Respiratory involvement in Crohn's disease: a case report.

Inflammatory bowel disease (IBD) predominantly affects the gastro-intestinal tract. There is however a large array of extra intestinal manifestations (EIM) associated with these diseases. A lesser known EIM is pulmonary involvement, which has been first described in 1973. Since the introduction of HRCT more attention is guided towards this specific involvement. Awareness of pulmonary involvement in IBD-patients may lead to better screening, guide appropriate therapy, and ultimately result in better patient care. When untreated, serious and persisting complications, such as stenosis or strictures of the large airways, as well as bronchiectasis or bronchiolitis obliterans might occur.

Hypercalcemia induced pancreatitis as a rare presentation of primary hyperparathyroidism.

Acute pancreatitis (AP) is an inflammatory process of the pancreas. It is a relatively common cause of acute upper abdominal pain and is potentially associated with high morbidity and mortality. Underlying hypercalcemia as a cause of AP is very rare. We present a case of a hypercalcemia-induced acute pancreatitis with an underlying parathyroid adenoma in an 81-year-old woman with no previous symptoms of hypercalcemia. The parathyroid adenoma was semi-urgently surgically resected with normalization of calcium-levels. This case report summarizes the causes of acute pancreatitis and hypercalcemia and its management.

Unexplained fever in a young man with Crohn's disease: a case report and review of literature.

A 23-year-old man with a known history of Crohn's disease (CD), who underwent an ileocaecal resection for localized disease activity three months ago, suffered from persistent fever with chills since 10 days. Despite the empirical antibiotic therapy that was started, his fever remained. A computed tomography (CT) angiography of the thorax and abdomen revealed a thrombosis of the iliacal veins bilateral and a pulmonary embolism (PE) in the right lower lobe with adjacent infiltrate. Venous thromboembolism (VTE) can be a life-threatening extraintestinal manifestation of inflammatory bowel disease (IBD). The risk that IBD patients develop a VTE is three times higher in comparison with healthy controls. They have a higher risk of recurrence and a higher mortality ratio. The pathogenesis of VTE in IBD is complex and until now not fully understood. More awareness should be raised, given the fact that it can be prevented by appropriate thromboprophylaxis.

Boerhaave's syndrome: successful conservative treatment in two patients.

The Boerhaave syndrome is a spontaneous, post-emetic rupture of the esophagus and a rare but potentially fatal cause of upper gastrointestinal bleeding. There are currently no guidelines on the optimal treatment of these patients, although there is a strong tendency towards a surgical approach. We present 2 cases of male patients, 66- and 77-year old respectively, both admitted to the emergency department with hematemesis. Unexpectedly, these turned out to be caused by the Boerhaave syndrome. Based on the severity of presentation, either a conservative or endoscopic treatment was adopted, both with good outcome.

Effectiveness and persistence of Vedolizumab in patients with inflammatory bowel disease : results from the Belgian REal-LIfe study with VEdolizumab (Be-RELIVE).

BACKGROUND AND STUDY AIMS: Vedolizumab (VDZ) is a gutselective integrin inhibitor used to treat Crohn's disease (CD) and ulcerative colitis (UC). This retrospective study assessed effectiveness and treatment persistence of VDZ in a Belgian reallife cohort of CD and UC patients. PATIENTS AND METHODS: CD and UC patients from 15 Belgian centers, who started VDZ between 01/09/2015 and 31/06/2016 and attended ≥1 visit after the first VDZ infusion, were included. Data were collected before first infusion, at week (W)10, W14 (CD patients only), month (M)6 and last follow-up. Treatment response and remission rates (changes in disease activity scores) and treatment persistence (Kaplan-Meier analysis) were assessed. RESULTS: Of the 348 patients receiving at least one dose of VDZ, 325 (202 CD, 45 biologic-naïve; and 123 UC, 42 biologic-naïve) patients were included in data analyses. At M6, 87.6% (176/201) of CD and 86.1% (105/122) of UC patients were still on VDZ treatment, 75.6% (34/45) and 83.9% (26/31) achieved clinical response, and 66.7% (44/66) and 42.9% (15/35) were in remission. At M6 remission rates was significantly higher while response rates tended to be higher among biologic-naïve versus biologic-failure CD patients. CONCLUSIONS: VDZ offers an effective treatment option in real-life settings and treatment effectiveness appears higher in biologic-naïve versus biologic-failure CD patients. (Acta gastroenterol. belg., 2020, 83, 15-23).

Capsule endoscopy : diagnosis of intestinal localisation of systemic follicular B-cell non-Hodgkin lymphoma.

We report the case of a 58 year old man with occult obscure gastro-intestinal bleeding (OGIB) without other significant symptoms, in which systemic localisation of follicular B-cell non-Hodgkin lymphoma was discovered trough capsule endoscopy. This case reflects the clinical significance of performing capsule endoscopy in patients with OGIB.

