biliary anatomy that involves either the presence of a septum within the common bile duct (CBD) or an accessory CBD. The first case of DCBD was reported by Vesarius in 1543. A classification system for DCBD that included five types was proposed in 2007. Type V DCBD involves a duplicated extrahepatic bile duct with common drainage of both ducts into the duodenum and can be further divided into type Va, where there are no communicating channels, and type Vb, where there are one or more communicating channels. By 2021, only eight cases of type V DCBD had been reported, of which only two were type Vb DCBDs. As far as we know, this is the third reported case of type Vb DCBD. In addition to choledocholithiasis, cholangitis, and pancreatitis, DCBD has been associated with an increased risk of malignancies such as cholangiocarcinoma and upper gastrointestinal tract cancers. Here, we present a case of a 28-year-old female with intrahepatic cholangiocarcinoma undergoing chemotherapy who was referred to our hospital for evaluation of worsening jaundice and suspicion of infected percutaneous transhepatic cholangiography (PTC) drain. After extensive investigation, she was found to have a type Vb DCBD, which meant that her PTC drain was only providing partial therapy for her biliary obstruction. Following the placement of metal stents in both CBDs, her jaundice resolved, allowing her to continue her chemotherapy regimen. In conclusion, this case highlights one of the rarest bile duct anatomical variations, a type Vb DCBD, as well as the importance of evaluating young cholangiocarcinoma patients with magnetic resonance cholangiopancreatography (MRCP) for the presence of a DCBD, especially when they present with worsening jaundice despite receiving appropriate therapy. These patients require stenting of both CBDs to properly address their biliary obstruction.

Ileo-Ileal Intussusception Secondary to Neuroendocrine Tumor in Adult Patient.

BACKGROUND Intussusception occurs when a proximal region of the intestine telescopes into a distal region. It is more common in the pediatric population, with only 5% of cases occurring in adults. The most frequent causes of adult intussusception are malignancy, polyps, or diverticula. A very rare cause is neuroendocrine tumor (NET). NETs are a diverse group of neoplasms that arise from endocrine cells throughout the body. Here, we present a case of a patient who presented with ileo-ileal intussusception due to a T3N1 NET, grade 1. CASE REPORT A 60-year-old man with a medical history of peptic ulcer disease presented for evaluation of lower abdominal pain, dark "maroon" colored stools, and hematemesis for the past 2 days. Computed tomography (CT) of the abdomen and pelvis showed ileo-ileal intussusception. Exploratory laparotomy revealed a small bowel mass approximately 30 cm from the ileocecal valve. After removal of 15 cm of small bowel and 13 lymph nodes, pathology confirmed the diagnosis of a T3N1 NET, grade 1. He was subsequently referred to the Oncology Department, where he was cleared, with no need for additional surveillance. CONCLUSIONS In adult patients presenting with nonspecific abdominal pain and concern for small bowel obstruction, a CT scan can be helpful in diagnosing intussusception. When dealing with adult intussusception, the etiology needs to be carefully investigated to search for an underlying malignancy. In rare occasions, small bowel NETs can be the cause of intussusception and can therefore be identified early, before they metastasize and present with carcinoid syndrome.