Palliative Stenting for Gastric Outlet Obstruction Secondary to Pancreatic Adenocarcinoma.

Pancreatic cancer is one of the most fatal malignancies due to its advanced stages at the time of presentation. Often, it is only diagnosed when patients present with late-stage complications, such as gastric outlet obstruction (GOO). Many patients experience a poor quality of life due to the side effects of GOO, such as persistent nausea, vomiting, and an inability to tolerate an oral diet, and as such, patients deteriorate quickly after their diagnosis. Because pancreatic cancer is diagnosed at advanced stages, many patients are not surgical candidates, and thus treatment is tailored for palliative measures. With GOO specifically, gastrojejunostomy has been the mainstay of palliative management; however, endoscopic stent placement is a new, innovative, and minimally invasive alternative option. Herein, we present a case of GOO as a complication of pancreatic adenocarcinoma, treated with palliative endoscopic stent placement. Further research is warranted to identify patients who would most benefit from this modality of palliation in the treatment of advanced pancreatic cancer.

Intracranial Hemorrhage Secondary to Vaping: A Case Report and Literature Review.

Vaping and marijuana use are becoming more common and accessible in young adults. However, questions remain regarding their long-term health implications. Current literature does not suggest that vaping causes intracranial hemorrhages. Here, we present a case of a 32-year-old male with no medical history other than vaping and marijuana use, who was found to have an acute intraventricular hemorrhage presenting as syncope. This paper explores the relationships between vaping, marijuana use, and strokes in the general population, and further elaborates on the effects of vaping in young adults. We hope to raise awareness of the negative health implications vaping has on otherwise healthy patients and encourage clinicians to take thorough histories and identify those who vape so that comprehensive education can be provided.

Diffuse malignant peritoneal mesothelioma presenting as small bowel obstruction.

Mesotheliomas are aggressive malignant tumors which can occur most commonly in the pleural space, however can occur in the peritoneum in those with an extensive history of asbestos exposure. Primary peritoneal mesothelioma is relatively rare and is a fatal diagnosis. The prognosis of primary peritoneal mesothelioma is very poor and individuals are at high risk of developing mesothelioma in another cavity within the first year after initial diagnosis. Herein, we present a case of primary peritoneal mesothelioma, presenting as small bowel obstruction.

Unique Case of Cardiogenic Shock in the Setting of Cumulative Calcium Channel Blocker Toxicity.

Calcium channel blockers (CCBs) are the most prescribed medications in clinical practice. These drugs treat many conditions, including migraine headaches, vasospasms, abnormal heart rhythms, and hypertension. This widespread use, however, has also been linked with the increased incidence of CCB toxicity cases. CCB toxicity may be from accidental ingestion or iatrogenic. Patients may show signs of cardiovascular toxicity such as hypotension, bradyarrhythmia, coma, or even death. The treatment includes discontinuing the offending medication, securing the airway, and raising blood pressure. Herein, we report a rare case of a 40-year-old male with a history of uncontrolled hypertension and advanced kidney disease who experienced iatrogenic cumulative calcium channel blocker toxicity while switching CCB classes due to a hypertensive emergency with concomitant atrial flutter. Although uncommon in clinical practice, iatrogenic CCB toxicity is possible and equally lethal. Clinicians must be cautious when initiating these drugs, switching between oral and intravenous formulations, or switching from one class to another to avoid overdoses.

Gastric Adenocarcinoma of the Remnant Stomach After Roux-en-Y Diagnosed by Endoscopic Ultrasound-Directed Transgastric Endoscopic Retrograde Cholangiopancreatography (EDGE).

It can be difficult to evaluate for pathology with traditional endoscopic modalities following a Roux-en-Y gastric bypass. This is due to the truncated gastrointestinal tract and excluded distal stomach formed during a Roux-en-Y procedure. In these circumstances, a modified endoscopic procedure, known as endoscopic ultrasound (EUS)-directed transgastric endoscopic retrograde cholangiopancreatography (ERCP) (EDGE) is used. Although the Roux-en-Y procedure slightly increases the risk of gastric adenocarcinoma in the general population, the occurrence of gastric adenocarcinoma in the excluded stomach, specifically, is uncommon. Herein, we present a case of gastric adenocarcinoma of the excluded stomach, diagnosed 20 years after a Roux-en-Y procedure. This case is unique because after an extensive five-year workup for melena and iron deficiency anemia, the malignancy was ultimately diagnosed utilizing the innovative EDGE procedure.

Chronic Lymphocytic Leukemia Causing Gastric Ulcer Perforation: A Case Presentation and Literature Review.