How dyspepsia led to the diagnosis of Morbus Crohn.

BACKGROUND: It is well known that Crohn's disease can involve the stomach. However, most often this upper gastrointestinal tract involvement is asymptomatic. Typically, there is involvement of the small intestine with the typical associated symptoms of Crohn's disease: abdominal cramps, diarrhoea and weight loss. METHODS: We report a case of a young woman with complaints of dyspepsia since 2 months. RESULTS: Gastroscopy revealed severe aphthous pangastritis with biopsies showing a focal active and chronic gastritis with presence of granulomas. We therefore performed a coloscopy showing an aphthous terminal ileum. The pathologic report indicated granulomatous reaction concordant with a slightly active, mildly chronic terminal ileitis typical for Crohn's disease. CONCLUSION: The incidence of upper gastrointestinal tract involvement of Crohn's disease is still underestimated, partially due to the asymptomatic nature in two thirds of patients. IBD gastritis should always be included in the differential diagnosis of gastritis, considering the increased risk of a more severe disease course and complications.

Whipple's disease in a man of North African descent : case report and brief review of the literature.

A 62-year-old man of North African descent presented with weight loss in the past year and diarrhea for three weeks. His medical history included erosive rheumatoid arthritis, treated with methotrexate and adalimumab. Histological examination of a duodenal biopsy showed foamy macrophages in the lamina propria, with PAS-positive cytoplasmatic inclusions. These findings are compatible with Whipple's disease, a rare chronic infectious disease caused by Tropheryma whipplei, an opportunistic bacterium. It is typically seen in middle-aged Caucasian men and the immunocompromised host. The classical presentation of Whipple's disease consists of intermittent migratory arthralgia, followed by intestinal symptoms which typically occur six to seven years later. The clinical image can be very variable, and this complicates the diagnostic process. PAS-staining and PCR are the diagnostic cornerstones. In our case, treatment consisted of a prolonged cure of antibiotics: intravenous ceftriaxone for two weeks, followed by an oral maintenance therapy of doxycycline and hydroxychloroquine for at least one year. A therapeutic dilemma arose as continued anti-TNF blockade was necessary to maintain remission of the rheumatoid arthritis. Lifelong follow-up is necessary because relapse is possible.

A Toothpick a day, keeps the doctor away?

A Toothpick is a dreaded offender when ingested, as it is risky to cause impaction, obstruction or perforation of the gut. When ingestion of a toothpick leads to one of these complications, it clinically mimics an acute abdomen. Often the patient doesn't recall the ingestion, leading to misdiagnosis as inflammatory bowel disease, appendicitis/diverticulitis, etc. We describe the case of a 50-year old woman presenting to the emergency department with right lower abdominal pain. CT-scan showed an obstruction without clear underlying cause. The hypothesis of obstruction due to intestinal adhesions without strangulation was assumed and non-operative management lead to recovery and dismissal of the patient. However, she presented 3 weeks later with identical complaints, this time showing a terminal ileitis on CT-scan. Surprisingly, a toothpick perforating the terminal ileum was found during endoscopy and could by removed. A clinician should think of foreign body ingestion when patients present with an acute abdomen with no clear underlying pathology.

Primary syphilitic proctitis : case report and literature review.

Rectal ulcerations are an uncommon presentation of a primary syphilis infection. Anorectal syphilis is difficult to diagnose because of its often asymptomatic or atypical clinical presentation. It is important to consider sexually transmitted diseases (STD) in all patients presenting with rectal symptoms. A history of anal sexual intercourse should be made, especially in men having sex with men (MSM). Moreover, the possibility of a primary syphilis infection of the rectum should be considered. Endoscopic findings might be diverse, whereas a typical chancre can present as an anorectal ulcer associated with regional lymphadenopathy. It is important to consider other causes of anorectal ulcers, like other STD, inflammatory bowel disease (IBD) or even malignant causes. The diagnosis of anorectal syphilis is based on the combination of the clinical presentation, serology tests, endoscopic findings and biopsies. The cornerstone of the treatment is based on an intramuscularly administration of a long-acting preparation of penicillin (benzathine penicillin G).

An atypical presentation of an acute gastric Helicobacter felis infection.

