Circumferential Wall Thickening Research Articles

Peri-Ampullary Tumour; An Unusual Cause of Upper Gastrointestinal Bleeding

Periampullary tumors are cancers that arise in the region of the around the ampulla of Vater, where the bile duct and pancreatic duct converge and empty into the small intestine. This region is very critical for digestive enzyme and bile secretions. This may be associated with slow disease progression, age related changes delayed onset of symptoms and lack of screening and diagnostic facilities. These tumours can be challenging to diagnose and manage due to their proximity to several vital structures. Upper gastrointestinal bleeding may be a rare clinical presentation following tumoral ulceration, erosion into blood vessels or nearby structures or secondary complications like pancreatitis or portal hypertension. Identifying the anatomical origin of these malignancies is usually a herculean task. This will require prompt oesophagogastroduodenoscopy and imaging to determine the source and appropriate management. This is especially true given the region's transitional character, closeness to various structures, and overlapping features among them. We present periampullary tumour an unusual cause of upper gastrointestinal bleeding in a resource limited setting. A52 year old Nigerian male was admitted at the Usmanu Danfodiyo University Teaching Hospital, Sokoto for evaluation following a 3 months history of progressive weight loss, generalized body weakness and a burning and occasionally colicky, persistent, non-radiating epigastric pain, loss of appetite, easy fatiguability, occasional dizziness and recurrent non-projectile post-prandial non-billous vomiting. Though he had no hematemesis, he had history of passage of malaena. The patient was fully conscious on admission, pale, wasted with a markedly tender epigstric region. He was tachycardic with a minimal elevation in blood pressure level of 138/94mmHg. He had an international normalized ratio (INR) of 1.0. Oesophagogastroduodenoscopy was performed which showed a polypoid fungating mass at the1st extending to the 2nd part of the duodenum. A Computerized Tomogram scan of the abdomen showed a diffuse circumferential duodenal wall thickening of 1st and 2nd parts (more in 2nd part) with reduction in luminal calibre of duodenum and mildly dilated pancreatic, common bile, common hepatic ducts. Multiple biopsies were taken for histology which showed moderately differentiated aadenocarcinoma. Surface epithelium composed of columnar epithelial cells which can be seen in the top right of the image below with an invasive tumour, seen infiltrating the lamina propria in the lower left. He went on to have an exploratory laparotomy with triple bypass involving a side to side gastrojejunal anastomosis and cholecystojejunostomy and entero-enterotomy folowing which he went on to receive chemotherapy. As of the time of this write up the patient has recuperated well following his treatment.

A Middle-Aged Patient Living with HIV (PLHIV), Presented with Persistent Hiccups, Imbalance, and Multifocal Myoclonus Secondary to Disseminated Tuberculosis

AbstractA middle aged male presented with chronic diarrhoea, persistent hiccups and unsteadiness while walking. His illness had subacute onset and progressive course. Clinically patient had cachexia, pallor, oral thrush and hepatosplenomegaly. On neurological examination, he had fine tremors, gait ataxia, and multifocal myoclonus. Investigations revealed normochromic normocytic anemia, transaminitis, hyponatremia and cerebrospinal fluid pleocytosis(lymphocytic predominance). Brain MRI revealed diffuse patchy meningeal enhancement; CECT abdomen showed circumferential bowel wall thickening, hepatosplenomegaly and necrotic lymphadenopathy. CECT chest exhibited mediastinal lymphadenopathy alongwith centrilobular nodular opacities. Sputum GeneXpert® was positive for mycobacterium tuberculosis with sensitivity to rifampicin. His serology for human immunodeficiency virus was positive. He was diagnosed as disseminated tuberculosis with tuberculer meningitis which caused persistent hiccups, gait abnormaliy and multifocal myoclonus. His symptom resolved with anti tubercular therapy. We aim to highlight here that myoclonus is a rare occurrence with tubercular meningitis.

Unveiling the Uncommon: Gastrointestinal Basidiobolomycosis of the Colon and its Distinctive Splendore-Hoeppli Phenomenon