Chronic lymphocytic leukemia (CLL) is a malignancy characterized by the progressive accumulation of lymphocytes in the bone marrow and lymphoid organs. Gastrointestinal manifestations are rare in all types of leukemia. Generally, this occurs during relapsing disease or in acute leukemias; however, recent advancements in treatment have reduced these complications. Most commonly, lesions in the stomach are hemorrhagic, and lesions in the lower gastrointestinal tract present as peritonitis or colitis. Our patient was unique because she had a perforated, rather than bleeding, peptic ulcer caused by infiltrative chronic lymphocytic leukemia after starting ibrutinib. Although this medication can impair wound healing and/or cause bleeding, there are no reports of perforation of existing ulcers. Additionally, chronic lymphocytic leukemia causing perforated peptic ulcer disease (PUD) is rare, and this is, to our knowledge, the first case of this phenomenon.

Esophageal Stab Wounds Repaired Endoscopically: A Case Report and Comprehensive Literature Review.

Esophageal injuries are typically iatrogenic after endoscopic/surgical procedures, but they are rarely caused by penetrative or blunt trauma. We present a case of patient who suffered multiple stab wounds to the neck and underwent surgical repair for hemorrhagic shock but was ultimately diagnosed and treated successfully via endoscopy for a thoracic esophageal injury. Early detection is imperative and usually diagnosed via contrast studies but less commonly via direct visualization endoscopically. Moreover, endoscopic treatment is also less commonly utilized, even if diagnosed from that modality. Cervical injuries also confer a lower mortality than thoracic injuries.

Acute Peritonitis Is Not Always a Surgical Fix: A Rare Case of Mixed Connective Tissue Disease Presenting as Polyserositis.

Mixed connective tissue disease (MCTD) is a complex rheumatologic condition whose diagnosis often presents a challenge to even specialists in the field. Many cases are therefore underrecognized or misdiagnosed due to the heterogeneity of the presentation and manifestations. This report highlights the intricacies of diagnosing a case of MCTD when the presenting symptom is atypical. Herein, we present a case of a young girl who had severe abdominal pain, initially concerning for acute peritonitis from cholecystitis, and was found to have polyserositis affecting the pleural space, pericardium, peritoneum and pelvis secondary to mixed connective tissue disease and adrenal insufficiency.

Endoscopic Treatment of Acute Cholelithiasis Using AXIOS Stenting and Lithotripsy: A Case Series.

The management of gallbladder diseases, including acute cholecystitis and choledocholithiasis, puts a significant strain on healthcare. The first-line treatment for acute cholecystitis is cholecystectomy. Patients who have concomitant choledocholithiasis, large stones, and/or gallstone pancreatitis may also benefit from endoscopic interventions. Endoscopic treatments may also be utilized in patients who are not surgical candidates due to underlying comorbidities. Studies examining the role of endoscopic lithotripsy in concomitant cholecystitis are limited. Herein we present a case series in which an AXIOS stent (Boston Scientific, Marlborough, Massachusetts) was placed into the gallbladder for decompression and utilized to access the gallbladder lumen to perform electrohydraulic lithotripsy in two patients.

A Rare Presentation of Gastrointestinal Stromal Tumor Causing Gastroduodenal Intussusception.

Adult intussusception is exceedingly rare and most commonly occurs in the stomach or ileum. It is less common for adult intussusception to be classified as gastroduodenal, which also carries a higher mortality rate. Adult intussusception usually warrants surgical intervention as the underlying cause is often malignancy. However, rarely, the etiology is a gastrointestinal stromal tumor (GIST). Here, we present the case of a patient who presented with abdominal pain, vomiting, and hemorrhagic shock and was diagnosed with gastroduodenal intussusception secondary to a gastric GIST.

Iatrogenic Cushing's From Celiac Plexus Blocks for Chronic Pancreatitis: A Case Report.

Chronic pancreatitis and pancreatic malignancies can result in chronic pain that is difficult to treat with traditional regimens. Various pain management strategies have been implemented to improve the quality of life for patients with these conditions, but these strategies are limited by their efficacy and side effects, including opiate dependence. Celiac plexus blocks (CPB) and celiac plexus neurolysis (CPN) were implemented to decrease opiate dependency and treat chronic pain for pancreatitis and pancreatic malignancy. Numerous approaches are used to facilitate CPB/CPN, including percutaneous, surgical, and endoscopic, guided as computerized tomography (CT), fluoroscopy, ultrasound (US), or endoscopic ultrasound (EUS) techniques. EUS is the latest development in CPB/CPN and the least commonly utilized method; however, it is highly efficacious and associated with minimal complications and/or risks. With endoscopic CPB/CPN, overall mortality improves. Despite the various complications associated with other techniques, no case report or current literature has documented the development of iatrogenic Cushing's disease from the use of steroids during CPB via any approach. Herein, we report the first case of iatrogenic Cushing's disease from CPB in the treatment of chronic pancreatitis. Future studies are warranted to examine the agents used in the chemical destruction for CPB/CPN, to avoid complications such as this.

