The Evolving Clinical Trajectory From a Sliding Hiatus Hernia to Mixed Sliding and Para-Oesophageal Subtype: A Case Report.

We present a compelling case of a patient initially diagnosed with a simple sliding hiatus hernia (HH), which was managed conservatively through optimised medical therapy. Over the span of a few years, she developed new symptoms which included epigastric discomfort and pain, prompting further clinical review and imaging investigation. These revealed the progression of her HH from a simple form to a more complex rolling or para-oesophageal type. This outcome highlights the importance of recognising a potential for progression during the clinical assessment of patients with a history of reflux symptoms and the onset of new epigastric discomfort or pain. Understanding this continuum of HHs is essential for physicians as management plans may need to switch from a conservative to a more invasive approach.

A Stroke Mimic With Postictal Todd's Paresis and a Simplified Guide to Management of Acute Hyponatremia.

Stroke mimics typically involve non-vascular disease processes, accounting for approximately half of hospital admissions for suspected stroke. These mimics may manifest as functional (conversion) disorders or indicate other neurological or medical conditions, including hypoglycemia, brain tumors, toxic poisoning, migraines, sepsis, seizures, and electrolyte imbalances, which can imitate stroke symptoms, making the diagnosis complex. In this report, we present a unique case of a man in his sixties who developed acute postoperative hyponatremia, an electrolyte abnormality frequently encountered but rarely presented with focal neurological deficits. This condition resulted in facial asymmetry and hemiparesis; however, the remarkable outcome was that these deficits were completely resolved once the hyponatremia was corrected.

The Conservative Management of Choledocholithiasis With Ursodeoxycholic Acid.

Choledocholithiasis has been defined as the presence of stones within the common bile duct (CBD) with up to one-half of the cases remaining asymptomatic. We report a case of an 84-year-old frail male admitted for the treatment of pneumonia, pleural effusion, and bacteraemia with co-incidental deranged liver function tests (LFTs). Ensuing magnetic resonance cholangiopancreatography (MRCP) noted three CBD stones; however, the patient remained asymptomatic. After discussing the benefits and risks of treatment options with the gastroenterology team, the patient refused endoscopic retrograde cholangiopancreatography (ERCP) and opted for close monitoring in the community whilst taking ursodeoxycholic acid (UDCA). In the months following, his LFTs normalised, and repeat MRCP no longer showed stones. This case demonstrates that UDCA with close monitoring may be considered a non-invasive alternative treatment of CBD stones, particularly in elderly or frail patients with multiple comorbidities.

A Case of Chronic Mesenteric Ischemia Due to Celiac and Mesenteric Artery Thrombosis.

Chronic mesenteric ischemia (CMI) is uncommon and accounts for approximately 5% of cases. CMI presents with non-specific symptoms, making it difficult to diagnose, and requires complex management involving interprofessional teams. We present the case of a 66-year-old female who presented with postprandial abdominal pain, vomiting, sitophobia, and weight loss. Investigations showed raised inflammatory markers, and plain film X-ray and endoscopy showed no significant findings. CT angiogram showed celiac and mesenteric artery thrombosis. The patient proceeded to have endovascular revascularization. With this case, we highlight the importance of considering CMI in an elderly patient with a history of microvascular disease or risk factors presenting with postprandial abdominal pain and weight loss. Early diagnosis and timely intervention are imperative for a good prognosis.

Complicated Native Aortic Valve Endocarditis: Complexities of Medical Optimisation Prior to Surgical Repair for Large Vegetations With Systemic Emboli.

A 43-year-old male with no history of valvular disease but ongoing intravenous drug use presented with acute confusion, pyrexia, and Osler's nodes. Transthoracic echocardiography uncovered a large 17 x 15 mm-sized vegetation on the aortic valve, causing moderate-to-severe aortic regurgitation. Subsequent multi-organ compromise and complexities regarding treatment adherence delayed surgical intervention; thus, six weeks of antibiotic therapy and medical optimisation, in close collaboration with cardiology, microbiology, and cardiothoracic teams, enabled definitive aortic valve repair to be performed. This case highlights the challenges encountered when managing this life-threatening condition and the obstacles of enacting the guidelines recommendations regarding the timing of surgical intervention. Our case portrays the effectiveness of medical management as bridge-to-surgery in patients not in a position to undergo immediate surgical repair.