Background Basidiobolomycosis is a rare fungal infection caused by Basidiobolus ranarum. Case Presentation A 53-year-old man from Saudi Arabia with a known history of diverticulosis presented with severe abdominal pain and diarrhea. A CT scan revealed circumferential wall thickening of the descending and sigmoid colon with surrounding fat stranding, suggesting a diagnosis of complicated diverticulitis. Additional thick fluid was observed around the affected area. Surgical excision was pursued. A gross examination of two received large bowel segments disclosed marked ulcerated mucosa and wall thickening with exudate-covered serosal surfaces and adhesions. Microscopic examination unveiled significant infiltration by eosinophils, polymorphonuclear leukocytes, and granulomatous inflammation. Thin-walled, broad fungal hyphae of Basidiobolus, surrounded by eosinophilic material, were identified. Granulomas displayed abundant multinucleated giant cells and palisading histiocytes around central necrosis or abscess formation. Thin-walled, broad fungal hyphae of Basidiobolus, with sparse septations, are surrounded by a radiating, intensely eosinophilic cuff (Splendore-Hoeppli phenomenon). These hyphae, visible with hematoxylin and eosin staining, were further highlighted with periodic acid-Schiff and Gomori methenamine silver staining. Discussion Basidiobolomycosis may mimic neoplastic lesions. Histologically, the characteristic features include broad, thin-walled septate hyphae surrounded by eosinophilic material, a finding that is accentuated by the Splendore-Hoeppli phenomenon. Microscopic examination, along with special stains such as periodic acid-Schiff (PAS) and Gomori methenamine silver, is essential for accurate diagnosis. Conclusion Prompt recognition and appropriate antifungal therapy are vital for favorable patient outcomes. This report highlights the distinctive features of Basidiobolomycosis to raise awareness and understanding of this infrequent yet clinically significant fungal infection.

Comprehensive CT Imaging Analysis of Primary Colorectal Squamous Cell Carcinoma: A Retrospective Study.

The aim of this study was to evaluate the findings of CT scans in patients with pathologically confirmed primary colorectal squamous-cell carcinoma (SCC). The clinical presentation and CT findings in eight patients with pathologically confirmed primary colorectal squamous-cell carcinoma were retrospectively reviewed by two gastrointestinal radiologists. Hematochezia was the most common symptom (n = 5). The tumors were located in the rectum (n = 7) and sigmoid colon (n = 1). The tumors showed circumferential wall thickening (n = 4), bulky mass (n = 3), or eccentric wall thickening (n = 1). The mean maximal wall thickness of the involved segment was 29.1 mm ± 13.4 mm. The degree of tumoral enhancement observed via CT was well enhanced (n = 4) or moderately enhanced (n = 4). Necrosis within the tumor was found in five patients. The mean total number of metastatic lymph nodes was 3.1 ± 3.3, and the mean short diameter of the largest metastatic lymph node was 16.6 ± 5.7 mm. Necrosis within the metastatic node was observed in six patients. Invasions to adjacent organs were identified in five patients (62.5%). Distant metastasis was detected in only one patient. In summary, primary SCCs that arise from the colorectum commonly present as marked invasive wall thickening or a bulky mass with heterogeneous well-defined enhancement, internal necrosis, and large metastatic lymphadenopathies.

Poorly differentiated mucinous carcinoma of the ascending colon complicated by bilateral ovarian mature cystic teratomas in a 17-year-old female patient: a case report

BackgroundColorectal cancer (CRC) is one of the most common cancers worldwide, and screening colonoscopy has led to a decreasing incidence rate. However, the incidence of CRC is increasing among young people, especially adolescents and young adults (AYAs) who are not routinely screened. Although CRC is the fourth most common cancer among AYAs, it is extremely rare. In younger patients, CRC is often diagnosed later, and the proportion of patients with advanced CRC is higher than that in older patients. We herein present a case of poorly differentiated mucinous carcinoma of the ascending colon complicated by bilateral ovarian mature cystic teratomas (MCTs) in an AYA.Case presentationA 17-year-old female patient presented with a chief complaint of abdominal pain and diarrhea that had persisted for more than 3 years. Colonoscopy revealed circumferential wall thickening of the ascending colon, and colonic biopsy revealed a mucous mass and findings of adenocarcinoma, predominantly signet ring cell carcinoma. Abdominal computed tomography (CT) and pelvic magnetic resonance imaging (MRI) showed bilateral ovarian tumors. Laparoscopic right hemicolectomy and enucleation of bilateral ovarian tumors were performed. Although the ascending colon cancer formed a large mass, there were no signs of peritoneal dissemination or direct invasion to the surrounding organs. Microscopically, the ascending colon was a poorly differentiated mucinous carcinoma with signet ring cell carcinoma and lymph node metastasis (9/42). The ovarian tumors were diagnosed as MCTs without any malignant components. The pathological diagnosis was ascending colon cancer (pT4aN2bM0, pStage IIIC) and bilateral ovarian MCTs. Microsatellite instability (MSI) testing was negative, and there were no gene mutations in either RAS or BRAF. Postoperative adjuvant chemotherapy with oxaliplatin and 5-FU was started.ConclusionsWe presented a case of locally advanced ascending colon cancer in a 17-year-old female patient. CRC rarely occurs in AYAs. However, the incidence has gradually increased in recent years. It should be considered as a differential diagnosis for young patients with long-term abdominal symptoms of unknown cause.

Cardiac Allograft Vasculopathy: Challenges and Advances in Invasive and Non-Invasive Diagnostic Modalities.