A Unique Case of Gallbladder Agenesis and Cholangiocarcinoma.

Gallbladder agenesis is a rare congenital anomaly of the biliary tract, due to failure of the gallbladder and cystic duct budding off of the common bile duct during fetal development. Cholangiocarcinoma (CCA) is a malignant tumor arising from the biliary ducts in patients with underlying chronic biliary tract inflammation, primary sclerosing cholangitis, or other diseases. Although few studies have reported cases of cholelithiasis in patients with congenital gallbladder agenesis, there is only one other known case of concomitant cholangiocarcinoma and congenital gallbladder agenesis. Herein we present a case of recurrent gallstones in a male, diagnosed with gallbladder agenesis intraoperatively and with pathology consistent with cholangiocarcinoma.

Accidental ingestion of an endodontic file: A case report and literary review.

Ingestion and aspiration can be accidental or intentional events in both adults and children. Approximately 1500 people in the United States die from ingestion of foreign bodies annually. Patients with cognitive disabilities, neurological disorders, elderly age or incarcerated patients carry the highest risk of intentional and/or accidental ingestion of foreign objects. Although uncommon, ingestion of foreign objects during dental procedures can be potentially life-threatening and increased awareness is important. Sharp objects ingested from dental procedures can cause impaction, obstruction, hemorrhage, or perforation and may need endoscopic or surgical intervention. Herein we report a case of a 22-year-old male, who underwent routine dental cleaning and accidentally ingested an endodontic file, retrieved from the ascending colon endoscopically without complications.

Atypical Stroke-Like Presentation in a Critically-Ill Patient With Serratia marcescens Bullous Cellulitis.

Skin and soft-tissue infections are common in critically ill patients, especially with gram-positive bacteria such as Streptococcus or Staphylococcus species. However, it is imperative to consider gram-negative infections in atypical presentations of bullous cellulitis, where patients do not initially respond to common empiric therapy for skin infections. Serratia marcescens is a gram-negative organism that manifests in nosocomial settings due to its affinity for moisture-rich environments. This bacteria is often difficult to treat due to extensive antibiotic resistance, and thus treatment is generally catered towards culture sensitivity. Rarely, this bacteria is an infective agent of infective endocarditis. We present a case of a 44-year-old gentleman who presented with stroke-like symptoms and was found to have bullous cellulitis with deep wound cultures growing S. marcescens. This case report highlights an atypical, severe presentation, and aims to provide a literature review of this rare manifestation of S. marcescens in skin and soft-tissue infections. We intend to improve rapid diagnosis and proper treatment for future critically-ill patients with skin and soft-tissue infections.

Mask-Induced Partial Transection of the External Ear Requiring Complex Surgical Reconstruction.

During the COVID-19 pandemic, wearing masks to prevent the spread of infection has been imperative. Though many wear N-95 masks with circumferential head straps, the use of surgical ear loop-style masks has increased. Dermatologic complications, such as contact dermatitis, psoriasis, and local irritation, have been described in several reports. One such complication has been pressure injury to the external ear, secondary to friction from the ear loops. While external ear pressure ulcers caused by mask-wearing have already been observed, injuries extensive enough to require surgical reconstruction have yet to be described. Herein, we present a unique case of an elderly male with a severe external ear deformity caused by prolonged, uninterrupted mask-wearing that was treated with a complex ear reconstruction. The pressure caused a full-thickness erosion of the helical and conchal cartilage with partial auricle amputation from constant mask wear. We describe an unusual and interesting problem caused indirectly by the coronavirus pandemic and discuss potential methods to protect oneself against skin injury from mask usage while simultaneously preventing viral transmission.

A Case of a gastropancreatic fistula in the setting of intraductal papillary mucinous neoplasms.

Intraductal papillary mucinous neoplasms (IPMN) are mucin producing tumors which arise from epithelial cells of the main pancreatic duct, pancreatic branch ducts, or both. They are characterized by mucin-producing columnar cells, papillary ductal proliferation, cyst formation, and varying degrees of dysplasia. IPMNs are classified as main duct or branch duct based upon the pancreatic duct anatomy which the IPMN is arising from. Additionally, they can be classified based on their histologic subtypes, which carry varying associations with dysplasia and/or malignancy. Many patients have incidentally identified IPMNs, which are asymptomatic. However, patients may also present with pancreatitis, elevation of liver enzymes, dilation of the pancreatic duct or bile duct as well as distention of the ampullary pancreatic orifice(s), due to impaction and obstruction with mucus. This is known as an endoscopically visualized "fish eye" sign. Patients may also develop exocrine and endocrine pancreatic insufficiency and maldigestion. Some studies also suggest that patients with IPMNs may also be at increased risk for gastric, colorectal, biliary, renal cell, and thyroid malignancies. Rarely, IPMNs can be complicated by fistulation between the main pancreatic duct and neighboring organs. Herein, we present an unusual case of simultaneous fistulation to both the gastric body and the duodenum.

