Metastatic Endometrial Cancer to the Sigmoid Colon Masquerading as Primary Colorectal Cancer.

A 67-year-old female presented with a chief complaint of hematochezia. Medical history was notable for stage 1a endometrial carcinoma status post treatment with radiotherapy alone. The patient was not considered a candidate for surgical intervention at the time due to multiple underlying comorbidities. Colonoscopy revealed a 4 cm, nonobstructive, friable, and ulcerated mass in the sigmoid colon. Initially this was concerning for a primary colorectal carcinoma, although immunohistochemistry revealed a uterine endometrial origin of the lesion. A total hysterectomy was eventually performed along with surgical resection of the affected segment of the colon, which was followed by radiation therapy. This case illustrates an unusual site of metastasis for endometrial carcinoma. The colonic metastasis of endometrial adenocarcinoma is reported to be rare and unusual, especially in the absence of endometriosis. Immunohistochemistry staining is an important adjunct in distinguishing the diagnosis of endometrial adenocarcinoma from primary colorectal carcinomas. Primary colon cancers are cytokeratin-7 negative and cytokeratin-20 positive, whereas endometrial cancers are cytokeratin-7 positive and cytokeratin-20 negative. This case is important given the scarcity and peculiarity of metastatic colon cancer originating from uterine adenocarcinomas. The possibility of metastatic disease should be maintained with identification of solitary colonic lesions, especially when there is a prior history of malignancy.

Portal Vein Thrombosis and Intra-Abdominal Hypertension Presenting as Complications of Hypertriglyceridemia-Induced Severe Acute Pancreatitis.

A 44-year-old male without any significant past medical history presented to the emergency department (ED) with the chief complaint of severe constant epigastric pain for three hours. On physical examination, the abdomen was distended and tender, particularly in the epigastric region. The lab work showed an elevation of the lipase (12,405 U/L) and triglycerides (5,837 mg/dL). An abdominal CT scan with contrast was ordered, which revealed non-necrotic pancreatitis. In addition, the liver ultrasound showed no evidence of gallstones. Subsequently, fluid infusion, meropenem, pain medication, and an insulin drip were started, and the patient was transferred to the intensive care unit (ICU). After six hours in the ICU, he complained of abdominal pain despite taking a high hydromorphone dose. On further physical examination, the abdomen was tender and distended but without rebound tenderness. The gastric distention on kidneys, ureter, and bladder (KUB) and a bladder pressure of 34 mmHg raised the suspicion for intra-abdominal hypertension (IAH), which led us to place a nasogastric tube (NGT) and consult the surgical team. The patient's symptoms and bladder pressure were closely followed and showed significant improvement. On day seven in the ICU, the patient responded well to medications; feeding through the Dobhoff tube was started, and his triglycerides decreased to approximately 1,000 mg/dL. Despite his general improvement and meropenem regimen, the patient spiked a fever of 38.5 °C. Due to the possibility of pancreatitis complications, a CT abdomen with contrast was ordered, which showed partial portal vein thrombosis (PVT). Subsequently, enoxaparin was started, and the patient was closely observed for gastrointestinal bleeding. Eventually, after 17 days in the ICU, the patient was transferred to the floor and then discharged from the hospital with normal lab tests and without evidence of portal thrombosis on abdominal CT. In this report, we illustrate and discuss a case of hypertriglyceridemia (HTG)-induced pancreatitis (HTGP), which progressed to PVT and IAH. Physicians should be aware that patients with HTG are inclined to have severe pancreatitis. In addition, the degree of triglyceride elevation is correlated with the severity of acute pancreatitis.

Nintedanib-Induced Colitis Treated Effectively With Budesonide.

A 68-year-old male with a past medical history of interstitial pulmonary fibrosis (IPF) on nintedanib and chronic nintedanib-induced diarrhea for three years presented with hematochezia and worsening diarrhea. Diarrhea had persisted despite the use of cholestyramine and oral antidiarrhea medications. As part of the evaluation of diarrhea, he had undergone colonoscopy two years prior, which had shown non-specific moderate diffuse colitis. No significant abnormalities had been noted on physical exam and lab tests. On the present admission, colonoscopy showed diffuse erythematous, friable, and granular mucosa throughout the entire colon. Biopsies were taken and pathology was reported as acute superficial inflammation and possible nintedanib-induced colitis. Since the patient wanted to continue nintedanib as a part of IPF treatment, 9 mg oral budesonide was started, and the patient was followed up after four months. At his follow-up visit, the patient reported that diarrhea had completely resolved. In this report, we illustrate and discuss a case of nintedanib-induced colitis, which can be resistant to oral antidiarrhea medication and cholestyramine. The mechanism of this side effect is not completely understood; however, it may be related to direct inflammation of the intestinal epithelium, given that nintedanib metabolites are excreted primarily in the stool. As a result, it has been hypothesized that steroids could potentially treat this diarrhea by relieving this inflammation. In our patient, we elected to use budesonide due to less associated systemic side effects and possible similarity of inflammation between nintedanib-associated colitis and inflammatory bowel disease.

Does the Presence of Giant Pseudopolyps in a Patient with Newly Diagnosed Inflammatory Bowel Disease Increase the Risk of Major Thrombotic Events?