Cardiac allograft vasculopathy (CAV) is a distinct form of coronary artery disease that represents a major cause of death beyond the first year after heart transplantation. The pathophysiology of CAV is still not completely elucidated; it involves progressive circumferential wall thickening of both the epicardial and intramyocardial coronary arteries. Coronary angiography is still considered the gold-standard test for the diagnosis of CAV, and intravascular ultrasound (IVUS) can detect early intimal thickening with improved sensitivity. However, these tests are invasive and are unable to visualize and evaluate coronary microcirculation. Increasing evidence for non-invasive surveillance techniques assessing both epicardial and microvascular components of CAV may help improve early detection. These include computed tomography coronary angiography (CTCA), single-photon emission computed tomography (SPECT), positron emission tomography (PET), and vasodilator stress myocardial contrast echocardiography perfusion imaging. This review summarizes the current state of diagnostic modalities and their utility and prognostic value for CAV and also evaluates emerging tools that may improve the early detection of this complex disease.

Xanthogranulomatous Cholecystitis - An Intimidating Diagnostic Dilemma - A Case Report

Xanthogranulomatous cholecystitis (XGC) is an uncommon form of chronic cholecystitis[1] characterized by inflammation and infiltration of gall bladder (GB) wall by lymphocytes and multinucleated histiocytic giant cells. There is transudation of bile into gall bladder wall and involvement of the Rokitansky-Aschoff sinuses leading to formation of submucosal abscess and xanthogranulomas.[2] On CECT, they appear as submucosal hypoattenuating nodules and circumferential wall thickening of gallbladder wall, a sign highly specific of XGC.[3]

High-resolution Magnetic Resonance Imaging visualizes intracranial large artery involvement in Giant Cell Arteritis.

Giant Cell arteritis (GCA) is a large vessel vasculitis, typically involving the aorta and its branches with predilection for the scalp arteries. Intracranial involvement is still part of ongoing research. We assess inflammation of the intracranial arteries on 3D-black-blood magnetic resonance imaging (3D-CS-BB-MRI) in patients with GCA and age-matched controls. 105 patients with 3D-CS-BB-MRI of the brain were included in this retrospective dual-center case-control study; 55 with diagnosed GCA and 50 age-matched controls. High-resolution 3D-CS-BB-MRI was performed on a 3 Tesla MR scanner with a post-contrast 3D-compressed-sensing (CS) MR pulse sequence, specifically a T1-weighted sampling perfection, application-optimized contrasts using different flip angle evolution (SPACE) pulse sequence with whole-brain coverage and isotropic resolution of 0.55 mm3. Two neuroradiologists blinded to clinical data independently scored the cerebral arteries qualitatively for inflammation; circumferential vessel wall thickening and contrast enhancement were scored positive for vasculitis. 8 of 55 GCA patients (14.5%) showed inflammation of at least one intracranial artery. The internal carotid artery (ICA) was affected in 6/55 (10.9%), the vertebral artery in 4/55 (7.3%) and the basilar artery and posterior cerebral artery in 1/55 (1.8%). All patients with inflammatory changes reported headaches and none showed any focal neurological deficit. Besides headache and general weakness, there was no significant correlation between inflammation of the intracranial arteries and clinical symptoms. No age-matched control patient showed inflammatory changes of the intracranial arteries. High-resolution 3D-CS-BB-MRI revealed inflammatory changes of intracranial arteries in 14.5% of GCA patients with the intradural ICA as the most frequently affected vessel.

A rare cause of dysphagia in children: Squamous cell carcinoma of the esophagus: A case report and review of literature

Globally, an estimated 572 000 cases occurred in 2018 of malignant tumors of the esophagus but in children and adolescents, this cancer is a rare disease. Through this case report, i tried to analyze the clinical, paraclinical, therapeutic and prognostic profile of squamous cell carcinoma of the esophagus in children. This 10 years old female school child is presented with a complaint of worsening of difficulty of swallowing of 01 week duration. She had Symptoms complex of TB for the last 3 months. FNAC from right axillary, bilateral inguinal LNs, discrete with pus oozing sinus tract about 2x2 cm Microscopy shows caseous necrotic material= suggestive of TB. SAM (NE) + Severe Pneumonia + R/O Diss TB (Lung, LN) + Tungiasis was considered and anti TB was started but the patient was deteriorating. After one month course in the hospital the patient condition was deteriorating, the dysphagia become worsened. CHEST CT SCAN of the child was taken and the Finding: there is multifocal coalescing tree in bud opacity in posterior segment of the right upper lobe and superior segment of the lower lobe on the same side. There is consolidation with bronchiectasis changes on the left lower lobe. Multiple enlarged Para tracheal, sub carinal and Para esophageal nodes noted. There is circumferential wall thickening of the mid and part of proximal esophagus with no fat plane from the enlarged adjacent nodes. Calcified right axillary nodes visualized. the Impression was Bilateral pulmonary opacities with mediastinal LAPs (likely 2ry to TB) + circumferential wall thickening of mid and part of proximal esophagus DDx: Esophageal malignant mass with mediastinal nodal deposits and aspiration pneumonia- so needs clinical correlation and endoscopic study. Esophageal biopsy was taken and section shows nests and single cells of malignant squamous cells having high N/C ratio hyper chromatic nucleo and dense eosinophilic cytoplasm along with keratin pearls along with monocular infiltration and atypical mitosis invading in to desmoplastic stroma. Conclusion: Squamous cell carcinoma The child was transferred to oncology ward for chemotherapy and radiotherapy after one week of ward stay the patient passed away. Malignant esophageal tumors in children and adolescents are extremely rare conditions. The ingestion of caustic products and smoking are currently the most well-known risk factors for this disease, factors not found in our patient. Dysphagia is the main clinical sign of squamous cell carcinoma of the esophagus. Thus, in the event of dysphagia in children or adolescents, a mediastinal process should be considered, and a paraclinical assessment should be carried out. Since squamous cell carcinoma of the esophagus is a rare malignant tumor in children, the interest of this case report is to underline the importance of evoking a malignant esophageal process in children who present a notion of dysphagia to solids then to liquids, associated with an alteration of the general condition and anemia.

