Metformin-Induced Acute Hepatitis.

Metformin is considered an initial oral pharmacotherapy of choice for treating hyperglycemia in type 2 diabetes mellitus (T2DM). Although safe in the vast majority of the population, rare side effects will come to light as the prevalence of T2DM continues to rise. We present a rare case of metformin-induced hepatotoxicity and possibly the first reported case of dose-dependent metformin-induced hepatotoxicity. This case report aims to make clinicians aware of this infrequent yet significant adverse reaction that can arise with metformin therapy.

Milky Ascites: A Diagnostic Dilemma.

Chylous ascites is a milky-appearing, triglyceride-rich fluid within the abdominal cavity. It is a rare finding that arises from the disruption of the lymphatic system and can be caused by a wide variety of pathologies. Here, we present a diagnostically challenging case of chylous ascites. In this article, we discuss the pathophysiology and various etiologies of chylous ascites, explore the diagnostic tools available, and highlight the management strategies implemented in this rare finding.

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.

Wandering Mucosal Melanoma Presenting as Occult Gastrointestinal Blood Loss Anemia.

Malignant melanoma is a highly aggressive cancer arising from the skin, retina, and mucosal lining of the respiratory, gastrointestinal (GI), or genitourinary tracts, all of which contain melanocytes. Mucosal or extracutaneous melanomas (ECMs) are rare accounting for 1% of all melanomas. We herein report a case of a metastatic mucosal melanoma presenting as occult blood loss anemia. A 58-year-old male presented with generalized weakness, anorexia, weight loss, and intermittent melena for one year. On exam, he was tachycardic, borderline hypotensive, and pale without epigastric tenderness. Labs showed severe anemia [hemoglobin, Hgb 3.8 mg/dL, mean corpuscular volume (MCV) 72 fl] for which he received two units of red cells. Endoscopy revealed an 8 mm non-bleeding, gastric ulcer with a raised border and a clean base on the wall of the gastric body. Histologic analysis was consistent with malignant melanoma displaying strong positivity for S-100, Melan A, and HMB 45 stains. The CT of the abdomen revealed multifocal metastatic disease with subcutaneous, intramuscular, and perinephric implants with suspicion of small bowel carcinomatosis. The patient underwent an excisional biopsy for the abdominal wall mass and surgical pathology confirmed melanoma. The patient is planned to be started on immunotherapy for advanced disease. Most melanomas found in the GI tract are metastatic. Mucosal melanoma presenting as a gastric ulcer is extremely rare. As a result, metastasis from other sites must be ruled out before making a diagnosis of primary gastric melanoma (PGM). In our case, a widespread disease with unknown primary elucidated the diagnosis but post-operative inspection failed to find any potential lesion on the skin, genitals, or other organs, suggesting the possible diagnosis of metastatic gastric melanoma. However, follow-up is still required to confirm the diagnosis according to the established criteria. Pathologic diagnosis of melanoma requires the identification of melanin in the cytoplasm and immunohistochemistry with specific markers such as S-100, Melan A, and HMB-45. Although the pathologic diagnosis of PGM is similar to cutaneous melanoma, preoperative diagnosis is difficult due to the extremely low incidence, lack of obvious melanin pigmentation, similar microscopic patterns as more common gastric cancers, and lack of awareness among physicians and pathologists. The prognosis of mucosal melanoma is poor, with a five-year survival rate of 25% versus 80% for cutaneous melanoma. Advanced age, surgically unresectable disease, and lymph node involvement are all poor prognostic markers. There is no standard protocol for treatment. Surgery is the only curative treatment for the resectable disease. Adjuvant chemotherapy, radiation, and immunotherapy have an established role in cutaneous melanoma but there is only limited data on adjuvant systemic therapy with mucosal melanoma. Further research is imperative to establish proper management guidelines for this rare disease entity.

Boerhaave Syndrome: A Report of Two Cases and Literature Review.

Boerhaave's syndrome is a rare yet serious condition associated with high mortality and morbidity. Diagnosis of this syndrome is usually done with the aid of imaging and prompt management should be initiated to improve the outcomes. Treatment for this syndrome has been mainly surgical since its discovery by Herman Boerhaave; however, multiple endoscopic approaches have been successfully used recently with the advancement of this field. Here, we describe two cases of Boerhaave's syndrome that were endoscopically managed along with a brief literature review of the different endoscopic methods used to manage this syndrome.

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).

Mycophenolate-Induced Colitis: A Rare Side Effect.

Mycophenolic acid (MPA) is a well-known immunosuppressive medication that is widely used in solid organ transplant recipients. This medication is known to have various gastrointestinal (GI) side effects. Some of those side effects are simple and temporary like nausea; on the other hand, it can also lead to more serious side effects like colitis. We herein report a case of MPA-induced colitis that presented with severe diarrhea. Unexpectedly, the endoscopic appearance of the colon was normal. Moreover, pathology findings were nonspecific. Symptoms had resolved after discontinuation of the medication. MPA-induced colitis is a rare side effect with no established guidelines for management or treatment. Furthermore, the nonspecific endoscopic and microscopic findings make it a diagnostic dilemma.

Esophageal Foreign Body Removal: A Novel Approach.

Upper esophageal foreign body impaction is a common clinical presentation and often requires medical attention. The most common foreign bodies encountered in the adult population are food-related, e.g., steak pieces and meat bones. Endoscopic interventions are indicated when the foreign objects fail to pass spontaneously. The standard methods to remove these foreign bodies include push technique and retrieval methods using various endoscopic instruments. However, we report a unique method that was used to remove a large upper esophageal impacted foreign body refractory to removal by standard procedures.