Unusual Case of Obstructive Jaundice.

Most malignant obstructive jaundice arises from primary periampullary tumors and rarely from metastatic cancer of the head and neck. A 60-year-old male was diagnosed with obstructive jaundice due to metastatic squamous cell carcinoma of the tonsil. Only 12 cases of small bowel metastasis from the head and neck have been reported. Most of them originate from laryngeal squamous cell carcinoma, and only one case reported tonsillar cancer metastasizing to the ileum. Our case is the first one, to the best of our knowledge, to illustrate tonsillar cancer with metastasis to the duodenum causing obstructive jaundice.

Triple Pancreatic Walled-off Fluid Collections Treated Simultaneously with Endoscopic Transmural Drainage.

Pancreatic pseudocysts and walled-off pancreatic necrosis arise as a complication of pancreatitis. Multiple fluid collections are seen in 5-20% of the patients who have walled-off peripancreatic fluid collections. There is a paucity of data regarding the role of endoscopic transmural drainage in the management of multiple pancreatic fluid collections. In this case report, we present the case of a 72-year-old male with three walled-off pancreatic fluid collections in the setting of acute necrotizing pancreatitis. The patient underwent simultaneous endoscopic ultrasound-assisted cyst gastrostomy and cyst duodenostomy and aggressive irrigation without index endoscopic necrosectomy of the three peripancreatic fluid collections. Significant improvement in the size of the fluid collections was seen on the computed tomography scan, as well as a remarkable immediate clinical improvement after 24 hours of the endoscopic intervention.

Vancomycin Enemas as Adjunctive Therapy for Clostridium difficile Infection.

BACKGROUND: For severe, complicated Clostridium difficile infection (CDI), concomitant treatment with IV metronidazole and oral vancomycin is usually prescribed. Sometimes vancomycin per rectum (VPR) is added to increase colonic drug delivery. Our purpose was to examine clinical outcomes of patients with CDI treated with VPR and compare results to a matched control group. METHODS: This was a retrospective case-control study in a setting of tertiary-care ICU on diarrhea patients with a positive toxin test for C. difficile. We identified all ICU patients prescribed VPR from January 2003 to December 2013. The dose of VPR mixed in 100 cc of tap water ranged from 125 to 250 mg Q 6 - 8 hours. All patients had diarrhea and a positive test for C. difficile toxin. Included patients received ≥ 4 doses of VPR. The primary outcome was the combined endpoint of colon surgery or death. We matched VPR cases 1:2 with CDI controls that had identical APACHE II scores. RESULTS: We identified 24 CDI patients who received VPR and met inclusion criteria: 11 male, mean age 61.8 ± 15.9 years. All patients received concomitant CDI therapy. Four patients (16.7%) required colectomy, and overall mortality was 45.8%. For the 48 controls, need for surgery was identical (16.7%; P = 1.00). The mortality rate also did not differ (41.7%; P = 0.74). For the combined outcome of surgery or death, the rate was 45.8% for the controls and 50.0% for the VPR group (P = 0.73). CONCLUSION: In a case-control study, the use of VPR was not demonstrated to reduce the need for colectomy or decrease mortality. Based on our modest sample size and failure to show efficacy, we cannot strongly advocate for the use of VPR.

A case of small intestinal cast causing SBO in complicated intestinal graft-versus-host disease.

We report an unusual case of small bowel obstruction caused by an intestinal cast in an 8-year-old female who developed intestinal graft-versus-host disease (GVHD) following two unrelated bone marrow transplants for aplastic anemia, and highlight the pathophysiology, common presentations, and surgical complications of intestinal GVHD from the surgeons' perspective.