Terminal ileitis and cytotoxic lesion of corpus callosum as the presenting features of Multisystem inflammatory syndrome in children (MIS-C): a case report

BackgroundMultisystem inflammatory syndrome in children (MIS-C) is a post-viral inflammatory vasculopathy characterized by persistent fever, multiorgan dysfunction, significant laboratory markers of inflammation, lack of an alternative diagnosis, and prior SARS-CoV-2 infection or exposure in children and adolescents. The most common early symptoms include a prolonged fever, as well as dermatologic, mucocutaneous, and gastrointestinal symptoms such abdominal pain, vomiting, and diarrhea.Case presentationWe present a pediatric patient with multisystem inflammatory syndrome with the development of abdominal pain and seizure who was found to have a circumferential wall thickening of the terminal ileum and ileocecal junction in abdominal CT scan. The brain MRI of the patient showed cytotoxic lesions of the corpus callosum (CLOCC) which had hypersignal intensity with a few diffusion restrictions in the splenium of the corpus callosum.ConclusionThis case is being reported to raise awareness of MIS-C presenting characteristics. Given the rising number of MIS-C patients and a lack of understanding regarding early diagnostic clinical characteristics and therapy, further research into clinical presentations, treatment, and outcomes is urgently needed.

S1971 Waldenstrom Macroglobulinemia: A Malignant Mimicker of IBD

Introduction: Waldenstrom macroglobulinemia (WM) is a lymphoplasmacytic lymphoma in the bone marrow with IgM gammopathy in the blood. Annually ∼1400 cases are diagnosed in the US, with typical presentation of B symptoms, fatigue, neuropathy, and mucosal bleeding. Only 3% of patients present with colonic symptoms. We describe a case of WM with rectal involvement presenting as bloody diarrhea, mimicking inflammatory bowel disease (IBD). Case Description/Methods: A 56-year-old man with depression, anxiety, and fibromyalgia presented with 6 months of diarrhea with mucous and rectal bleeding. He underwent upper endoscopy and colonoscopy with Helicobacter pylori gastritis, proctitis, and inflammatory polyps. He symptoms worsened despite rectal mesalamine, including weight loss and night sweats. Budesonide oral and foam resolved the bleeding but diarrhea continued despite rifaximin. Around this time, he was thought to have irritable bowel syndrome. Two years later, he had recurrence of daily bowel movements with mucous and rectal bleeding, plus fecal incontinence, tenesmus, and rectal and abdominal pain. He also noticed myalgias, arthralgias, parasthesias, fatigue, and chills. Rheumatology suggested fibromyalgia as the culprit, in part due to elevated ESR. After his GI symptoms renewed suspicion for IBD, repeat colonoscopy showed a 3 cm rectal mass with ulcer and stenosis at the recto-sigmoid colon. Biopsies showed eosinophilic proteinaceous material positive for PAS-D, negative for fibrosis and amyloid and concerning for malignancy. EUS confirmed inflammatory polyps and rectal thickness ( Figure 1). Hematology performed immunofixation with faint monoclonal IgM-lambda, and bone marrow biopsy confirmed lymphoplasmacytic lymphoma concerning for WM. Discussion: WM rarely involves the GI tract, with fewer colonic and rectal presentations than small bowel. The IgM deposition can cause severe malabsorption, steatorrhea, obstructive symptoms, or GI bleeding. Especially in cases of bloody stools and localized colonic thickening, WM can be mistaken for IBD. In our case, factors more suggestive of WM included degree of colonic thickening and pathologic PAS-D positivity. Particularly, raised lesions should prompt investigation for malignant processes, despite surrounding inflammatory changes. Diagnosis of WM usually involves multiple specialists and procedures such as bone marrow biopsy. WM treatment includes bruton tyrosine kinase inhibitors or bendamustine with rituximab, the latter of which improved our patient’s GI symptoms.Figure 1.: Image 1. Colonoscopy and lower endoscopic ultrasound (EUS) visualized circumferential wall thickening and stenosis in rectum, with polyps and stenosis in sigmoid colon. a. During colonoscopy, a benign-appearing, intrinsic moderate stenosis measuring 4 cm in length was found in the recto-sigmoid colon, due to circumferentially congested edematous polypoid mucosa with overlying exudate. b. Several 10 to 16 mm sessile polyps were seen with inflammatory appearance in the sigmoid colon. c-d. During EUS, circumferential wall thickening was found in the rectum at the superficial and deep mucosa. There was no evidence of an infiltrative subepithelial mass. The muscularis propria layer was normal throughout.

