Acute Liver Injury as a Manifestation of Secondary Syphilis.

In the United States, the incidence of new cases of syphilis has been rising. The number of cases of primary and secondary syphilis has continued to increase almost every year over the past 2 decades. Secondary syphilis has a variety of clinical manifestations. A frequently overlooked presentation is that of syphilitic hepatitis, which should be part of the differential diagnosis for patients with elevated liver enzymes, a maculopapular rash, and/or risk factors for contracting syphilis. In this study, we report a rare and unusual case of a man with a remote history of syphilis infection who developed acute liver injury.

Gastric Outlet Obstruction due to Malposition of Gastrostomy Tube: A Rare and Commonly Misdiagnosed Condition.

Nearly all disease processes worsen with malnutrition. However, providing adequate and optimal nourishment can be challenging in individuals who are not able to eat. Insertion of a gastrostomy tube is a well-established method for providing enteral access for long-term nutritional support. Although enteral tube feedings are generally well tolerated, gastrostomy tube placement is associated with several complications. An uncommon, and often initially misdiagnosed, complication of gastrostomy tube placement is gastric outlet obstruction (GOO), which refers to the clinical outcome of any disease process that mechanically obstructs gastric emptying. GOO is a clinical syndrome characterized by nausea, postprandial nonbilious vomiting, epigastric pain, early satiety, abdominal distention, and insidious weight loss due to mechanical obstruction in the distal stomach, pylorus, or duodenum. Rarely, migration and malposition of a gastrostomy tube can lead to this condition. Therefore, physicians should be aware of GOO as a rare complication of gastrostomy tube placement. Often, simple adjustment of the tube can lead to rapid improvement and resolution of the patient's clinical condition as well as prevent needless medical tests, overly aggressive management, and further complications. Here, we present an interesting case of a woman who developed a GOO after unintended migration of a gastrostomy tube.

Gastric Diverticulum: A Comprehensive Review.

BACKGROUND: Gastric diverticula (GD) are outpouchings of the stomach wall that typically form in the fundus. They are the least common gastrointestinal diverticula, and are very rare anatomic abnormalities overall. SUMMARY: Although most GD are asymptomatic and are usually discovered incidentally during routine diagnostic testing, they can present with variable symptoms. Occasionally, complications can develop that may be life-threatening and are indications for surgical management. KEY MESSAGES: Here, we provide a literature review of GD where we discuss the pathogenesis, clinical manifestations, investigations and diagnostic approach, and various management options for this uncommon disorder.

Reducing the Unintended Dislodgement of Gastrostomy Tubes in a Long-Term Acute Care Hospital: A QA/QI Pilot Study.

BACKGROUND: Since their introduction in 1980, gastrostomy tubes have become effective means of providing both short-term and long-term enteral access and nutritional support. These feeding tubes are ubiquitous in many health care facilities that care for the elderly, but carry high rates of unintended dislodgement - a complication that, if not detected promptly, is associated with substantial morbidity and health care costs. This study determined the dislodgment rate of gastrostomy tubes at 90 days in a cohort of 221 patients and tested the hypothesis that the implementation of a concise protocol to care for patients' gastrostomy tubes would reduce these unintended dislodgements. METHODS: The dislodgment rate of gastrostomy tubes at 90 days in a cohort of 221 patients was determined. In addition, a randomized controlled trial was conducted in a long-term acute care hospital in which patients were alternately allocated to either of two geographically separate units: 1) a selected unit where a concise protocol to care for patients' gastrostomy tubes was implemented, and 2) a separate unit where standard care was provided. Enrollment included patients diagnosed with dysphagia - who were receiving mechanical ventilatory support for chronic respiratory failure - who were being administered feedings, fluids and medications via a balloon gastrostomy tube. The primary endpoint was the number of unintended dislodgements of gastrostomy tubes during a 90-day study period. RESULTS: In a cohort of 221 patients with balloon gastrostomy tubes placed that was observed for a period of 90 days, 64 (29.0%) had unintended gastrostomy tube dislodgement (P < 0.028). A total of 34 patients were enrolled in the randomized controlled trial with 17 in the treatment group and 17 in the control group. All subjects were followed for a maximum of 90 days. During the study period, there was one episode of unintended gastrostomy tube dislodgement (5.9%) in the treatment group, compared with six episodes (35.3%) in the control group (P < 0.047) and the previous cohort of 221 patients (P < 0.028). CONCLUSION: This study showed a significant reduction in dislodgements after implementation of a protocol that is an innovative, straightforward and economical solution to the problem of the unintended dislodgement of gastrostomy tubes.

Drug-Induced Autoimmune Hepatitis in a Patient Treated with Minocycline: A Rare Adverse Effect.

Drug-induced autoimmune hepatitis is an acute and potentially severe adverse effect, which has been reported following the long-term use of minocycline. The condition's typical biochemical findings include an elevated antinuclear antibody titer, hypergammaglobulinemia with elevated levels of serum immunoglobulin G, and, sometimes, positive anti-smooth muscle antibodies. Characteristically, transaminase levels are very elevated, while markers of cholestasis and bilirubin levels are mildly increased, and histological features are very similar to those observed in sporadic autoimmune hepatitis. Here, we describe an interesting case of a young female who developed drug-induced autoimmune hepatitis after taking minocycline for the treatment of acne vulgaris.

