March of the Eosinophils: A Case of Eosinophilic Gastroenteritis, Immune Thrombocytopenia, and Iron Deficiency Anemia.

Eosinophilic gastrointestinal disorders (EGIDs) refer to eosinophilic infiltration of various sections of the gastrointestinal tract in the absence of secondary causes. Diagnosis of EGID requires histological evidence of eosinophilic infiltration of the GI tract. Here, we present a case of a young male with biopsy-proven eosinophilic gastroenteritis with a concomitant established diagnosis of immune thrombocytopenic purpura (ITP).  Presently, EGIDs remain an underexplored clinical entity. While its pathophysiology is not fully understood at this time, TH2 mediated activation of B-cells and subsequent stimulation of eosinophils locally appears to be at play. This is in contrast to the TH1 predominant cytokine profile underlying ITP, which this patient also has. Treatment typically involves dietary modifications and glucocorticoids.

Helicobacter pylori-Negative Gastric Mucosa-Associated Lymphoid Tissue Lymphoma Presenting as Massive Gastrointestinal Bleed.

This case reports a patient that represents the minority of patients with gastric mucosa-associated lymphoid tissue (MALT) lymphoma who do not have underlying Helicobacter pylori gastritis. Gastric MALT lymphoma is a type of primary gastric lymphoma (PGL), which are extremely rare gastric malignancies characterized by proliferation of B-cells and infiltration of lymphoid tissue leading to destruction of gastric glands. Development of gastric MALT lymphoma is associated with H. pylori gastritis. Patients typically present with a wide range of symptoms including but not limited to epigastric pain, weight loss, gastrointestinal bleeding and gastric wall perforation. Gastric MALT lymphoma presenting as a massive gastrointestinal bleed is quite rare and only a few cases have been documented. Our case demonstrates that it is important to recognize that acute presentations of this disease may also occur.

Dysphagia: A Rare Presentation of Sarcoidosis.

Gastrointestinal (GI) sarcoidosis is a rare manifestation of this multi-systemic granulomatous disorder. Esophageal involvement is extremely rare and there have been few case reports about this. Our article reports a case of esophageal sarcoidosis in which dysphagia was the main presenting symptom. The main initial treatment of symptomatic sarcoidosis in general and pulmonary sarcoidosis in specific usually involves corticosteroids, however, there are no specific guidelines for the management of GI sarcoidosis. Surprisingly, or maybe not, in our case, the dysphagia did not improve with steroid therapy which prompted further investigations as well as endoscopic intervention.

Endoscopic Retrograde Cholangiopancreatography (ERCP): Used to Diagnose and Treat Cholecystoduodenal Fistula, a Rare Clinical Entity.

Biliary enteric fistula is a rare diagnosis. Common etiologies include chronic cholecystitis with cholelithiasis and peptic ulcer disease. Of these, the number one cause is chronic cholecystitis with cholelithiasis. Adhesion of a chronically inflamed gallbladder to the duodenum followed by erosion of the gallbladder wall by gallstones leads to the establishment of an abnormal communication between the gallbladder and duodenum. This abnormal communication, namely, cholecystoduodenal fistula, has a high mortality rate and therefore must be managed in a timely manner. The case presented in this report is that of a 76-year-old female suffering from chronic cholecystitis and cholelithiasis who was both diagnosed with as well as managed for cholecystoduodenal fistula by the use of endoscopic retrograde cholangiopancreatography (ERCP).

Focal Active Colitis Presented With Chronic Diarrhea.

There are various etiologies of colonic injury and inflammation. The most commonly described colitides in clinical practice are associated with infection, inflammatory bowel disease, ischemia, radiation and medications. The colonic wall has a limited set of responses to different types of injury; therefore, there is overlap between many of these disorders. Focal active colitis is characterized by isolated neutrophilic cryptitis with the background mucosa displaying normal crypt architecture. This inflammatory pattern can be easily unnoticed by pathologists because on low-power examination the mucosa may have almost normal appearance. General practitioners also may not be familiar with this term, underlying etiologies, associated risk factors, course, available therapies and follow up.  We present a case of an 82-year-old female with chronic diarrhea and weight loss. She had a negative infectious workup and normal radiology series. She subsequently underwent endoscopic evaluation in lieu of persistent and debilitating symptoms which revealed nonspecific macroscopic findings with pathology noting focal active colitis. She was empirically treated with a 14-day course of Xifaxan and responded well to management with almost complete resolution of her symptoms and no recurrence on six-month follow-up.