S3664 Russel Body Gastritis: When the Rare Meets the Odd

Introduction: The significance of chronic gastritis is underrated. Even though Helicobacter pylori (HP) has been the main contributing factor to this condition, if testing for it comes back negative, we should always rule out other underlying diseases, especially if the biopsy reveals Russell body (RB) gastritis. Case Description/Methods: A 67-year-old male with a past medical history of immune thrombocytopenic purpura (ITP) on prednisone and eltrombopag, hypertension, and choledocholithiasis status post cholecystectomy complicated by abscess formation and drain placement, presented with worsening nausea, vomiting, and abdominal pain for three days associated with early satiety and weight loss. His symptoms were not related to food or activity. Vital signs and physical exam were unremarkable except for right upper quadrant abdominal tenderness. Labs were remarkable for WBC 55 k/ul, HGB 11 g/dl, and PLT 90 k/ul. Full infectious workup was negative. CT scan showed massive splenomegaly with widespread lymphadenopathy and circumferential wall thickening of the gastric fundus and body. An upper endoscopy was performed and revealed diffuse gastric erythema in a mosaic pattern, most pronounced in the body of the stomach (Fig. 1a). Biopsies were obtained from the gastric antrum and body. Gastric body biopsies revealed gastric oxyntic mucosa with RB gastritis (Fig. 1b), and it was negative for HP, intestinal metaplasia, dysplasia, or malignancy. Kappa and lambda immunohistochemistry stain showed a polyclonal mixed population of plasma cells (Fig. 1c), indicating no underlying malignancy. HP stool antigen was checked twice, and it was negative. His WBC continued to rise, and bone marrow (BM) biopsy was performed. Findings were suspicious for myelodysplastic/myeloproliferative disorder; however, a reactive process could not be ruled out. Since the patient's condition significantly deteriorated, a repeat BM biopsy revealed morphological changes consistent with chronic myelomonocytic leukemia (CMML). After discussing goals of care with the patient, he opted for hospice care and expired after three days.Figure 1.: (a) An upper endoscopy showing diffuse punctuate gastric erythema with mucosal mosaic pattern. (b) A high power stomach biopsy with Hematoxylin and Eosin stain showing atypical plasma cells with Russell bodies (yellow arrow) which are eosinophilic homogeneous immunoglobulin-containing inclusions. (c) A high power stomach biopsy with kappa and lambda immunohistochemistry stain showing polyclonal mixed population of plasma cells (positive for both kappa and lambda). Discussion: RB gastritis is a reactive mucosal infiltration of plasma cells filled with cytoplasmic RB. There is a strong association with HP infection, but there is also an association with hematopoietic malignancies and gastric adenocarcinoma. Our case represents the vital importance of looking for underlying malignancies in HP negative RB gastritis patients.

S2068 Malignant Colo-Duodenal Fistula in a Rare Anatomic Position

Introduction: The first case of malignant colo-duodenal fistula (MCDF) was reported in 1862 and since then only 70 MCDF cases had been reported. We describe a case of MCDF between the hepatic flexure and second part of the duodenum, a rarely observed anatomic location. Case Description/Methods: A 63-year-old male presented to an outside hospital with lethargy and a weight loss of 30 lbs over 3 months without any overt GI bleed and was found to be anemic. He had RUQ rebound tenderness and a positive stool occult blood test. A large duodenal ulcer was found on EGD that was concerning for malignancy. He was subsequently transferred to our hospital for further evaluation. CT abdomen showed a contrast-filled fistulous communication with associated circumferential wall thickening and luminal narrowing between the duodenum and the colon. Scattered noncalcified pulmonary nodules in both lungs were also observed. A repeat EGD showed a large, partially circumferential, friable ulcer in the first part of the duodenum with a fistulous tract connecting to the colon. A colonoscopy showed a fistulous tract with surrounding ulceration and adenomatous-appearing mucosa in the hepatic flexure of the colon connecting to the duodenum. The endoscope could not be advanced safely beyond the hepatic flexure due to edema around the fistulous tract. Pathology revealed invasive moderately differentiated adenocarcinoma with ulceration and detached fragments of small intestinal and colonic mucosa in the duodenal biopsies and invasive moderately differentiated adenocarcinoma with cells that were CK20+, SATB2+, and CK7− consistent with metastatic colorectal cancer in the colon biopsies. Surgical and medical oncology were consulted for management (Figure 1). Discussion: Most MCDF involve the second portion of the duodenum. In our patient, the fistula connected the first portion of the duodenum to the hepatic flexure of the colon. Although, 20% of hepatic flexure tumors are adherent to the duodenum, very few fistulate into it. Cross-sectional imaging with contrast studies help confirm and stage the primary tumor and fistulous tract by delineating extent of local invasion and evaluating for metastatic spread. Upper and lower endoscopy help demonstrate the fistulous communication and biopsy allows for a pathological diagnosis. Definitive treatment involves a surgical resection of the primary malignancy. However, but once the disease has progressed to point of fistulization or metastases, the overall prognosis is poor.Figure 1.: A, CT Abdomen with contrast showing colo-duodenal fistula (red arrow) B, EGD showing fistula in 2nd part of the duodenum (black arrow) and ulceration. C, Colonoscopy showing fistula (green arrow) in the hepatic flexure with ulceration and edema.

