Proctitis in men having sex with men: anything else you can think of?

We report two cases of proctitis in men having sex with men.

Disconnected pancreatic duct syndrome. Endoscopic approach.

Disconnected pancreatic duct syndrome (DPCS) is due to disruption of the main pancreatic duct (PC) or its secondary branches, a complication present in 30-80% of acute necrotizing pancreatitis. The secretion of pancreatic enzymes by isolated functioning pancreatic tissue can facilitate the recurrence of encapsulated necrotic collections, so its endoscopic management remains a controversial issue in daily practice. We present a case of disconnected pancreatic duct syndrome resolved after placement of a pancreatic stent.

Lemmel syndrome: an uncommon complication of periampular duodenal diverticulum.

Lemmel's syndrome consists of obstructive jaundice due to compression of a periampular duodenal diverticulum (DDP), in the absence of choledocholithiasis or tumor. DDP are pseudodiverticula without a muscle layer within a radius of 2-3 centimeters from the ampulla of Vater. They rarely cause obstructive jaundice, although the prevalence is estimated at up to 22 % according to the sensitivity of the diagnostic test. They are usually incidental findings, but up to 1-5 % can be complicated with diverticulitis, bleeding, perforation, obstructive jaundice (Lemmel syndrome), choledocholithiasis, pancreatitis or cholangitis.

Splenic rupture as an endoscopic complication: as rare as it appears?

The case was an 86-year-old male with multiple cardiovascular comorbidites, including anticoagulated atrial fibrillation, who underwent a colonoscopy due to acute lower gastrointestinal bleeding and anemia. Colonoscopy only showed some small angiodysplasias in the cecum. A few hours later, the patient presented with abdominal pain and hemodynamic instability. An abdominal computed tomography was performed, which showed a splenic laceration and hemoperitoneum. An expectant attitude was decided, with a good evolution from the abdominal point of view. There was no sign of active splenic bleeding in a control computed tomography. However, he developed decompensated heart failure and finally died.

Subcapsular hepatic hematoma as a complication of ERCP: what do we know about its etiology?

We present the case of a 79-year-old male who underwent endoscopic retrograde cholangiopancreatography (ERCP) after cholangitis. The papilla was rigid and the biliary tract was dilated with sharpening of the distal bile duct, with no obvious cause. There was no bile flow after sphincterotomy, no stone after sweeping the duct with a balloon and the brush did not expand properly when trying to obtain cytologic material. Finally, a plastic stent was placed and purulent bile flowed. Biopsies of the papilla were taken due to the suspicion of tumor infiltration. The next day, the patient had pain in the right upper quadrant and blood tests highlighted mild anemization.

Intestinal spirochetosis: normal intestinal flora or etiology of diarrhea?

A 22-year-old male began with up to 12 loose stools per day, with mucus and no blood. They were present for two months, even during the night. Moreover, he complained of abdominal pain and weight loss. There were no findings on the blood tests. Fecal calprotectin was 225 µg/g. Stool microbiology tests were negative. Ileocolonoscopy displayed normal mucosa but the histological study of the biopsies showed Treponemas genus Brachispira. The patient had a sexual risk behavior. Treatment with metronidazole was initiated with clinical improvement.

Aortomesenteric clamp: association with Wilkie syndrome and nutcracker syndrome.

A 67-year-old female was referred due to epigastric pain, vomiting and weight loss of 6 kg in the past months. Blood tests were performed showing hematuria. An abdominal Doppler ultrasound did not show anything abnormal. Thus, an abdominal computed tomography (CT) angiography and a magnetic resonance imaging (MRI) enterography were performed, objectifying an aortomesenteric angle of 10.8° (reference range 38-56°), which caused a complete collapse of the left renal vein ("nutcracker phenomenon") and duodenal compression with retrograde dilatation ("Wilkie syndrome"). Conservative measures and nutritional support were adopted during hospitalization. She was discharged due to a good tolerance to an oral diet, the absence of symptoms and a good contrast pass in the esophagogastroduodenal transit.

Familial dysphagia: eosinophilic esophagitis.

We present a family with several cases of eosinophilic esophagitis. Some cases of eosinophilic esophagitis in the same family have been previously described. Patients with eosinophilic esophagitis present frequently atopy, and atopy has a strong family association due to complex interactions between genetic and environment. However, eosinophilic esophagitis has a stronger genetic component than other atopic diseases. Eosinophilic esophagitis has been linked to variations in genes like eotaxin-3, TSLP and its receptor and CAPN14, although the inheritance pattern has not yet well defined.

Gastrointestinal tuberculosis, the great simulator. From inflammatory disease to a tumor.

A 52-year-old Senegalese male presented due to abdominal pain and fever, with findings suggestive of a stenosing tumor of the right colon. Biopsies during colonoscopy were compatible with adenocarcinoma and infiltration into neighboring organs was observed during the surgery. New biopsies were taken that did not show dysplasia but granulomatous foci that were suggestive of a non-filiated infection. Thus, tuberculosis was ruled out.

Megacolon with infectious etiology that is infrequent in our country: Chagas disease.

We present the case of a 37-year-old male with constipation refractory to medical treatment, in the context of megacolon due to Chagas disease. The entire gastrointestinal tract may be affected but the digestive form is characterized by megaesophagus and megacolon. There is altered peristalsis due to the destruction of the neurons of the enteric nervous system caused by the parasite. Although the mortality rate is low, the disease can have a considerable impact upon quality of life. Chagas disease is poorly recognized and undertreated by healthcare providers in non-endemic regions.