Liver Abscess Secondary to Crohn's Disease: A Case Report.

Crohn's disease (CD) is a type of inflammatory bowel disease (IBD) and extra-intestinal manifestations are common. Although common features of CD include fistulation and abscess formation, they typically manifest exclusively in the lower gastrointestinal (GI) tract and in patients who do not have adequate control over their disease. Pyogenic liver abscess is rare in the general population and is an unusual and extra-intestinal manifestation of CD. Herein, we present a patient with Crohn's ileo-colitis who presented with generalized abdominal pain and fevers and was found to have multiple pyogenic liver abscesses biopsy-proven to be secondary to CD. The patient's liver abscesses were refractory to repeated CT-guided drainage and antibiotic therapy. This paper illustrates a rare condition in the general population and those with CD. We intend to discuss the differences of pyogenic liver abscesses in CD compared to the general population, the rarity of this presentation and propose a unique mechanism by which the patient may have developed this liver abscess. It is common for clinicians to mistake the diagnosis of febrile illness with or without abdominal pain as a simple reactivation of CD, and thus it is important to keep pyogenic liver abscess on the differential even if their disease state is otherwise well controlled.

A Case Report of Recurrent Glomerulonephritis 27 Years After Renal Transplant.

Herein we present the case of a patient who was diagnosed with membranoproliferative glomerulonephritis and underwent renal transplant 27 years prior to presentation with new kidney failure. Although our patient did not undergo renal biopsy, it is our thought that she developed recurrent membranoproliferative disease, as she was well maintained on immunosuppressants and steroids for many years. This case is unique, because she was outside of the typical window for both chronic rejection and recurrent disease. This case also raises awareness of the utility of renal biopsy to differentiate these two conditions, which allows physicians to treat accordingly.

Delayed Metastasis of Clear Cell Renal Carcinoma to the Colon in the Setting of Benign Kidney Disease.

Clear cell renal carcinoma (CCRC) is a common variant of renal cell carcinoma (RCC), which presents with unpredictable features. The occurrence of RCC in those with autosomal dominant polycystic kidney disease (ADPKD) is debated. Most studies agree that ADPKD does not increase the risk of RCC; however, it makes diagnosing RCC difficult due to the nature of the disease. RCC frequently metastasizes to the lungs, lymph nodes, bones, liver, adrenal glands, and brain, but rarely metastasizes to the colon. In all previous reports, primary RCC was already diagnosed in the kidneys; thus, metastatic CCRC to the colon has never been described in the current literature in the absence of a primary renal tumor. Here, we report a rare presentation of metastatic CCRC wherein a patient with ADPKD presented with an obstructing sigmoid mass six years after bilateral nephrectomy for pathologically benign cysts. Despite a close follow-up after nephrectomy, our patient's non-specific symptoms were attributed to underlying comorbidities and more likely etiologies of back pain, diarrhea, and anemia, thus delaying and complicating the diagnosis of CCRC which subsequently led to metastases at the time of presentation. Although past literature has described CCRC metastases to other parts of the gastrointestinal tract or even described primary clear cell carcinoma of the colon, this is the first case in which a patient with benign cystic renal disease developed CCRC presenting as metastatic disease of the colon, rectum, liver, and lung. This paper will address the manifestations of ADPKD and postulate mechanisms for the unpredictable nature of this patient's RCC metastasis.

Isolated IgG4 Autoimmune Cholangitis in the Absence of Pancreatitis.

The IgG4-related disease is an uncommon immune-mediated condition affecting multiple organ systems concomitantly; however, it is very rare for a patient to have isolated IgG4 autoimmune cholangitis or IgG4-related disease confined to the hepatobiliary system. The majority of cases are associated with pancreatitis and are incidentally discovered in the workup of acute or chronic pancreatitis. When it affects the hepatobiliary system, it develops as inflammatory fibrosclerosing cholangitis, which can mimic other hepatobiliary diseases such as primary sclerosing cholangitis. Herein, we present a case of type 1 IgG4 autoimmune cholangitis in the absence of pancreatitis. Our case is particularly unique because type 1 is the most common type associated with autoimmune pancreatitis; however, our patient had type 1 without any evidence of pancreatic involvement. Additionally, like most cases of isolated IgG4 autoimmune cholangitis, our patient was refractory to standard therapy. This case highlights the clinical significance, rarity and severity of isolated IgG4 autoimmune cholangitis.