Huge Colonic Granuloma of Schistosomiasis Mimicked Cancer in a 10-Years-Old Child: A Case Report

IntroductionSchistosomiasis is a trematodes infection more prevalent in tropical and subtropical areas such as Yemen. Giant colonic polyp manifestations of intestinal bilharziasis are uncommon, difficult to differentiate from other colonic polyps, and can mimic cancer.Case ReportA 10-year-old child presented with chronic abdominal pain that started ten months ago. The patient had a family history of lymphoma in his brother. The computed tomography scan showed a sigmoid luminal mass measuring 10×3 cm with significant lumen narrowing and diffuse circumferential wall thickening of the sigmoid colon, hepatomegaly, and multiple perilesional, para-hepatic, and pulmonary lymph nodes enlargements. The mass was morphologically mimicked cancer and proved to be of bilharzial etiology (Schistosoma mansoni) after surgical excision.ConclusionEven though the bilharzial colonic polyps are rare, it is challenging to differentiate them from other malignant colonic polyps. Clinicians should have a high suspicion regarding its manifestations to avoid unnecessary surgical interventions, especially in an endemic area, even in patients with a strong family history of cancer.

Diffuse Common Bile Duct Mural Thickening in a Patient With Pancreatitis

Question: A 64-year-old man experienced acute episodes of abdominal and back pain 5 months ago, followed by jaundice, which prompted him to seek evaluation at his local hospital. Laboratory evaluation was notable for elevated bilirubin 3.4 mg/dL (reference range, 0–1.2 mg/dL), alkaline phosphatase of 1352 U/L (reference range, 50–121 U/L), alanine aminotransferase of 219 U/L (reference range, 12–52 U/L), and lipase 361 U/L (reference range, 13–78 U/L). The patient underwent several endoscopic retrograde cholangiopancreatography (ERCP) procedures with brush cytology and common bile duct (CBD) stent placement for an indeterminate stricture, and endoscopic ultrasound (EUS) examination with fine needle aspiration of the stricture without an identifiable etiology. At presentation for a second opinion, the patient noted resolution of jaundice, but complained of pruritus, greasy stools, flatulence, and bloating, along with a 30-lb weight loss and fatigue. He denied excessive alcohol consumption, smoking, or a history of gallstones. On physical examination, the patient was without jaundice or abdominal pain. Routine laboratory evaluation was unremarkable except for a mildly elevated alanine aminotransferase of 56 U/L and alkaline phosphatase of 260 U/L. Carbohydrate antigen 19-9 and alpha fetoprotein levels were within normal limits. Hepatitis B and C serologies, anti–smooth muscle actin and anti–mitochondrial antibodies were unremarkable. IgG4 subclass was elevated at 172 mg/dL (reference range, 2.4–121 mg/dL). A magnetic resonance cholangiopancreatography showed enhancement of the CBD with mural thickening and pancreatic parenchymal atrophy (Figure A). A repeat ERCP did not show significant intrahepatic biliary duct dilation, but a stricture was noted in the distal CBD. EUS examination demonstrated pancreatic body and tail atrophy with pancreatic head changes consistent with moderate to severe chronic pancreatitis. The entire visualized CBD and cystic duct had circumferential wall thickening (Figure B). Cholangioscopy showed nonspecific findings. Based on the clinical scenario and images, what is the most likely diagnosis? Look on page 827 for the answer and see the Gastroenterology website (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. Cholangioscopic biliary mucosal biopsies showed active chronic inflammation and increased IgG4-positive cells. Pancreatic head biopsies showed fibrosis with lymphoplasmacytic infiltrate and increased IgG4-positive cells with an IgG4 to IgG ratio of >40%. Cytology and fluorescence in situ hybridization of bile duct brushings were again unremarkable. The patient was initiated on pancreatic enzyme replacement therapy and a slow taper of prednisone. On follow-up 3 months later, his gastrointestinal symptoms had resolved, and weight had stabilized. Likewise, his liver chemistries and IgG4 subclass level had normalized. Follow-up ERCP revealed improvement in the CBD stricture. IgG4-related disease (IgG4-RD) is an immune-mediated, fibroinflammatory, multiorgan disease. It can present with regions of inflammatory thickening or mass formation that is often confused for a malignancy. The disease presents insidiously and is progressive. Most frequently involved organs include the pancreas resulting in type 1 autoimmune pancreatitis with diffuse enlargement, diabetes, and exocrine insufficiency; salivary and lacrimal glands resulting in asymptomatic symmetric enlargement; retroperitoneum resulting in soft tissue mass; and bile ducts resulting in intrahepatic and extrahepatic strictures.1Perugino C.A. Stone J.H. IgG4-related disease: an update on pathophysiology and implications for clinical care.Nat Rev Rheumatol. 2020; 16: 702-714Crossref PubMed Scopus (90) Google Scholar Additionally, our patient had a diffusely thickened CBD and cystic duct wall well-characterized by EUS examination (Figure B). The diagnosis is based on a comprehensive workup to distinguish from conditions presenting similarly. In this case, pancreatic cancer, cholangiocarcinoma, and primary sclerosing cholangitis were carefully ruled out. Various criteria have been proposed to diagnose IgG4-RD that predominantly rely on (1) imaging features, (2) an elevated serum IgG4 with various cut-off values, and (3) histological findings of lymphoplasmacytic infiltrate with fibrosis, a ratio of IgG4-positive plasma cells/IgG-positive cells of >40%, and the number of IgG4-positive plasma cells greater than 10 per high-powered fields, and typical fibrosis, storiform, or obliterative phlebitis.2Löhr J.M. Beuers U. Vujasinovic M. et al.European guideline on IgG4-related digestive disease - UEG and SGF evidence-based recommendations.United European Gastroenterol J. 2020; 8: 637-666Crossref PubMed Scopus (0) Google Scholar,3Umehara H. Okazaki K. Kawa S. et al.The 2020 revised comprehensive diagnostic (RCD) criteria for IgG4-RD.Mod Rheumatol. 2021; 31: 529-533Crossref PubMed Scopus (77) Google Scholar Multiple organ involvement and steroid responsiveness are also considered supportive of IgG4-RD. Our patient met the diagnostic criteria for IgG4-RD with excellent response to steroid treatment.