A Rare Complication of Cardiac Ablation: Atrial-esophageal Fistula Presenting as Odynophagia.

Radiofrequency catheter ablation has been commonly used for the treatment of drug-refractory atrial fibrillation. The esophageal injury along with the development of atrial-esophageal fistula (AE fistula) is fairly rare but is a devastating complication of catheter ablation. Described in 2004 for the first time, it is the most lethal of all the complications of catheter ablation with a high mortality rate. The clinical presentation of an AE fistula is variable, however, early diagnosis and treatment can prevent a fatality. We have reported a case of an AE fistula post catheter ablation for drug-resistant atrial fibrillation, along with its treatment, diagnosis, and possible preventive measures.

Postsurgical Refractory Gastroparesis: Response to Botulinum Toxin Therapy.

Gastroparesis is a complex dysmotility disorder characterized by chronic dyspepsia and delayed gastric emptying in the absence of mechanical obstruction. Postsurgical gastroparesis is the third most common cause and accounts for 13% of total cases. Studies have shown that catheter ablation procedures for atrial fibrillation can rarely result in gastroparesis, secondary to damage to the vagus nerve. Once the diagnosis is confirmed, treatment options include: dietary management, prokinetic drugs, and new invasive treatments. Botulinum toxin injection is an emerging pyloric intervention, increasingly used in the management of gastroparesis refractory to pharmacological therapy. It is given as an injection into the pyloric sphincter, with the help of an endoscope. Botulinum toxin acts by inhibiting smooth muscle contraction through a decreased response to acetylcholine. Here we report a case of postsurgical gastroparesis that responded well to botulinum toxin therapy.

Carcinoid Tumor: Advances in Treatment Options.

Small bowel neoplasms are rare, accounting for only 3%-6% of all gastrointestinal neoplasms. Carcinoid tumors represent a large portion of these (20%-30%), making them the second most common small bowel malignancy after adenocarcinoma. Gastrointestinal carcinoids constitute 70% of all neuroendocrine tumors, and out of those, 42% originate in the small bowel. They are predominantly seen in older patients around the age of 65 years. From 1973 to 2004, there has been more than a fourfold increase in the incidence of carcinoid tumors. This can be probably due to increased diagnostic accuracy rather than an actual increase in the number of new cases. The workup of a suspicious case of gastrointestinal bleeding consists of esophagogastroduodenoscopy and/or colonoscopy, and other imaging tests including video capsule endoscopy and balloon-assisted endoscopy. Management of the tumors is dependent on the size and location of the lesion. Treatment options include surgery, endoscopic removal of tumors, and various immunotherapy and chemotherapeutic agents.

Hydrogen Peroxide Enema-induced Proctitis in a Young Female: A Case Report.

Hydrogen peroxide is a disinfectant commonly used for cleansing superficial wounds due to its oxidizing capacity. In the past, it has also been used for the management of meconium ileus in children as the oxidizing action of hydrogen peroxide potentiates peristalsis that relieves ileus or fecal impaction. The potential dangers were unknown till Pumphrey, in 1951, described the harmful effects of its use as an enema. We present a case of a 32-year-old female who was admitted for complaints of perianal pain. She used an enema, consisting of water and hydrogen peroxide, for constipation. It improved her symptoms but subsequently, she developed a burning sensation in her rectum. The patient had a colonoscopy which revealed severe proctitis up to 15 cm from the anal verge manifested by superficial mucosal ulceration, marked erythema, and edema with friable mucosa and hemorrhage. The patient was subsequently given mesalamine, and the symptoms resolved.