Helicobacter pylori is a Gram negative bacterium that has been associated with a wide variety of gastric pathologies in humans. Besides this well studied gastric pathogen, other Helicobacter spp. have been detected in a minority of patients with gastric disease. These species, also referred to as "H. heilmanii sensu lato" or "non Helicobacter pylori Helicobacter spp. (NHPH)", have a very fastidious nature which makes their in vitro isolation difficult. This group compromises several different Helicobacter species which naturally colonize the stomach of animals. In this article we present a case of a patient with severe gastritis in which H. felis was identified. The necrotic lesions observed at gastroscopy differ from the less active and less severe lesions generally associated with NHPH infections in human patients. The patient was successfully treated with a combination of amoxicillin, clarithromycin and pantoprazole. Infections with NHPH should be included in the differential diagnosis of gastritis when anatomopathological findings show an atypically shaped helicobacter.

Acute non-cirrhotic portal vein thrombosis : review.

A 35-year-old man with a medical history of myocardial infarction, presenting with fever, general malaise and vague abdominal discomfort, was diagnosed with a portomesenteric venous thrombosis and acute cytomegalovirus (CMV) infection. Thrombophilia screening resulted in detection of heterozygosity for factor II G20210A gene mutation. Low molecular weight heparin in therapeutic dose was started, followed by disappearance of thrombus on imaging CT two months after diagnosis. The multifactorial origin of portal thrombosis and the importance of awareness of the link between CMV infection and an increased risk of thrombosis is emphasized with this case and review of the literature. Identifying CMV infection as a trigger for thrombosis can help to avoid extended anticoagulation. Acute non-cirrhotic PVT is a rare but probably underestimated condition as symptoms may be discrete or non-specific. The origin of portal thrombosis is frequently multifactorial. Recent literature has emphasized the increasing prevalence of CMV-induced PVT in immunocompetent patients. The multifactorial origin of portal thrombosis and the importance of awareness of the link between CMV infection and an increased risk of thrombosis is emphasized with this review of the literature and included case. Identifying CMV infection as a trigger for thrombosis can help to avoid extended anticoagulation.

A case of pseudorenal failure - spontaneous rupture of the urinary bladder.

A 64-year old woman was admitted to the hospital for severe abdominal pain and distension after gardening and chopping wood the day before. She had a medical history of superficial transitional cell carcinoma (TCC) of the urinary bladder and a laparoscopic nefro-ureterectomy for an invasive TCC of the upper urothelial tract in 2012. Clinical examination showed an acute abdomen. Laboratory analysis revealed a plasma creatinine level of 4,23 mg/dl. Computed tomography (CT) imaging of the abdomen showed hypodense free intraperitoneal fluid, suspicious for ascites. Serum creatinine level decreased to 1.8 mg/dl after placement of a urinary catheter. Laparoscopic exploration revealed a perforated ulcer in the urinary bladder dome, the intraperitoneal fluid showed abnormally high levels of urea and creatinine, confirming uroperitoneum. This case shows that uroperitoneum must be in-cluded in the differential diagnosis of patients with diffuse/acute abdominal pain, abdominal distension and elevated levels of serum creatinine, and that vigilance is indicated.

Henoch-Schönlein Purpura complicated with major gastro-intestinal hemorrhage.

We report a case of Henoch-Schönlein Purpura in a 83-year old patient. The patient presented with a purpuric rash and arthralgia. During admission, he developed hematochezia and acute kidney injury. Because of protracted gastro-intestinal bleeding after initiating therapy with methylprednisolone and ileocaecal resection, azathioprine was started. Gastro-intestinal bleeding resolved, and renal function normalized. We present the clinical and pathological findings of Henoch-Schönlein Purpura, focusing on gastro-intestinal manifestations.

Montelukast as a treatment modality for eosinophilic gastroenteritis.

Eosinophilic Gastroenteritis (EG) is a rare condition, caused by eosinophilic inflammatory infiltrates in the gastrointestinal tract. It is usually treated successfully with systemic glucocorticoids. Because of frequent relapses, however, there is need for alternatives. We describe a 38-year old man with steroid-dependent EG, who was successfully treated with montelukast, a leukotriene receptor antagonist. It inhibits leukotriene D4, an important cytokine in the inflammatory cascade. Although montelukast could not replace steroid therapy, it acted as a steroid sparing agent in our patient. Review of the literature shows that montelukast is efficient in the treatment of EG in a part of the patients. The low cost, the low number of side effects and its efficiency make it an interesting alternative in relapsing or steroid dependent EG. There is need for multicentric studies regarding the treatment of EG.

Autoimmune pancreatitis and extrapancreatic manifestations of IgG4-related sclerosing disease.

In a review of the literature concerning autoimmune pancreatitis we had special interest for the concept of IgG4-related pathology as a systemic disease with several clinical manifestations. In general, IgG4-positivity can not only be found in the pancreas, but also at the level of the kidneys, extrahepatic biliary ducts, gallbladder, lungs, salivary glands, lacrimal glands, retroperitoneal tissue, ureters, prostate, meninges and lymph nodes. IgG4 seems to be a central key player in the pathophysiology of this disease.