Gastroparesis in geriatrics population: A United States population study.

BACKGROUND: Older patients with upper gastrointestinal diseases may lack disease-specific symptoms that are required to make the correct diagnosis. This study aimed to compare the gastroparesis demographics, clinical presentation, and surgical management between the older adult and young populations. METHODS: The National Inpatient Sample database was used between the years 2012 and 2014 with the primary diagnosis of gastroparesis. Patients were further divided based on their age into two groups: 70 years or older and younger than 70 years. RESULTS: The older adults were more likely to have early satiety and bloating compared to younger population with an odds ratio (OR) = 3.79; 95% Confidence Interval (95%CI) 2.80- 5.11, p < 0.0001 and OR = 2.80, 95%CI 2.07-3.78, p<0.0001 respectively. Older adults had low odds of having nausea with vomiting (OR = 0.86, 95%CI 0.76-0.95, p = 0.003), or abdominal pain (OR = 0.56, 95%CI 0.50-0.63, p<0.0001). CONCLUSIONS: Older adults had more early satiety and bloating, whereas younger patients had more nausea with vomiting and abdominal pain.

Delayed Retroperitoneal Hemorrhage as a Complication of Large-volume Paracentesis.

Large-volume paracentesis (LVP) consists of the removal of more than four liters of ascitic fluid. This procedure can cause complications such as hemorrhage, infection, bowel perforation, circulatory failure, or ascitic fluid leakage. The main presentation of paracentesis-induced hemorrhage is abdominal wall hematoma. An 81-year-old male with a past medical history of obesity and diabetes mellitus presented to our hospital with confusion, new onset black tarry stools, and foul-smelling urine. He was found to be oriented only to person and had abdominal distention with positive fluid wave sign and melanotic stools on rectal exam. Laboratory results elucidated pancytopenia, hypoalbuminemia, elevated aspartate aminotransferase (AST) of 43 U/L, and elevated D-dimer levels. Urinalysis was abnormal, showing >180 white blood cells (WBC) with positive leukocyte esterase and nitrites. Liver ultrasound evidenced cirrhosis. Octreotide drip, ceftriaxone, lactulose, and pantoprazole were initiated for upper gastrointestinal (GI) hemorrhage and cirrhosis. A computed tomography angiogram (CTA) of the chest was positive for bilateral segmental pulmonary embolism, therefore, he also started receiving heparin drip. On the fifth day of admission, an ultrasound-guided paracentesis was done, with six liters of ascitic fluid removed. On the seventh day of admission, the patient presented acute left flank pain with an associated episode of hypotension and drop in hemoglobin. A CTA of the abdomen showed left retroperitoneal hemorrhage but no signs of active bleeding. Heparin drip was discontinued, and the patient was transferred to the intensive care unit (ICU). The patient's hemoglobin was stable throughout the days after ICU admission, and he did not require any more transfusions of packed red blood cells. His respiratory status was steady although heparin was discontinued due to a bleeding episode. He was discharged without anticoagulation therapy due to his high risk for rebleeding. One of the proposed mechanisms leading to variceal bleeding is the rapid decompression of splanchnic circulation due to decreased abdominal pressure. Since the source of bleeding is venous, initially, the patients can be asymptomatic. Treatment can be conservative, surgical or by means of transcatheter interventions. We would like to emphasize the need for the close monitoring of patients undergoing large-volume paracentesis, especially in the setting of anticoagulation therapy, as survival depends upon early diagnosis and treatment. It is important to mention that international normalized ratio (INR) is neither a reliable anticoagulation test nor a predictive factor of bleeding in cirrhotic patients.

Benign Granular Cell Tumor of the Cecum.

Granular cell tumors (GCT) are usually benign, soft tissue tumors that are mostly found in the oral cavity, skin, and subcutaneous tissue. GCTs in the gastrointestinal (GI) tract are mainly located in the esophagus. A 63-year-old male was referred to the gastroenterology clinic for a major complaint of six months of painless rectal bleeding. Laboratory results showed mild macrocytic anemia. He denied any prior colonoscopies and hence, a lower endoscopic procedure was done. The colonoscopy showed multiple polyps, one of them located at the cecum. The cecal polyp showed polygonal cells with abundant eosinophilic infiltration and S100 stain positive. This confirmed a diagnosis of GCT. GCTs are thought to be derived from the neural tissue (Schwann cells). This entity is usually asymptomatic; however, tumors located at the lower GI tract can present with hematochezia. Only 2% of GCTs follow a malignant course, with associated poor prognosis.  This case is being presented because of its asymptomatic nature. It is important to monitor these lesions in order to recognize early signs/symptoms concerning for malignancy.

