Eosinophilic esophagitis: Current concepts in diagnosis and management.

ABSTRACT: Eosinophilic esophagitis is an antigen-mediated chronic inflammatory disorder that has risen in incidence and prevalence over the past 2 decades. The clinical presentation is variable and consists of mainly esophageal symptoms such as dysphagia, heartburn, food impaction, and vomiting. Current management relies on dietary elimination, proton-pump inhibitors, and topical corticosteroids with different response rates and relapses after treatment discontinuation. With a better understanding of the underlying pathophysiology, many molecules emerged recently as targeted treatment including dupilumab (IL4/IL13 blocker), as the first FDA-approved biological treatment, which has changed the management paradigm.

Progressive Familial Intrahepatic Cholestasis: A Descriptive Study in a Tertiary Care Center.

Background: Progressive familial intrahepatic cholestasis (PFIC) is a rare genetic disorder that results from defective mechanisms of bile secretion. We aim to describe different types of PFIC and their clinical features, treatment modalities, and outcomes in Saudi Arabia. Patients and Methods. This is a retrospective study of all patients diagnosed with PFIC at King Faisal Specialist Hospital and Research Center in Riyadh from January 1, 2002, to December 31, 2021. All relevant information was collected from patient charts and transferred into the REDcap® database for statistical analysis. Results: A total of 79 patients were identified with PFIC, and PFIC type 3 was the most common (59.5%), followed by PFIC type 2 (34.2%), PFIC type 1 (5.1%), and PFIC type 4 (1.3%). Males and females were affected in 54.4% and 45.6%, respectively. Mutations in ATP8B1, ABCB11, and ABCB4 genes were observed in PFIC type 1, PFIC type 2, and PFIC type 3, and loss of function in a variant of TJP2 was detected in PFIC type 4, respectively. A total of 51 (64.6%) patients underwent liver transplantation: three patients (3/4) with PFIC type 1 (75%), twenty patients (20/27) with PFIC type 2 (74.1%), twenty-seven patients (27/47) with PFIC type 3 (57.4%), and one patient with PFIC type 4 (100%). The mean duration of disease before transplantation was 53.9 ± 67 months with a median of 30 months. Following liver transplantation, symptomatic control was achieved in 47 patients (92.2%). Recurrence after transplantation occurred in 4 patients (7.8%) within an average of 22.5 months and a median of 17 months. Conclusion: PFIC is considered a rare disorder in Saudi Arabia; however, early recognition of the disease is important for appropriate management and early referral for liver transplantation evaluation. The overall rate of liver transplantation in our cohort was 64.6% with an excellent five-year survival rate.

Mucormycosis and Cryptococcosis with Gastrointestinal Involvement in a Patient with Poorly Managed Diabetes.

Mucormycosis and cryptococcosis are invasive fungal infections that mostly infect immunocompromised patients and are associated with high mortality rates. Here, we report a case of a 54-year-old male with poorly controlled diabetes mellitus who was initially admitted with a complaint of right frontal headache and vomiting for 5 days. The patient was found to have paranasal sinuses mucormycosis, and later developed gastrointestinal cryptococcosis. A multidisciplinary approach and early management are important to avoid any delay in managing these life-threatening infections. To the best of the authors' knowledge, this is the first case reporting concurrent invasive fungal infections in a patient.

Extramedullary Involvement of the Ascending Colon in Relapsing Acute Lymphocytic Leukemia: A Case Report.

Acute lymphoblastic leukemia (ALL) accounts for <1% of adult cancers. Extramedullary relapse of ALL has been primarily reported in pediatric patients or hematopoietic stem cell transplant recipients, and the gastrointestinal (GI) tract is a less frequently reported site of extramedullary relapse. Here, we report a case of a 30-year-old male who was a known case of ALL with multiple relapses and allogenic stem cell transplantations. The patient presented with acute lower GI bleeding and was confirmed to have an extramedullary relapse of ALL in the ascending colon. As the patient already had early relapses after two hematopoietic stem cell transplants in the past, he was managed with palliative chemotherapy, consisting of vincristine, dexamethasone, and rituximab, following which the patient achieved complete remission. This case highlights the importance of recognizing uncommon presentations of ALL such as those involving the GI tract.