Marchiafava-Bignami Disease: A Rare Association With Dysdiadochokinesia and Ataxic Gait.

Marchiafava-Bignami disease (MBD) is a rare neurological disorder characterized by demyelination and necrosis of the corpus callosum. The non-specific signs and symptoms associated with MBD including dysarthria, impaired walking, pyramidal signs, primitive reflexes, seizures, incontinence, sensory symptoms, gaze palsies, and altered mental state result in a challenging diagnosis. Here, we report the case of a 64-year-old female presenting with dizziness, gait ataxia, and a history of recurrent falls for several months. Initial blood tests indicated anaemia, hypokalemia, hypomagnesemia, and mildly elevated inflammatory markers. Her presentation was initially attributed to a multifactorial aetiology, including a urinary tract infection, orthostatic hypotension, and electrolyte imbalances; however, on correction of reversible causes, her symptoms persisted. Moreover, further examination revealed right-hand dysdiadochokinesia. Subsequent brain MRI revealed fluid-attenuated inversion recovery hyperintensity within the corpus callosum and a right-sided pericallosal white matter hyperintensity. Neuro-radiology multidisciplinary team reported these findings consistent with MBD. Management with vitamin B supplementation was promptly initiated alongside alcohol cessation advice. She was also reviewed by physiotherapy teams. This case adds to the paucity of literature on MBD.

Cerebral Autosomal Dominant Arteriopathy With Subcortical Infarcts and Leukoencephalopathy Presenting During the Postpartum Period as Postpartum Depression and Postpartum Psychosis.

Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) is a rare inherited disease that presents with neurologic manifestations such as stroke, psychiatric disturbances, migraine, and cognitive decline. We report a case of a previously well 27-year-old lady presenting with new onset confusion four weeks postpartum. On examination, there was right-sided weakness and tremors. A thorough history revealed existing diagnoses of CADASIL in 1st and 2nd-degree relatives. The diagnosis in this patient was confirmed by MRI of the brain and genetic testing for NOTCH 3 mutation. The patient was admitted to the stroke ward, treated with a single antiplatelet agent for stroke, and supported by speech and language therapy. There was a significant symptomatic improvement in her speech at the time of discharge. The mainstay of treatment for CADASIL remains symptomatic at this stage. This case report shows that the first presentation of CADASIL can mimic postpartum psychiatric disorders in a puerperal woman.

Shortness of breath due to portopulmonary hypertension and hepatopulmonary syndrome: diagnostic challenges and complex management approach in frail patients.

A 60-year-old woman with a background of frailty, non-alcoholic fatty liver disease (NAFLD), cirrhosis and type 2 diabetes mellitus (T2DM), presented with worsening shortness of breath and a drop in oxygen saturation on sitting and standing up. Her chest X-ray demonstrated evidence of upper lobe venous diversion. Given the hypoxia, she had a computed tomography pulmonary angiography (CTPA) to rule out a pulmonary embolism. The only finding from the CTPA was pulmonary hypertension in the absence of any clots in the lungs. An ultrasound of the abdomen confirmed portal hypertension with splenomegaly and a cirrhotic liver, therefore, an initial diagnosis of portopulmonary hypertension and hepatopulmonary syndrome was made.The patient declined an agitated saline contrast echocardiography. Based on frailty she was not deemed to be a suitable candidate for a liver transplant and was discharged with a package of care alongside home oxygen therapy with periodic review in the gastroenterology clinic. She was assessed as stable with no new concerns while on home oxygen and diuretics.This case highlights challenges in diagnosing and managing patients with cirrhosis, portopulmonary hypertension and hepatopulmonary syndrome with a background of complex comorbidities and frailty.

An Unusual Case of Acute Confusion in an Elderly Man: Pituitary Apoplexy With Lateral Rectus Palsy.

Often, the provisional diagnosis for an elderly patient who arrives at the hospital with confusion is presumed to be delirium stemming from confusion usually caused by an infectious cause. The famous mnemonic PINCH ME signifies the ruling out of pain, infection (that usually has a urinary cause), constipation, dehydration, medication (particularly narcotics), and the environment (factors triggering confusion in a patient with a background of dementia). However, we report a rare case of sudden confusion in an elderly male with no previous history of cognitive impairment. This is the first ever reported case to the best of our knowledge of a patient that presented with sudden confusion, impaired extraocular mobility, and spontaneous cranial hemorrhage that was ultimately determined to be due to a hypothalamic and/or a pituitary cause. It signifies a need for prompt evaluation to arrive at an early diagnosis. Additionally, we hope this case report would serve as a guide to look beyond the current mnemonic of PINCH ME and instead to a new mnemonic of 'PINCH ME HOT' where the latter most mnemonic connotes the need to look at a hypothalamic/pituitary, ocular, or traumatic origin for the delirium.

