Percutaneous Endoscopic Gastrostomy: A Possible Trigger for Dieulafoy's Lesion.

Introduction: Upper gastrointestinal (GI) bleeding is a medical condition commonly seen in clinical practice due to variable etiologies and a multitude of presentations. The patients can present with hematemesis, melena, or hematochezia in case of severe bleeding. The initial evaluation should involve assessing the hemodynamic status with adequate resuscitation followed by diagnostic tests to identify the source and potentially treat it. Dieulafoy's lesion, sometimes referred to as Dieulafoy's disease, is a rare cause of upper GI bleeding with no clear risk factors, which makes it a diagnostic conundrum. Here we describe an unusual case of Dieulafoy's lesion developing following percutaneous endoscopic gastrostomy (PEG) placement. Case Presentation: We describe a case of a 70-year-old female patient with a past medical history of hyperlipidemia, well-controlled hypertension, and an ischemic cerebrovascular accident, which caused neurologic dysphagia and placement of a PEG tube 3 weeks prior. She presented to the emergency department due to melena, with hypotension of 90/50 mmHg, tachycardia of 126 beats/minute, and hemoglobin of 5.6 g/dl. An endoscopy revealed a Dieulafoy's lesion on the lesser curvature of the stomach just across the PEG tube, which was managed with epinephrine and hemoclips. Conclusion: This is a rare case of Dieulafoy's lesion on the lesser curvature of the stomach, potentially developing due to PEG placement.

Benign Pneumoperitoneum Following Mitral Valve Replacement.

The pneumoperitoneum refers to the presence of free air inside the abdominal cavity. This finding is usually a sequela of a gastrointestinal tract perforation. Still, in rare instances, it can present after cardiac surgery due to the proximity of the peritoneal cavity and pericardium, allowing air to enter the peritoneal cavity. Our patient was a 63-year-old female who initially presented for revision of the mitral valve replacement. A chest X-ray on postoperative day 13 revealed a 6.6 cm lucency under the right diaphragm suggestive of pneumoperitoneum. She was discharged after serial chest X-rays revealed a decrease in the size of the pneumoperitoneum. Twelve days later, our patient was readmitted, as another chest X-ray revealed that the size of the pneumoperitoneum was again increasing. An endoscopy was performed, but it did not reveal any lesions or etiology that would lead to a leak from the gastrointestinal tract. Finally, due to the benign nature of the pneumoperitoneum and the decrease in its size over the following days, we opted for conservative management, and she was discharged again. This case emphasizes the rare occurrence of benign pneumoperitoneum post-mitral valve surgery. While surgery may not always be required for asymptomatic cases, careful vigilance post-cardiac surgery remains crucial to detect potential abdominal complications promptly.

A Rare Case of Primary Extra-Nodal Marginal Zone Lymphoma of Mucosa-Associated Lymphoid Tissue (MALT) in the Rectum.

Mucosa-associated lymphoid tissue (MALT) is a unique clinical condition that can manifest in different anatomic locations. In the gastrointestinal tract, it is typically seen in the stomach but is less commonly found in other sites. There have been a few cases in the literature in which primary MALT lymphoma is found in the rectum. We describe a case of a 63-year-old male who presented with rectal pain and bleeding. Colonoscopy revealed a rectal mass, which was excised with a trans-anal approach. Histopathological examination of the biopsy specimen was significant for MALT lymphoma. Therefore, the patient underwent radiation therapy followed by repeat colonoscopies to monitor disease recurrence.

The First Case of Daratumumab-Induced Fulminant Hepatic Failure.

Drug-induced liver failure is a relatively uncommon condition with a vast spectrum of clinical manifestations, and it is a leading cause of acute hepatic failure in the United States. We describe the first case of fulminant hepatic failure induced by chemotherapeutic drug daratumumab, a common FDA-approved agent. A 77-year-old male, with a history of multiple myeloma, was admitted for left lower extremity cellulitis, two weeks after receiving his first intravenous infusion of daratumumab. He developed fulminant hepatic failure in the hospital a few days later. Despite multiple doses of N-acetylcysteine, his liver function continued to decline, and he expired shortly after.