Gastroduodenal amyloidosis: a case report and review of literature.

Amyloidosis is a disorder characterized by deposition of abnormally folded proteins in the extracellular space of various tissues and organs, possibly leading to their dysfunction. In the majority of cases, amyloidosis presents with systemic involvement including the gastrointestinal tract; however, localized gastroduodenal amyloidosis is rare. We report a case of gastroduodenal amyloidosis in a 36-year-old male with multiple comorbidities who presented with right upper quadrant abdominal pain. Reports of gastroduodenal amyloidosis and other relevant literature were also reviewed and discussed alongside this case.

Large lipoma of the ascending colon: a case report and review of literature.

Gastrointestinal lipomas are a rare benign non-epithelial neoplasms derived from mature adipocytes. The colon is the commonest organ involved in the entire digestive tract and has an incidence rate ~4.4% in autopsy series. Most of the colonic lipomas are asymptomatic and incidentally detected. Lipomas need to be distinguished from true neoplasia, because in most cases they do not need to be resected unless when they cause a clear symptom or they are large in size. Surgical rather than endoscopic resection is preferred for lipomas > 2 cm to avoid complications such as bleeding and perforation. We report a case of a 56-year-old female, a known case of locally advanced breast cancer and positive adenomatous polyposis coli mutation, who was found to have 4 cm ascending colon lipoma by imaging and confirmed by colonoscopy and histopathology.

Brunner's glands hamartoma with pylorus obstruction: a case report and review of literature.

Proliferative lesions of the Brunner's glands are uncommonly encountered lesions of the small intestine, originating from the deeply seated mucosal and submucosal Brunner's glands, mainly in the duodenum. The vast majorities of these lesions are benign and include Brunner's glands hyperplasia (adenomas/nodules) and hamartomas. The etiology and pathogenesis of these lesions are not fully understood, and the diagnosis can sometimes be challenging. We report a case of Brunner's gland hamartoma in a 57-year-old man who presented with chronic dyspepsia, hematemesis and weight loss. Endoscopic and radiological investigations show a submucosal polypoid lesion at the first part of the duodenum. Routine endoscopic biopsies demonstrated normal duodenal mucosa. The lesion considered endoscopically unresectable and was surgically resected. Frozen section examination and intraoperative consultation showed unremarkable duodenal mucosa and histologically bland Brunner's glands.

COVID-19 and endoscopy services in intermediately affected countries: a position statement from the saudi gastroenterology association.

With the global pandemic due to coronavirus disease 2019 (COVID-19), there has been a significant strain on healthcare facilities. The infectivity rate, as well as the rate of healthcare workers who have fallen ill to the disease, has raised concerns globally on the proper management of patients as well as the role of safe healthcare provision utilizing personal protective equipment (PPE). Furthermore, the limited supply of PPEs has mandated rationing their use to achieve maximum utility and preservation. Multiple gastroenterology associations have issued guidance and statements that would help healthcare providers in navigating these unprecedented and difficult times, and the Saudi Gastroenterology Association has provided this statement in an effort to bring the most up to date information for the management of endoscopy units in terms of resources, manpower planning, scheduling, as well as infection control policies and leadership.

Acute Pancreatitis as a Complication of Intragastric Balloons: a Case Series.

Intragastric balloon (IGB) placement for the treatment of obesity has been in use for more than three decades. The major advantage of IGBs is that they preserve the anatomy of the stomach and are generally considered safe; the most common complications are nausea/vomiting and abdominal pain, and very rarely are IGBs associated with mortality (0.05%). A total of 14 cases of pancreatitis complicating IGBs have been reported in the literature. In this series, we reported 10 patients who developed acute pancreatitis in association with IGBs of which half were treated conservatively without the removal of the IGBs.