Malignant Peritoneal Mesothelioma Mimicking Recurrent Diverticulitis.

Mesothelioma is an uncommon type of cancer arising from the mesothelial cells that form the lining of several cavities in the body. Exposure to asbestos is the leading known cause of mesothelioma. We present a 73-year-old male with a significant asbestos exposure and a recent history of recurrent diverticulitis who reported persistent left lower quadrant (LLQ) pain despite several courses of empiric antibiotic therapy. A recent computed tomography (CT) performed due to nonresolving symptoms showed possible nodularity of the mesentery and subsequent positron emission tomography (PET) scan demonstrated multiple hypermetabolic mesenteric lesions, notably in the left paracolic gutter. A colonoscopy was subsequently performed which demonstrated severe diverticulosis, but no obvious luminal lesions. The patient underwent an exploratory laparoscopy showing extensive peritoneal carcinomatosis involving all mesenteric surfaces and partial involvement of the right diaphragm. Final pathology revealed malignant epithelial mesothelioma with peritoneal seeding. The patient was referred to oncology and was started on hyperthermic intraperitoneal chemotherapy (HIPEC) and cytoreductive surgery (CRS). Our case highlights a challenging presentation of malignant peritoneal mesothelioma (MPM), which is often initially misdiagnosed due to vague symptoms. Physicians should consider further diagnostic workup for unrelenting LLQ abdominal pain after diverticulitis has been treated.

Where is My Spleen? - A Case of Splenosis Diagnosed Years Later after Splenectomy.

Hepatic splenosis was first described in 1939 and is a rare condition that results from splenic trauma or splenectomy. A 43-year-old man with a past medical history significant for a prior splenectomy was admitted to the hospital due to right upper quadrant pain for two days. Magnetic resonance imaging (MRI) of the abdomen suggested features of hepatic adenoma, however, a percutaneous biopsy showed the mass within the liver to be a discrete collection of splenic tissue, apparently the result of a traumatic splenic rupture years ago. Hepatic splenosis is a rare entity, and due to the asymptomatic nature of this condition, most cases are found incidentally after different imaging modalities are done. The management of this entity is based on conservative measures. We report this case to emphasize that in the appropriate clinical setting, hepatic splenosis should be considered in the differential diagnosis of a patient with a homogenous well-circumscribed liver mass.

Spontaneous Pneumomediastinum as a Consequence of Severe Vomiting in Diabetic Ketoacidosis.

Spontaneous pneumomediastinum (SPM) is a rare entity with a reported incidence of approximately 1:7,000 to 1:100,000 of hospital admissions. It has been described as a complication of various conditions related to increased intrathoracic pressure, like recurrent vomiting, post-partum state, vigorous coughing or sneezing, and others. We present a 25-year-old man who came in with intractable vomiting, secondary to diabetic ketoacidosis (DKA), and was found to have pneumomediastinum on chest imaging. The patient was treated conservatively, eventually recovering and being discharged after several days. SPM is rarely seen as a complication of DKA. Diagnosis and management may present a challenge. Usually, the condition is benign and treated conservatively. We report this case to increase awareness among physicians of possible pneumomediastinum in a young male presenting with DKA and dyspnea and to emphasize the benign course of this condition.

Primary Gastric Squamous Cell Carcinoma.

Primary gastric squamous cell carcinoma (PGSCC) is an extremely rare cause of gastric malignancy. We present a 66-year-old man with a past medical history of stage I left palpebral marginal zone lymphoma status post radiation. The patient was complaining of a two-year history of bloating and early satiety. An upper endoscopy was performed, showing a 2.5 cm polypoid lesion at proximal corpus; however, the cardia and esophagus were normal. Biopsies were positive for gastric squamous cell carcinoma. He underwent partial gastrectomy and was referred to oncology for treatment. In 2011, the Japanese Gastric Cancer Association proposed diagnostic criteria for the diagnosis of PGSCC. The clinical presentation of this malignancy does not differentiate from that of other types of gastric tumors. We report this case to highlight squamous cell carcinoma as a cause of primary gastric cancer. Gastroenterologists should be aware of this entity to facilitate prompt referral to specialized centers, where surgical resection can be done.