A Rare Cause of Pedunculated Polyps Caused by Strongyloides

Introduction: Strongyloidiasis is a systemic disease caused by the nematode Strongyloides stercoralis. Strongyloides is unique among parasites in that it can remain undetected for decades. Although patients may present with the typical symptoms of a skin rash, cough or diarrhoea, a rare manifestation of infection is pseudopolyposis in the colon. This case highlights the unique finding of pseudopolyposis in a patient with strongyloidiasis with negative stool studies. Case description: We present the case of an 81-year-old man with a delayed diagnosis of strongyloidiasis. The patient initially presented to the clinic for evaluation of productive cough and was treated empirically for bronchitis. He subsequently developed vomiting and diarrhoea with imaging revealing circumferential wall thickening of the ascending colon, consistent with colitis. Although stool tests were negative, the patient was treated with antibiotics, and then underwent a colonoscopy which revealed multiple polyps. Biopsy results confirmed Strongyloides infection. The patient was treated with ivermectin and improved. Discussion: This case describes the unique finding of colonic pseudopolyposis in a patient infected with Strongyloides in rural southwest Virginia. Strongyloidiasis is often misdiagnosed due to its non-specific gastrointestinal symptoms and the chronic nature of the disease. Although stool studies are routinely negative for parasitic infection, CT scan findings suggestive of colitis should be followed by colonoscopy with biopsy of any abnormal lesion in the right clinical context. Determining the definitive diagnosis in a timely manner is crucial for establishing the specific treatment and for resolution of the disease.

A Rare Cause of Pedunculated Polyps Caused by Strongyloides.