Primary Dedifferentiated Duodenal Liposarcoma With Gastric Outlet Obstruction: A Rare Small Bowel Tumor.

Liposarcoma is the most prevalent malignant soft tissue tumor and is primarily found in extremities and retroperitoneum, but its occurrence within abdominal viscera is rare. Most of these cases have been reported in the esophagus and stomach. Among liposarcomas of the gastrointestinal tract, primary duodenal liposarcomas are exceptionally rare, with only five documented cases in the literature. We describe a case of a 66-year-old female presenting with syncope, melena, and anemia. Computed tomography (CT) showed soft tissue mass involving the superior wall of the duodenum and hypo-enhancing hepatic mass. An endoscopy was performed, which revealed a duodenal mass causing gastric outlet obstruction and significant bleeding. Therefore, laparotomy was performed with extensive lysis of adhesions and gastrojejunostomy.

Real-Time XFEL Data Analysis at SLAC and NERSC: a Trial Run of Nascent Exascale Experimental Data Analysis.

X-ray scattering experiments using Free Electron Lasers (XFELs) are a powerful tool to determine the molecular structure and function of unknown samples (such as COVID-19 viral proteins). XFEL experiments are a challenge to computing in two ways: i) due to the high cost of running XFELs, a fast turnaround time from data acquisition to data analysis is essential to make informed decisions on experimental protocols; ii) data collection rates are growing exponentially, requiring new scalable algorithms. Here we report our experiences analyzing data from two experiments at the Linac Coherent Light Source (LCLS) during September 2020. Raw data were analyzed on NERSC's Cori XC40 system, using the Superfacility paradigm: our workflow automatically moves raw data between LCLS and NERSC, where it is analyzed using the software package CCTBX. We achieved real time data analysis with a turnaround time from data acquisition to full molecular reconstruction in as little as 10 min -- sufficient time for the experiment's operators to make informed decisions. By hosting the data analysis on Cori, and by automating LCLS-NERSC interoperability, we achieved a data analysis rate which matches the data acquisition rate. Completing data analysis with 10 mins is a first for XFEL experiments and an important milestone if we are to keep up with data collection trends.

An endoscopic study of the lacuna magna and reappraisal of its clinical significance in contemporary urological practice.

OBJECTIVE: To endoscopically study the Lacuna Magna (LM) and attempt to explain some of the anatomical, clinical and embryological issues pertaining to it. The LM, stated to be present in 30 to 50 percent of males and linked to congenital distal urethral obstructions, post-void bloody-spotting and dysuria in young boys, has few studies on its endoscopic characterization. In this study, its incidence, normal spectrum of appearance and variations have been endoscopically recorded and documented. METHODS: The fossa navicularis of 50 consecutive male patients undergoing endourological procedures for non-meatal pathologies was examined for the presence of the LM and its endoscopic characteristics, and variations were video-recorded. The variants of the LM were classified into 4 groups. RESULTS: The LM could be demonstrated in 98% of subjects. Group-wise percentage was 2%, 52%, 26%, and 20% in Type O, Type I, Type II, and Type III categories, respectively. Variations included "bi-channeled" LM and deviations in positions of the orifices off the commonest position at 12 o'clock. CONCLUSION: The LM is a constant structural component of the fossa navicularis. The "valve" of Guerin (1864), described as a leaflet between the LM and the urethra has no valvular properties. Type III variant of the LM could be mistaken for a urethral stricture during ureteroscopy as well as act as a mechanical obstruction to contrast during retrograde urethrography. The LM is indemonstrable on a micturating cystourethrogram. Further studies could determine whether the location and disposition of the LM favor the development of submeatal post-instrumentation strictures.