Intestinal Spirochetosis in an Immunocompetent Patient.

Intestinal spirochetosis (IS) is an infestation defined by the presence of spirochetes on the surface of the colonic mucosa. The implicated organisms can be Brachyspiraaalborgior Brachyspirapilosicoli. We present the case of a 66-year-old man with a past medical history of diabetes mellitus, hypertension, morbid obesity, and gastroesophageal reflux. The patient was sent to the gastroenterology clinic for a screening colonoscopy due to a prior history of colonic polyps. The patient was completely asymptomatic as he denies any abdominal pain, diarrhea, melena, or hematochezia. A colonoscopy was done showing colitis in the cecum and at the ileocecal valve, for which random biopsies were taken in the terminal ileum, cecum, and ascending colon. The histopathology result was positive for spirochetosis. Due to this finding, the patient was referred to the infectious diseases clinic, where a rapid plasma reagin (RPR) and human immunodeficiency virus (HIV) tests were found to be negative. Since the patient was immunocompetent and asymptomatic, it was decided to monitor and not initiate antibiotic treatment. Human IS are not related to non-intestinal spirochetes like Treponema pallidum. An infection of T. pallidum leads to a malignant picture called syphilitic proctitis and appears in the setting of an immunocompromised patient. The treatment of IS is based on the clinical presentation, severity of symptoms, and immune status. The purpose of this case is to emphasize the correct antibiotic indication in patients with IS.

[Acute liver failure as presentation of adult T-cell leukemia in an HTLV-1 patient]. / Falla hepática aguda fulminante como manifestación de leucemia de células T del adulto en paciente con infección por HTLV-1.

Acute liver failure is the development of severe hepatic injury with deterioration of liver synthesis function and encephalopathy. Among all the variety of causes, neoplastic infiltration represents less than 0.5%. We present the case of a male patient with a past medical history of HTLV-1 infection, who reports symptoms of acute hepatitis, being diagnosed with Adult T-cell leukemia/lymphoma. Unfortunately, the patient had a rapid deterioration and passed away a few days after admission.

[Familiar adenomatous polyposis: report of 2 cases]. / Poliposis adenomatosa familiar: a propósito de 2 casos.

Familial Adenomatous polyposis (FAP) it is based on an autosomal dominant mutation which results in loss of function of theAPC tumor suppressor gene. On the other hand, Gardner syndrome is a type of FAP and is characterized for multiple colonic adenomatous polyps and extracolonic abnormalities as desmoid tumors, osteomas, lipomas, dental abnormalities, dermoid cysts and duodenal adenomas. This report aims to present two patients with FAP: The first one is a patient who presented with osteomas and hematochezia, being diagnosed with Gardner Syndrome after the colonoscopy. The second patient has a family history of colon cancer, who is diagnosed with FAP with tubular adenocarcinoma. We decide to report both cases due to the absence of previous reports in Peru.

Adenoid Cystic Carcinoma Metastasized to Colon.

Adenoid cystic carcinoma (ACC) is an infrequent cause of malignancy that accounts for 1% of all tumors of the oral and maxillofacial region. We present a 59-year-old woman with a past medical history of adenoid cystic carcinoma of the left salivary gland treated with radiation and thoracotomy due to lung metastasis. Years after the onset of diagnosis, she presented with nonspecific gastrointestinal symptoms. For this reason, an abdominal computed tomography (CT) scan was done, revealing a liver mass in the right lobe, involving segments eight and five, concerning for malignancy. A colonoscopy was indicated for screening purposes, showing a large polyp that was biopsied. A histopathologic examination of the colon polyp and a liver biopsy was compatible with ACC metastatic carcinoma. We report this case to highlight an unusual location of metastatic ACC. Furthermore, there is no case report in the literature where colon metastasis has been described.