Giant inflammatory polyp and thromboembolism are uncommon complications in inflammatory bowel disease (IBD) patients. Colon mucosal inflammation is possibly the main mechanism of pathogenesis for these two complications. IBD has long been associated with hypercoagulability and thromboembolism. In fact, thromboembolism has been noted in 0.7% to 7.7% of IBD patients, with the deep veins of the legs and the pulmonary veins accounting for 90% of the cases. The proposed mechanism of this hypercoagulability involves the promotion of hemostasis that results from the inflammatory process underlying the IBD, as well as the loss of proteins, including antithrombotic factors, resulting from the inflamed bowel and increased permeability of the colonic mucosa. This process may be exacerbated by the presence of giant inflammatory polyps, which are defined as polyps in the setting of IBD with dimensions greater than 1.5 cm. The presence of these polyps leads to an increase in inflamed colonic surface area, which can accelerate the rate of protein loss, leading to an increased incidence of thrombosis. Here, we report the case of a 21-year-old female with inferior vena cava and left renal vein thromboses secondary to a newly diagnosed IBD and the presence of severe giant inflammatory polyposis. These thromboses were detected incidentally in this patient after 1 week of hospitalization. She had presented with hypoalbuminemia and elevated inflammatory markers, which raised the suspicion for possible giant inflammatory polyposis as a potential risk for her major thromboembolic events. More studies are required to explore this plausible correlation further.

Idiopathic Ileo-Ileo-Cecal Intussuception in a 25-Year-Old Female.

BACKGROUND Intussusception is defined as the penetration or telescoping of a segment of bowel into a more distal segment. Intussusception is a common cause of small bowel obstruction, especially in children. However, this finding is much less common in adults. Furthermore, when present in adults, intussusception is often found in association with some sort of organic mass, such as a tumor or pancreatic divisum that acts as a lead point, dragging the proximal segment into the distal one. The presence of an intussusception in an adult patient with no obvious lead point is very uncommon. CASE REPORT Here we report a case of ileo-ileo-cecal double intussusception in an adult patient that yielded no lead point on surgical exploration. The patient was a 25-year-old female who presented with symptoms of obstruction and was diagnosed with the intussusception via computed tomography scan. Surgical resection of the bowel was necessary as reduction could not be accomplished. CONCLUSIONS The finding of intussusception in an adult patient is far less common than in children, and even more rare when a lead point is not established. When surgery is required, a thorough exploration should be performed to search any signs of a potential lead point. Laparoscopy is usually preferred to laparotomy; however, in this case the degree of distention determined the surgical approach. Thus, due to severe distention, laparotomy was preferred.

Leishmania in a Patient with Small Lymphocytic Lymphoma/Chronic Lymphocytic Leukemia.

BACKGROUND Leishmaniasis is a parasitic infection spread by the bite of infected sand flies that are usually present in the Middle East, Africa, and some parts of Asia and Europe. Leishmaniasis manifests in 3 different forms: Visceral (also known as Kala Azar), which is the most serious type; cutaneous, which is the most common type; and mucocutaneous. The symptoms of this infection range from a silent infection to fever, enlargement of the liver and spleen, weight loss, and pancytopenia. CASE REPORT In this case report, we discuss a 73-year-old man known to have chronic lymphocytic leukemia (CLL), presenting with unremitting fever and who to our surprise was found to have Kala Azar. CONCLUSIONS Early diagnosis and treatment are very important in treating visceral leishmaniasis. While the conventional treatment in immunocompromised patients is liposomal amphotericin B, our patient responded to corticosteroids.

Foreign Body Ingestion Causing Recurrent Diverticulitis.

BACKGROUND Ingested foreign bodies (IFBs) are usually asymptomatic and are excreted uneventfully. IFBs become a major concern in elderly patients due to the increase number of diverticuloses where the foreign body can lodge and cause severe complications. CASE REPORT We report a case of an elderly patient who ingested a chicken bone that caused recurrent diverticulitis. CONCLUSIONS The diagnosis of complicated IFB cases is challenging, requires physician clinical expertise, and must be considered in individuals at risk.

Diagnosis and Treatment of Small Bowel Strangulation Due To Congenital Band: Three Cases of Congenital Band in Adults Lacking a History of Trauma or Surgery.

BACKGROUND Among the causes of constipation are bands and adhesions that lead to obstructions at different points in the intestinal tract. These can occur as a consequence of healing following surgery or trauma. However, an entity known as congenital band exists where a band is present from birth. Here we report three such cases of adults with symptoms of intestinal obstruction, in whom a congenital band was discovered through exploratory laparoscopy. CASE REPORT All three of these patients presented lacking a history of any abdominal trauma or previous abdominal surgeries, a fact that is often used to exclude an adhesion as a differential. All three recovered quickly and had relief of their symptoms following surgical intervention. CONCLUSIONS Bands and adhesions are common surgical causes of small bowel obstruction, leading to symptoms such as nausea, vomiting, constipation, and obstipation. These bands almost always result from a prior abdominal surgery or from a recent abdominal trauma. The three cases presented here show a far more unusual picture of a band, one that is congenitally present, as there was an absence of such a history. This is significant because clinical suspicion of a band is often very low due to a lack of distinguishing clinical and diagnostic features, and when the past history is negative.