Elizabethkingia Meningoseptica in a Case of Biliary Tract Infection Following Liver Transplantation.

BACKGROUND Elizabethkingia meningoseptica (E. meningoseptica) is an aerobic Gram-negative bacillus known to thrive in moist environments, and is now recognized as a hospital-acquired infection, being found to contaminate hospital equipment, respiratory apparatus, hospital solutions, water, and drainage systems. Nosocomial infection with E. meningoseptica occurs in immunocompromised patients, requires specialized identification methods, and is resistant to conventional antibiotics. We report a case of E. meningoseptica infection arising from a percutaneous transhepatic biliary drainage (PTBD) tube. CASE REPORT A 55-year-old Saudi woman underwent liver transplantation. The post-operative period immediately following transplantation was complicated by anastomotic biliary stricture and bile leak, which was managed with percutaneous transhepatic cholangiography (PTC) with PTBD. She developed right upper quadrant abdominal pain, and her ultrasound (US) showed a subdiaphragmatic collection. Microbial culture from the PTBD tube was positive for E. meningoseptica, which was treated with intravenous ciprofloxacin and metronidazole. This case is the second identified infection with E. meningoseptica at our specialist center, fifteen years after isolating the first case in a hemodialysis patient. We believe that this is the first case of E. meningoseptica infection to be reported in a liver transplant patient. CONCLUSIONS The emerging nosocomial infectious organism, E. meningoseptica is being seen more often on hospital equipment and medical devices and in water. This case report highlights the need for awareness of this infection in hospitalized immunocompromised patients and the appropriate identification and management of infection with E. meningoseptica.

Solitary rectal ulcer syndrome: A single-center case series.

BACKGROUND/AIM: Solitary rectal ulcer syndrome (SRUS) is a benign, chronic defecation disorder with varied presentations. The aim of this study is to summarize the clinical features, endoscopic findings, histological appearance, and treatment strategies associated with SRUS. PATIENTS AND METHODS: This is a retrospective study of all patients diagnosed with SRUS at the King Faisal Specialist Hospital and Research Centre in Riyadh from January 2003 to December 2013. Cases were identified using the Department of Pathology database. Data were obtained from medical records that included clinical manifestation, endoscopic findings, and histopathological features. RESULTS: Twenty patients were identified. The mean age was 42.5 years (±18.5) and 55% were females. Most of the patients presented with bleeding per rectum (85%), constipation (75%), and straining (50%), with a mean symptom duration of 26.7 months. The most common associated factors identified were constipation (75%), history of rectal surgery (25%), digital rectal manipulation (20%), and rectal prolapse (20%). Endoscopic findings included a single ulcer (50%) and multiple ulcers (30%); 55% had a polypoidal appearance. On histopathology, there was surface ulceration (95%), fibrosis of the lamina propria (60%), distorted architecture (55%), and muscle hypertrophy with increased mucin production (50%). Patients were treated conservatively and none required surgery. CONCLUSION: SRUS is a rare disorder with variable clinical presentations. Stool softeners, a high fiber diet in addition to topical mesalamine, and biofeedback proved to be effective in this patient population.

Hepatosplenic T-cell lymphoma.

We report an uncommon case of 38-year-old male patient with Hepatosplenic T-Cell lymphoma (HSTCL) which is a rare aggressive form of Peripheral T-Cell lymphoma that is characterized by primary extranodal disease with malignant T-cell proliferation in the liver, spleen, and bone marrow. Our patient presented with progressive painless jaundice, weight loss and massive hepatosplenomegaly. The diagnosis was challenging as he required an extensive investigations that ultimately showed the characteristic clinical, histopathologic, and cytogenetic features of hepatosplenic T-cell lymphoma.