Poliposis adenomatosa familiar: a propósito de 2 casos / Familiar Adenomatous Polyposis: Report of 2 Cases

La poliposis adenomatosa familiar (PAF) se basa en una mutación autosómica dominante de pérdida de la función en el gen supresor tumoral APC. El síndrome de Gardner es un tipo de PAF y está caracterizado por múltiples pólipos adenomatosos colónicos además de anormalidades extracolónicas como tumores desmoides, osteomas, lipomas, anormalidades dentales, quistes dermoides y adenomas duodenales. Este reporte tiene como propósito presentar dos casos referentes a PAF. El primer caso, trata de un paciente con osteomas e historia de hematoquezia, con diagnóstico de sindrome de Gardner posterior a la colonoscopia. El segundo caso es un paciente con historia familiar de cáncer de colon, que al examen colonoscópico se le diagnostica PAF con adenocarcinoma tubular bien diferenciado. Se decide reportar los casos debido a que son los primeros reportes en el Perú sobre esta entidad

Familial Adenomatous polyposis (FAP) it is based on an autosomal dominant mutation which results in loss of function of the APC tumor suppressor gene. On the other hand, Gardner syndrome is a type of FAP and is characterized for multiple colonic adenomatous polyps and extracolonic abnormalities as desmoid tumors, osteomas, lipomas, dental abnormalities, dermoid cysts and duodenal adenomas. This report aims to present two patients with FAP: The first one is a patient who presented with osteomas and hematochezia, being diagnosed with Gardner Syndrome after the colonoscopy. The second patient has a family history of colon cancer, who is diagnosed with FAP with tubular adenocarcinoma. We decide to report both cases due to the absence of previous reports in Peru

Falla hepática aguda fulminante como manifestación de leucemia de células T del adulto en paciente con infección por HTLV-1 / Acute Liver Failure as Presentation of Adult T-cell Leukemia in an HTLV-1 Patient

La falla hepática aguda es el desarrollo de injuria hepática severa con deterioro de la función de síntesis y encefalopatía. Dentro de la variedad de causas, las infiltraciones neoplásicas representan menos del 0,5%. Presentamos el caso de un paciente varón HTLV1 positivo que debuta con una clínica de hepatitis aguda, siendo posteriormente diagnosticado con diseminación de linfoma/leucemia de células T del adulto. Desafortunadamente el paciente presentó deterioro rápido y progresivo de la función hepática, falleciendo a los pocos días de la hospitalización

Acute liver failure is the development of severe hepatic injury with deterioration of liver synthesis function and encephalopathy. Among all the variety of causes, neoplastic infiltration represents less than 0.5%. We present the case of a male patient with a past medical history of HTLV-1 infection, who reports symptoms of acute hepatitis, being diagnosed with Adult T-cell leukemia/ lymphoma. Unfortunately, the patient had a rapid deterioration and passed away a few days after admission

[Duodenal Linphoma asociated to Strongyloides stercoralis infection. Two types of HTLV-1 infection]. / Linfoma duodenal asociado a infección por Strongyloides stercoralis. Dos manifestaciones de la infección por HTLV-1.

Infection by the Human T- Lymphotropic virus I (HTLV-1) causes Adult T cell Leukemia-lymphoma (ATLL), being the duodenal involvement rare. Commonly, patients co-infected with HTLV-1 and Strongyloides stercoralis are seen due to the lack of TH2 response found on these patients. We describe a 48-year- old woman, from the jungle of Peru, with a family history of HTLV-1 infection, who presented with a History of chronic diarrhea and weight loss. HTLV-1 infection with ATLL and strongyloidiasis were diagnosed. Ivermectin treatment and chemotherapy were initiated, being stabilized, and discharged. We report this case because of the unusual coexistence in the duodenum of ATLL and strongyloidiasis.