Enteroscopic diagnosis of intestinal malabsorption of a rare etiology: diaphragm disease.

We present the case of a 59-year-old patient with malabsorption syndrome which started with polyneuropathy. Capsule endoscopy and enteroscopy show villous denudation. Histological study confirms diaphragm disease of the small bowel. Diaphragm disease is a rare disease characterized by the presence of multiple thin diaphragms, such as septa, that narrow the intestinal lumen. The clinical features can be iron deficiency anemia, intestinal obstruction, change in bowel habits or acute abdomen secondary to perforation. It is usually generally with sustained use of high doses of non-steroidal anti-inflammatory drugs. The diagnosis usually requires the use of a capsule endoscopy or enteroscopy with biopsies.

Digestive involvement in a patient with Lambert-Eaton syndrome.

We present the case of a 50-year-old male diagnosed with myasthenia gravis, secondary to thymoma or Lambert-Eaton syndrome during the study of repeated vomiting. Gastrointestinal symptoms persisted despite the treatment of the thymoma. He suffered from sigma volvulus that required sigmoidectomy 9 years after diagnosis. Neuromuscular junction disorders are not characterized by gastrointestinal involvement, as in our case. They have previously sporadically been related to intestinal motility dysfunction.

Rhabdomyolysis in a patient under treatment with sorafenib.

We present a case of rhabdomyolysis related to treatment with sorafenib in a patient with multifocal hepatocellular carcinoma. Rhabdomyolysis is a severe situation and potentially fatal. There are no laboratory data that can predict this condition. Early diagnosis is essential for prognosis. Rhabdomyolysis has been described as an adverse reaction of several drugs but it is not frequently related to sorafenib.

Vitamin D and inflammatory bowel disease: what do we know so far?

In the last years,several studies have focused on the involement of vitamin D in different physiological and pathological processes. One of the most interesting actions occurs in the Inflammatory bowel disease, where a higher prevalence of vitamin D deficiency has been observed. This study aimed to review the literature in order to explain its relationship with the disease, the risk factors, measuring the importance of sun exposure, describing how treatments are affected or observing the effect of vitamin supplementation in this type of patients.

Invasive aspergillosis of gastrointestinal debut without apparent respiratory involvement in an immunocompetent host.

A 72-year-old female presented with abdominal pain and constipation and intestinal dilation was found. Abdominal computed tomography showed two areas of thickening and stenosis in the proximal jejunum and preterminal ileum, with an unknown etiology. Exploratory laparotomy was proposed but the patient suffered a sudden and progressive decrease in consciousness. Cranial computed tomography showed an ischemic area and a midline shift. Brain biopsies suggested infection by Aspergillus Fumigatus. Despite antifungal drugs, the patient had a progressive clinical deterioration and died. The autopsy concluded a systemic infection due to Aspergillus Fumigatus. Invasive aspergillosis is a serious fungal infection and usually occurs in immunocompromised patients. It mainly affects the lungs, followed by the gastrointestinal tract. The most frequent location in gastrointestinal involvement is the small bowel. Gastrointestinal involvement is more frequent in invasive disease. Although, there are case reports of isolated gastrointestinal aspergillosis, even in immunocompetent patients without risk factors. The prognosis is poor.

Enteroscopy in the diagnosis of melanoma metastases.

We present abdominal computed tomography and enteroscopy images of a 48-year-old male patient with a previous melanoma who presented with epigastric pain. The pain was not controlled with medical management. Abdominal computed tomography and a histological study of biopsies form enteroscopy confirmed the diagnosis of metastatic melanoma. The gastrointestinal involvement of melanoma is usually metastatic. Symptomatic gastrointestinal involvement occurs in less than 5% of melanomas, although postmortem analyses have reported up to 70%. The clinical presentation is variable and usually presents as abdominal pain. The diagnosis of small intestinal involvement of melanoma is a challenge due to its poor accessibility. The enteroscopy has a fundamental role as it allows a direct visualization and biopsies to be taken for histological study.

Xanthogranulomatous cholecystitis: differential diagnosis between acute cholecystitis and gallbladder cancer.

We present the images of ultrasound, magnetic resonance and histology of a patient with suggestive findings of xanthogranulomatous cholecystitis. Gallbladder cancer cannot be completely ruled out until the histological study of the surgical sample is performed.

Prehepatic portal hypertension of a vascular origin: Klippel-Trenaunay syndrome.

Female of 17 years-old with Klippel-Trenaunay syndrome: port-wine stain, overgrowth of bone and soft tissue in limbs, dental malposition and intellectual disability. Moreover, severe portal hypertension due to portal vein malformation. The Klippel-Trenaunay syndrome includes venous and capillary malformations in the skin, hypertrophy of bones and soft tissue in a limb and, in some patients, lymphatic malformations. Structural abnormalities of the deep venous system can also occur in addition to the key clinical features, although there are few case reports with portal hypertension due to portal vein malformation published.

Colon perforation due to fistulization of a pancreatic pseudocyst.

We present a computed tomography image of a patient with acute necrotizing pancreatitis due to alcohol, who developed several pseudocysts, one of which fistulized into the colon.

Complicated peribiliary cysts in patient without any prior liver disease.

Peribiliary cysts involve cystic dilation of the extramural peribiliary glands in the liver hilum and portal tracts. Most peribiliary cysts are asymptomatic. We present the case of a patient without any prior liver disease who developed obstructive jaundice and a liver abscess due to peribiliary cysts. Peribiliary cysts usually appear in patients with severe chronic liver disease and are asymptomatic, although they sometimes appear in patients without prior liver disease and cause serious complications.