Hepatic arterioportal fistula presenting as gastric variceal hemorrhage.

Hepatic arterioportal fistulae (APF) are abnormal communications between the hepatic artery and the portal vein. In this report, we present the second case in the literature of a symptomatic APF presenting as a gastric variceal bleeding. A 55-year-old female presented to our facility with hematemesis. Upper endoscopy revealed a bleeding gastric varix. A computed tomography scan identified a large left hepatic lobe APF between the left hepatic artery and the left portal vein. Through angiography coil embolization was performed and with resultant loss of arterial flow, the APF was decompressed. On hospital day 3, the patient developed new melena. Portovenogram was performed and a TIPS stent was deployed. The patient subsequently did well. Hepatic arterioportal fistulae can result in portal hypertension secondary to arterial blood flowing directly into the portal vein bypassing the hepatic sinusoids. Iatrogenic causes (e.g. percutaneous liver biopsy) represent more than 50% of published cases of APFs. Most APFs resolve spontaneously as they are small and peripherally located. In rare instances, when APFs are centrally located, clinical symptoms develop. There have been 30 reported cases of symptomatic intrahepatic APFs following percutaneous liver biopsy. Of those, only one case presented as a gastric variceal bleed. Digital subtraction angiography is the gold standard in the diagnosis and treatment of APFs. In addition to initial embolization, we elected to treat the patient with TIPS due to the magnitude of her bleed. Although rare, intrahepatic APF should be kept on the differential of a patient presenting with isolated gastric varices.

Colonic perforation following polypectomy of a gastrointestinal follicular lymphoma masquerading as a colon polyp.

INTRODUCTION: The gastrointestinal (GI) tract is the predominant site for primary extranodal non-Hodgkin lymphomas (NHL), accounting for 5-10% of all extranodal disease. CASE: A 74-year-old man underwent colonoscopy for a positive fecal occult blood test. Colonoscopy revealed a 3.5-cm polyp in the descending colon and was removed by snare cautery polypectomy. Post-polypectomy site showed a 0.3-0.5-cm mucosal defect. Five endoclips were applied to close the mucosal defect. The patient remained stable during subsequent intensive monitoring and never required surgical intervention. Pathology of the polyp revealed follicular lymphoma (FL) involving the lamina propria of the mucosa with extension into the submucosa. The patient had no systemic symptoms, and staging for NHL with contrast computerized tomography of the chest, abdomen, and pelvis revealed no evidence suggestive of lymphoma. DISCUSSION: Approximately 6-20% of all primary GI-NHL are in the colon. The frequency of GI-FL accounts for 1-3.6% of all GI-NHL. After a search of the current literature, there have been no cases of a follicular lymphoma presenting solely as an isolated colon polyp. Likewise, bowel perforation due to polypectomy of such polyps has never been cited. Retrospectively, the diagnosis and extent of the polyp could have been established using endoscopic end-to-end forceps biopsy and/or endoscopic ultrasound with a radial scanning catheter probe and fine-needle aspiration of the lesion. Such a diagnosis could have changed the strategy for endoscopic removal of the polyp. Our case is interesting because it is the first report of a follicular lymphoma presenting as a single isolated colon polyp involving all layers of the colonic mucosa.

Extensive extramedullary disease involving the colon in multiple myeloma: a case report and review of literature.

INTRODUCTION: Organ involvement in multiple myeloma (MM) is characterized by infiltrative disease or by a myelomatous mass known as a plasmacytoma. We present a patient with MM who had extensive extramedullary involvement of the colon and a review of the literature on colon plasmacytomas. CASE REPORT: A 57-year-old male with MM presented with disease relapse in 2007, workup showing biopsy confirmed left perinephric extra-medullary disease involving the adjacent colon. Positron emission-tomography (PET) exhibited intense pan-colonic fluoro-deoxyglucose (FDG) uptake and computed-tomography confirmed extensive infiltrating soft tissue thickening in the ascending, transverse, and descending colon representing plasmacytomas. The patient underwent an autologous hematopoietic stem cell transplantation after conditioning with high-dose melphalan. Restaging PET-scan showed complete resolution of colonic extra-medullary plasmacytomas. Extramedullary plasmacytomas (EMP) are rare and constitute 4% of all plasma cell tumors. DISCUSSION AND CONCLUSION: Colonic plasmacytoma is an extremely rare site, with fewer than 25 cases reported in the literature. Colonic plasmacytomas have different presentations depending on the size and location. Treatment options for primary EMPs include surgical resection, radiotherapy, and chemotherapy. The primary treatment option for secondary EMP is systemic chemotherapy. This rare pan-colonic plasmacytoma, as a part of extramedullary myeloma, showed an impressive response to chemotherapy.

Rare case of dysphagia.

Wound botulism is exceedingly rare and occurs almost exclusively among injection drug users. In 2008 there was a case of wound botulism in a noninjecting drug user reported to the Centers for Disease Control and Prevention (CDC). We report a case of a Caucasian male developing dysphagia due to wound botulism after having a motorcycle accident that left him with open fractures. The CDC was contacted and the patient was transferred to medical intensive care unit to be emergently started on hepatavalent Clostridium botulinum antitoxin. Early suspicion of wound botulism is essential for effective therapy with antitoxin in this life-threatening disease. If not suspected, this patient would likely have died. Nevertheless, the delay in diagnosis and treatment resulted in the patient's suffering dysphagia and neurological deficits. The patient required a percutaneous endoscopic gastrostomy tube and months of dysphagia therapy, supportive care, and rehabilitation. Our aim is to increase the awareness for wound botulism when a patient presents with dysphagia and diplopia after suffering open wounds. If suspected early, the morbidity and mortality from this disease can be prevented.