Spontaneous Expulsion per Rectum of a Colorectal Polyp: A Rare and Unusual Case.

Colorectal polyps are growths that form on the epithelium of the colon and rectum. While their prevalence varies considerably from region to region, they are common in adults. In fact, among asymptomatic, average-risk individuals at 50 years of age, the prevalence of colorectal polyps averages roughly 10% in sigmoidoscopy studies and more than 25% in colonoscopy studies. Approximately two-thirds of all colorectal polyps are adenomatous precancerous lesions that have the potential to become malignant. Usually, they are discovered and resected during colonoscopy. The spontaneous expulsion per rectum of a colorectal polyp is exceedingly rare. Here, we report a rare and unusual case that we believe is the first of spontaneous expulsion of an adenomatous polyp during defecation. These patients should undergo colonoscopy to search for additional polyps as well as other gastrointestinal pathology.

Gastric Ulcer from the Pressure of a Gastrostomy Tube: A Rare Cause of Upper Gastrointestinal Bleeding.

Gastrostomy tube placement is a well-known procedure for obtaining permanent enteral access and providing long-term nutritional support. Although it is usually well tolerated, a diverse array of complications can occur. A rare, and often unrecognized, complication of gastrostomy tube placement is upper gastrointestinal bleeding secondary to a gastric ulcer caused by pressure from a gastrostomy tube bumper or balloon. Here, we present a case of an elderly woman who experienced hematemesis and bleeding around the gastrostomy site. This report should alert healthcare staff that excessive tightening of the gastrostomy tube retainer or prolonged traction of the gastrostomy tube can cause pressure necrosis manifesting as gastric ulceration.

Chronic Intestinal Pseudo-Obstruction in Systemic Sclerosis: An Uncommon Presentation.

Chronic intestinal pseudo-obstruction (CIPO) is an uncommon disorder characterized by the presence of bowel dilatation and abnormal motility. It is an important cause of chronic intestinal failure in patients with systemic sclerosis (SSc). Although intestinal pseudo-obstruction is an infrequent reason for hospitalization in these patients, it has been correlated with high in-hospital mortality compared to SSc patients hospitalized for other reasons as well as patients with intestinal pseudo-obstruction arising from other causes. Patients present with signs and symptoms of mechanical bowel obstruction, such as nausea, vomiting, constipation, abdominal pain, and abdominal distension, in the absence of an anatomic lesion blocking the movement of intestinal contents. Despite breakthroughs in our understanding of this disorder, these patients continue to be treated largely with organ-based symptomatic therapy. Unfortunately, despite treatment, they often experience decreased quality of life and impairment in their everyday lives. Here, we present an interesting case of an individual with SSc for many years who presented with signs and symptoms of CIPO.

Ascaris lumbricoides: A Startling Discovery during Screening Colonoscopy.

Intestinal parasitic infections are a major public health issue across the world and particularly in rural and urban areas of tropical and subtropical countries. Those at increased risk include inhabitants of poor and disadvantaged regions, which are more likely to have inadequate environmental sanitation, insufficient water supply, greater contact rates with reservoirs of infection, limited health literacy, and socioeconomic disparities. Of the intestinal nematodes (roundworms) that parasitize the human gastrointestinal tract, Ascaris lumbricoides is the largest in terms of size. It causes ascariasis, a "neglected tropical disease," or NTD, that is among the most common helminthic human infections worldwide with an estimated 800 million to 1.2 billion people infected. It causes more than 60,000 deaths annually. However, in more than 85% of cases, infections do not result in symptoms - especially in individuals infected with a small number of worms. Thus, many individuals with intestinal ascariasis remain undiagnosed for years until either they experience symptoms and seek medical attention, the macroscopic adult worms are passed with the stool, or the adult worms are incidentally discovered during routine endoscopic procedures. Here, we present an interesting case of an elderly Bangladeshi man with seemingly innocuous complaints of intermittent mild abdominal symptoms and no recent travel history, who was discovered to have intestinal ascariasis during a screening colonoscopy.

Crohn's Disease Manifesting as a Duodenal Obstruction: An Unusual Case.

We describe a case of a 31-year-old man who presented with a 3-year history of worsening upper abdominal pain, nausea, and vomiting: symptoms that were resistant to medical treatment and unexplained despite a thorough diagnostic evaluation. Then, an upper gastrointestinal series with small bowel follow-through showed proximal duodenal dilation and distal decompression of the duodenum, suggestive of a partial duodenal obstruction. An abdominal computed tomography (CT) scan revealed a transition point in the distal duodenum. At surgery, a segmental resection of the distal duodenum with a duodenojejunal anastomosis was performed. Histopathologic examination of the specimen revealed Crohn's disease. Therefore, making the diagnosis of duodenal obstruction has significant clinical implications and, in the setting of Crohn's disease, is evidence of an underlying intestinal stricture, stenotic area, or adhesion.