Linfoma duodenal asociado a infección por Strongyloides stercoralis. Dos manifestaciones de la infección por HTLV-1 / Duodenal Lynphoma associated to Strongyloides stercoralis infection. Two types of HTLV-1 infection

La infección por el virus linfotrópico de células T humanas tipo 1 (HTLV-1), es causante de la leucemia/linfoma de células T del Adulto (ATLL), siendo la afectación duodenal poco usual. La coinfección de HTLV-1 con Strongyloides stercolaris es común en los pacientes con HTLV- 1 debido a la inadecuada respuesta TH2 que presentan estos sujetos. Describimos a una paciente mujer de 48 años de edad, natural y procedente de la selva del Perú con historia familiar de infección por HTLV- 1 quien acude con diarrea crónica y baja de peso. Se le diagnosticó infección por HTLV-1 así como ATLL duodenal y estrongiloidiasis. Se inició tratamiento con ivermectina y quimioterapia, siendo estabilizada y dada de alta. Reportamos el presente caso debido a la poca frecuencia de coexistencia en duodeno de ATLL y estrongiloidiasis.

Infection by the Human T- Lymphotropic virus I (HTLV-1) causes Adult T cell Leukemia-lymphoma (ATLL), being the duodenal involvement rare. Commonly, patients co-infected with HTLV-1 and Strongyloides stercoralis are seen due to the lack of TH2 response found on these patients. We describe a 48-year-old woman, from the jungle of Peru, with a family history of HTLV-1 infection, who presented with a History of chronic diarrhea and weight loss. HTLV-1 infection with ATLL and strongyloidiasis were diagnosed. Ivermectin treatment and chemotherapy were initiated, being stabilized, and discharged. We report this case because of the unusual coexistence in the duodenum of ATLL and strongyloidiasis.

A Barium Swallow Study Leading to an Incidental Finding on a Screening Colonoscopy.

Barolith is a mixture of firm feces with barium sulfate, and a frequent cause of obstruction of the appendiceal lumen that can result in appendicitis. Nonetheless, some other complications like aspiration, allergic reaction, and bowel obstruction have also been reported.  We present the case of a 71-year-old man with a history of amyotrophic lateral sclerosis (ALS), who came to the gastroenterology clinic complaining of intermittent loose stools and dysphagia to solids for the past months. The patient underwent a barium swallow study six days prior and was completely normal. A colonoscopy was done showing normal appearing mucosa, with a whitish foreign object found on the appendiceal orifice. Removal of the barolith was done by means of a biopsy forceps. Our patient did not have any signs or symptoms of appendicitis prior to the procedure, and the successful removal of the barolith was achieved. Elderly patients, and patients with decreased gastrointestinal (GI) transit, could be a population at risk for barium retention/appendicitis; for this reason, more research studies should be done to assess possible preventive treatments.

[Venous tromboembolism in a patient with Crohn disease with ileal stenosis]. / Trombosis venosa profunda en un paciente con enfermedad de Crohnilealestenosante.

Inflammatory bowel disease is associated with extraintestinal manifestations. Among these manifestations is the venous tromboembolism which presents a risk three times more than that presented in general population. We report the case of a 61-year-old male with a history of abdominal pain, chronic diarrhea and fever, with leukocytosis, and fecal samples containing leukocytes, partial ileal stenosis with multiple ulcers in the enteroscopy, with histologic findings compatible with Crohn's disease. The patient has a good outcome with prednisone and maintenence azathioprine, presenting at the fifth month deep venous thrombosis of both lower extremities that resolvewith anticoagulation treatment.

[Actinic enteritis as a cause of digestive bleeding of obscure origin]. / Enteritis actínica como causa de hemorragia digestiva de origen oscuro.

Chronic actinic enteritis is a malfunction of the small bowel, occurring in the 6 months post-radiotherapy, and it can be manifestated as malabsortion, stenosis, fistula formation, local abscesses, perforation and bleeding, We report a case of an elderly patient who presents an episode of obscure gastrointestinal bleeding (OGIB) secondary to actinic enteritis. She is a 64-year- old female patient with the past medical history of cervical cancer who received radiotherapy and brachytherapy. One year after the treatment, the patient presents a chronic episode of melena and symptomatic anemia and 1 week before the admission she had hematochezia. At admission she has hemodynamic instability with a hemoglobin value of 2.7 gr/dl. We did an upper endoscopy, a colonoscopy and abdomino-pelvic tomography without any findings of the bleeding’s source. Reason why an endoscopic capsule was done, showing bleeding areas in the medial and distal small bowel. The patient had another gastrointestinal bleeding requiring a surgery where they decide to do a resection of the small bowel and a right hemicholectomy. The pathology was compatible with actinic enteritis. The patient after the surgery had a torpid evolution, and finally dies. We describe this case and do a review of all the existent data around the world, because is the first case reported in Peru of an actinic enteritis as a cause of OGIB.