COVID-19 Vaccination-Induced Cholangiopathy and Autoimmune Hepatitis: A Series of Two Cases.

The coronavirus disease 2019 (COVID-19) pandemic has been associated with significant morbidity and mortality. Following the introduction of vaccines, various side effects have been reported. Whilst those reported may be attributed to the vaccine itself, at times, it may simply incite an immunological phenomenon. We present a case series of two patients who presented with symptoms of yellowing of the eyes and the skin along with fatigue, and tiredness, following vaccination for COVID-19. The diagnosis of post COVID-19-vaccination related hepatitis is one of the fewer, less understood, yet reported side effects associated with significant morbidity. The diagnosis of COVID-19 vaccination-related cholangitis is an outcome reported here for the first time to the best of our knowledge. It was alarming that both patients did not have any significant past history of medical ailments. A prompt assessment followed by investigations including liver biopsy assisted in a timely understanding of the phenomenon with complete resolution of the symptoms.

Hepatobiliary Metastasis of Colorectal Cancer in a Frail Patient and the Role of Immunohistochemistry and Endoscopic Retrograde Cholangiopancreatography (ERCP): A Case Report.

Primary cholangiocarcinoma (malignancy of the bile ducts) is potentially a treatable malignancy via surgery. It presents with a derangement in the liver function blood test results, which results in raised bilirubin. It may also be accompanied by the complaint of itching of skin, dark urine, and light color stool. Bile duct metastasis from primary colorectal cancer, although a very rare condition presents with similar symptomatology and blood test results. Immunohistochemistry staining of tissue biopsy has significantly improved differentiation, detection, and hence plan management of both malignancies (cholangiocarcinoma and bile duct metastasis from primary colorectal cancer). The role of endoscopic retrograde cholangiopancreatography (ERCP) is important with the insertion of a stent towards symptom relief when palliative management is indicated in patients with an incurable disease.

A Stroke of Vision as One-and-a-Half Syndrome: Is It Time to Update the FAST Criteria and ABCD2 Score?

FAST (Face, Arm, Speech, Time) is the most commonly used acronym to identify a possible acute stroke. However, it fails to include visual or vestibular changes as potential hallmarks of an acute event. In this case report, we discuss a patient presenting with visual disturbances and internuclear ophthalmoplegia, with a resulting diagnosis of acute ischaemia. We discuss the associated causes, syndromes, and acute management. Though FAST is an important tool for early recognition of a possible stroke, we want to highlight the consideration of visual changes as an increasing phenomenon in an acute cerebrovascular event.

Complexities of Long-Term Care With Gastro-Jejunal (GJ) Feeding Tubes and Enteral Migration During COVID-19 Pandemic Times: A Case Report.

Gastro-jejunostomy tubes, or percutaneous endoscopic gastrostomy tubes with jejunal extension (PEG-J), hold a significant role in the long-term nutritional management of patients with poor oral intake. This can be for a variety of reasons; ranging from metabolic conditions, including diabetes mellitus, inherited or congenital conditions like Ehler Danlos syndrome, or patients with neurological disorders, such as stroke, advanced Parkinson's disease or multiple sclerosis. Although they are very helpful for the overall nutritional needs of such patients, they are associated with complications, including the dislodging of jejunal tubes. The need to promptly recognise, investigate and manage this, in a timely manner, is vital, particularly during the COVID-19 pandemic times, as such patients may be associated with multiple comorbidities.

Gastric Volvulus: Diagnosis and Successful Endoscopic De-rotation Towards Conservative Management in a Patient With Multiple Comorbidities.