IntroductionStrongyloidiasis is a systemic disease caused by the nematode Strongyloides stercoralis. Strongyloides is unique among parasites in that it can remain undetected for decades. Although patients may present with the typical symptoms of a skin rash, cough or diarrhoea, a rare manifestation of infection is pseudopolyposis in the colon. This case highlights the unique finding of pseudopolyposis in a patient with strongyloidiasis with negative stool studies.Case descriptionWe present the case of an 81-year-old man with a delayed diagnosis of strongyloidiasis. The patient initially presented to the clinic for evaluation of productive cough and was treated empirically for bronchitis. He subsequently developed vomiting and diarrhoea with imaging revealing circumferential wall thickening of the ascending colon, consistent with colitis. Although stool tests were negative, the patient was treated with antibiotics, and then underwent a colonoscopy which revealed multiple polyps. Biopsy results confirmed Strongyloides infection. The patient was treated with ivermectin and improved.DiscussionThis case describes the unique finding of colonic pseudopolyposis in a patient infected with Strongyloides in rural southwest Virginia. Strongyloidiasis is often misdiagnosed due to its non-specific gastrointestinal symptoms and the chronic nature of the disease. Although stool studies are routinely negative for parasitic infection, CT scan findings suggestive of colitis should be followed by colonoscopy with biopsy of any abnormal lesion in the right clinical context. Determining the definitive diagnosis in a timely manner is crucial for establishing the specific treatment and for resolution of the disease.LEARNING POINTSCT scan findings suggestive of colitis should be followed by colonoscopy with biopsy of any abnormal lesion in the right clinical context; stool studies may be negative, as in this case.Internists should know the incidence, even if it is low, of certain parasitic infections in their local area.Strongyloides infection in the colon can mimic colitis and initiating the wrong treatment can lead to worse outcomes.

Mirrored Appearance of Complete Common Mesentery Discovered on CT Scan for Crohn's Disease.

Complete common mesentery in the mirror image is an anomaly of intestinal rotation, placing the colon in the right half of the abdomen and the small intestine in the left half of the abdomen.It can be asymptomatic and discovered incidentally during assessment for other conditions.

S2151 A Rare Cause for Dysphagia and Malignancy: Esophageal Neuroendocrine Tumor

Introduction: Esophageal cancer accounts for roughly 1% of newly diagnosed cancers yearly in the United States with most common being squamous cell carcinoma (SCCA) and adenocarcinoma. Our case describes an esophageal neuroendocrine cell carcinoma (NEC), which is a malignant neoplasm included in a small subset, 0.04%, of gastrointestinal (GI) neuroendocrine tumors (NET). They are characterized by high malignant potential, rapid growth, and overall poor prognosis. Case Description/Methods: A 59 year old man with history of hypertension presented with a 1 week history of fatigue, diarrhea, and dysphagia. He had a 5 year history of dysphagia to solid foods with acute worsening over the last 3 weeks. He denied abdominal pain, melena, weight loss. Labs revealed hemoglobin of 7.0, MCV 76.7, and iron deficiency anemia. CT scan showed circumferential wall thickening of the distal esophagus, multiple enlarged lymph nodes, and innumerable masses in the liver. EGD revealed a large ulcerated non-bleeding mass at the GE junction extending along the lesser curvature of the cardia. Pathology revealed poorly differentiated high grade neuroendocrine carcinoma. Stains were positive for pancytokeratin and synaptophysin with near 100% Ki-67 proliferative index. Chromogranin A was negative. Several days after the EGD, the patient acutely decompensated requiring intubation. Due to poor prognosis in the setting of multi-organ failure, he was placed on comfort care and passed away shortly after. Discussion: Esophageal NECs are a rare cause of malignancy, contributing to 0.4 to 2% of esophageal cancers. NEC has a male predominance (4:1) with median age 50-60. Predominant clinical symptoms are dysphagia and weight loss but abdominal pain and melena can also be seen. Endoscopic findings are typically a single, submucosal lesion that is demarcated, ulcerated, and exophytic located in the middle (55%) and lower third (37%) of the esophagus. This is thought to be from a larger distribution of neuroendocrine cells located in the middle esophagus. One retrospective study also noted co-existence of SCC and adenocarcinoma in NEC on pathology. Unfortunately, the prognosis of esophageal NECs are poor due to advanced disease at time of diagnosis. Due to lack of sufficient data about esophageal NEC, there is not a standardized therapeutic strategy available. Most frequently, NEC undergoes multi-modal treatment including surgery, chemotherapy, and/or radiotherapy depending on localized or metastatic disease.Figure 1.: A: Large fungating and ulcerating mass with no evidence of bleeding or stigmata of recent bleeding B. Partial circumferential mass extending along lesser curvature of cardia region.

Primary Gastric Lymphoma (Diffuse Large B Cell Type)

The most frequent extra-nodal site of lymphoma is gastric lymphoma. The bulk of such lesions are extra nodal marginal zone B mucosal cell lymphoma correlated with lymphoid tissue (MALT) type or diffuse lymphoma of large B cells. We are reporting a case of diffuse major B-Cellular gastric lymphoma, which at first showed indigestion, abdominal heaviness, nausea and widespread weakness with 3-4 months of weight loss. In the antropyloric region and distal portion of lesser curvature of stomach suggestive of aetiology of cancer, the CT abdomen shows circumferential wall thickening. DLBCL has been confirmed by HPE and IHC. The neoplasm entered serosa and was found to have adherence to the pancreatic capsule in stage IIE of gastric lymphoma. Following the staging, treatment with an R-CHOP regimen (rituximab, cyclophosphamide, oncovin (vincristine), hydroxydaunorubicin, and prednisone) was done.