[Association between ulcerative colitis and primary esclerosing cholangitis]. / Asociación entre colitis ulcerativa y colangitis esclerosante primaria.

Ulcerative Colitis (UC) is associated to Primary Sclerosing Cholangitis (PSC) in 80% of cases, and this association is more common than the one with Crohn’s disease. Nevertheless, the prevalence of PSC in patients with UC is only 2.9% in Latin America. We present the case of a female patient who presents a clinical history characterized for chronic diarrhea of one year of evolution, associated to fever, oral ulcers and loss of weight. In the laboratory results there is an elevation in the following: alkaline phosphatase, GGT, ALT and AST, for that reason we decide to do an abdominal ultrasound finding a hepatomegaly. In the colonoscopy we found an ulcerative colitis. Later, we do a magnetic resonance cholangiopancreatography, because of the diagnosis of UC and the abnormalities at the liver function tests, diagnosing PSC associated to UC. At that moment, the patient starts treatment with sulfasalazine that is stopped because of an adverse effect, starting prednisone and azathioprine. The patient then is discharged with the medication already mentioned and has a favorable clinical outcome. We decide to report the case because is the second reported case in Peru, being this association not commonly found in the South hemispheric.

Enteritis actínica como causa de hemorragia digestiva de origen oscuro / Actinic enteritis as a cause of digestive bleeding of obscure origin

La enteritis actínica crónica es un trastorno del intestino delgado que ocurre a partir de los 6 meses post radioterapia y se puede manifestar como malabsorción, estenosis, formación de fístulas, abscesos locales, perforación y sangrado. Se reporta el caso de una paciente adulta mayor la cual presentó un cuadro de hemorragia digestiva de origen oscuro (HDO) secundario a enteritis actínica. Es una paciente mujer de 64 años con antecedente de neoplasia maligna de cérvix quien recibió sesiones de radioterapia y braquiterapia, La paciente un año después de dicho tratamiento presenta un cuadro crónico de melena y anemia, presentando hematoquezia en la última semana previa a la hospitalización. Al ingreso presenta inestabilidad hemodinámica con valores de hemoglobina en 2,7gr/dL. Se realiza una endoscopia, colonoscopia y tomografía abdomino pélvica, las cuales no mostraron la causa del sangrado, motivo por el cual se realiza una cápsula endoscópica evidenciando áreas de sangrado en intestino delgado medio y distal. La paciente vuelve a presentar un episodio de sangrado agudo siendo sometida a una cirugía de emergencia en donde se decide realizar resección de intestino más hemicolectomia derecha. En la biopsia de la pieza quirúrgica se encuentran hallazgos compatibles con enteropatía actínica. La paciente posterior a la cirugía evoluciona tórpidamente, llegando a fallecer. Describimos el presente caso y hacemos una recolección de la data existente debido a que es el primer caso en el Perú en el que se reporta a una enteritis actínica como causante de HDO...

Chronic actinic enteritis is a malfunction of the small bowel, occurring in the 6 months post-radiotherapy, and it can be manifestated as malabsortion, stenosis, fistula formation, local abscesses, perforation and bleeding, We report a case of an elderly patient who presents an episode of obscure gastrointestinal bleeding (OGIB) secondary to actinic enteritis. She is a 64-year-old female patient with the past medical history of cervical cancer who received radiotherapy and brachytherapy. One year after the treatment, the patient presents a chronic episode of melena and symptomatic anemia and 1 week before the admission she had hematochezia. At admission she has hemodynamic instability with a hemoglobin value of 2.7 gr/dl. We did an upper endoscopy, a colonoscopy and abdomino-pelvic tomography without any findings of the bleedingÆs source. Reason why an endoscopic capsule was done, showing bleeding areas in the medial and distal small bowel. The patient had another gastrointestinal bleeding requiring a surgery where they decide to do a resection of the small bowel and a right hemicholectomy. The pathology was compatible with actinic enteritis. The patient after the surgery had a torpid evolution, and finally dies. We describe this case and do a review of all the existent data around the world, because is the first case reported in Peru of an actinic enteritis as a cause of OGIB...