Gastric volvulus is a condition that is not frequently seen in clinical practice and can present with a myriad of symptoms, meaning it can be challenging to diagnose. We present an 82-year-old female attending the emergency department with epigastric pain and coffee ground vomiting on a background of rectosigmoid cancer and a large, complex hiatus hernia. On investigation there was no drop in haemoglobin. However, the chest X-ray showed air-fluid levels and raised the suspicion of gastric volvulus, particularly given her past medical history. The timely organisation of a computed tomogram (CT) scan allowed for prompt decision-making with involvement of surgical colleagues. The patient proceeded to successful conservative management with upper gastroduodenal endoscopy and a de-rotation technique. This case highlights the importance of considering gastric volvulus as a differential diagnosis in those presenting with epigastric pain and vomiting particularly in patients over 50 with a history of large hiatus hernia. This allows for prompt diagnosis and management and avoidance of major complications like gastric mucosal ischaemia.

Splenic Vein Thrombosis: A Case Series of Consequential Chronic Pancreatitis and Sequential Myeloproliferative Disorder.

We present a case series of two patients with splenic vein thrombosis (SVT), a relatively uncommon condition supposed to occur in the context of pancreatitis or pancreatic malignancies. Splenic vein thrombosis may also be seen in cases of chronic pancreatitis, as in one of our patients. At times, splenic vein thrombosis may present with an incidental, isolated finding of gastric varices on computed tomography pulmonary angiogram (CTPA) while investigating for pulmonary embolus; such a result should prompt further investigation to rule out associated splenic vein thrombosis in a sequence. We attempt to highlight the importance of performing a blood count and hematocrit, supplementary to a liver screen, in another patient where the cause was not related to liver disease, but to myeloproliferative disorder, which resulted in a hyper-thrombotic state and splenic vein thrombosis as a consequence.

Voriconazole-Induced Cholestatic Hepatotoxicity in an Immune Competent Patient.

Voriconazole is a frequently prescribed anti-fungal medication used in particular for invasive aspergillosis. Voriconazole-induced hepatotoxicity is a relatively rare but serious clinicopathologic entity. We report a patient presenting with impaired liver function test results pointing towards the cholestatic picture. The patient had initial blood tests to confirm cholestasis, followed by imaging modalities that did not show any obstruction along the common bile duct and/or pancreatic pathway. The patient's voriconazole dose reduction was advised, resulting in lower levels of abnormal liver function tests.

Functional Vitamin B12 Deficiency in Association With Nitrous Oxide Inhalation.

There is a rise in the use and abuse of nitrous oxide (N2O) as a recreational drug. In spite of the laws enforced internationally, it remains readily available and is an inexpensive mode of recreational drug. Commonly known as the 'laughing gas', its use as a euphoric agent is on the rise. Subsequently, the side effects are also coming to light, associated with medical, financial and social implications. It is not detected in routine drug testing. The key differential in an acute setting is often confused with the query for Guillain-Barré syndrome, chronic inflammatory demyelinating polyneuropathy and malabsorption syndromes associated with vitamin B12 and folate deficiencies. This is a case report of a 21-year-old male who presented to the hospital with concerns for weakness and tingling sensations in his extremities accompanied by an inability to bear weight, which he suggested to seem to be worsening over a period of three weeks. His blood tests suggest mild deficiencies of vitamin B12 and folate levels, and MRI revealed subacute combined degeneration of the cervical cord from C2 to C6. The radiologist advised to rule out B12 deficiency and the use of nitrous oxide as a recreational drug. This led to the discussion with the patient, during which he admitted to the use of nitrous oxide. Prompt management with B12 injections intramuscularly every two to three days a week for 11 days followed by folate supplements and monthly B12 injections were advised. He was also reviewed by the physiotherapy teams, and the patient agreed to not use nitrous oxide in the future as a recreational drug.

Post COVID-19 Vaccine Related Cerebral Venous Sinus Thrombosis and Thrombocytopenia.

During the height of the COVID-19 pandemic, there was great relief with the global mass rollout of the Covid-19 vaccination programs. While they have proven to be safe and effective, the gradual emergence of side effects to the vaccines has undermined public trust in the vaccination program and, whilst rare, can lead to significant morbidity and mortality. The most serious was the emergence of vaccine-induced immune thrombocytopenia and thrombosis (VITT), also known as thrombosis with thrombocytopenia syndrome (TTS) or vaccine-induced prothrombotic immune thrombocytopenia (VIPIT). VITT is a serious and often fatal complication of some COVID vaccines that seem more prevalent in younger people and women. We present a case of a 48-year-old woman who presented with VITT following COVID vaccination.