Extensive Ulceration Research Articles

Drug-induced esophageal injuries with an atypical presentation mimicking acute coronary syndrome

BackgroundPill-induced esophageal injury may cause severe complications if not diagnosed in a timely fashion. The condition is under-recognized and under-reported, and some patients present with atypical clinical or endoscopic features mimicking other common conditions. If the diagnosis is missed the patient will continue to take the offending drug, potentially worsening the illness. We present a case in which acute coronary syndrome was the initial working diagnosis leading to a delay in diagnosis of doxycycline-induced esophageal injury. The patient developed multiple esophageal ulcers and hemorrhage.Case presentationA 50-year-old male driver with a history of hypertension and dyslipidemia was brought to the emergency department with complaints of severe retrosternal chest pain, vomiting, diaphoresis and syncope. On initial evaluation, acute coronary syndrome was considered due to the clinical presentation and history of cardiovascular risk factors. Electrocardiogram and serum troponins were normal. On the second day of his admission, the patient developed odynophagia and bloody vomitus. Esophagogastroduodenoscopy revealed extensive esophageal ulcerations with hemorrhage. The patient was taking Doxycycline capsules for an acute febrile illness. Doxycycline is the oral medication most commonly reported to cause esophageal injury. Doxycycline was discontinued, and the patient was treated with intravenous omeprazole and oral antacid suspension. The patient improved, was discharged after 6 days of hospitalization, and reported resolution of all symptoms at an outpatient follow-up visit 3 weeks later.ConclusionMedication-induced esophageal injury can present with atypical symptoms mimicking acute coronary syndrome. This condition should be included in the initial differential diagnosis of patients presenting with acute chest pain, especially those taking oral medications known to cause esophageal injury.

Dnmt3a Mutations in the Hematopoietic System Promote Colitis-Associated Colon Cancer: A Model of Clonal Hematopoiesis in Solid Tumors

Clonal hematopoiesis (CH) is a condition wherein hematopoietic stem cells (HSCs) acquire mutations, often in presumed leukemia driver genes such as in DNMT3A, leading to clonal dominance and disproportionate contribution to peripheral blood without overt hematologic abnormalities (Jaiswal et al. 2014). In large cohorts of patients with solid tumors including colorectal cancer, presence of CH is associated with inferior overall survival due to progression of primary malignancy (Coombs et al. 2017). While potential involvement of CH in the pathogenesis of solid tumors driven by unrelated genetic alterations has far-reaching translational implications, the mechanistic understanding of this relationship is lacking.Colorectal cancer is a leading cause of cancer deaths worldwide and can arise from preceding inflammatory bowel disease. More than 20% of patients with colon cancer have detectable CH, which is notably more prevalent than in age-matched general population. We hypothesized that bone marrow-derived cells harboring alterations in DNMT3A, the most commonly disrupted gene in CH (up to 40% of cases), contribute to the pathogenesis of colorectal cancer. To address this, we combined a bone marrow transplantation-based model of CH driven by heterozygous loss of Dnmt3a with a well-established induction of colitis-associated colon cancer (CAC) by azoxymethane (AOM, a carcinogen) and dextran sodium sulfate (DSS, a colitogen). High resolution colonoscopy demonstrated increased colon wall opacity, visible bleeding, numerous fibrin patches and earlier onset of tumor formation with higher penetrance in animals with partial ablation of Dnmt3a in the hematopoietic compartment. Heightened colon pathology was reflected by modified murine endoscopic index of CAC severity (MEICS) (Fung and Putoczki 2018) (MEICS scores 7.5±2.0 in WT vs 10.0±3.2 in Dnmt3a +/-, p=0.05, n=14,13). We observed elevated incidence of tumors >2mm in diameter (40.2±22.2% in WT vs 74.2±15.7% in Dnmt3a +/-, p=0.03, in 5 independent trials) and a higher tumor burden in Dnmt3a +/- chimerae (7.4±7.8 mm 3 in WT vs 14.5±13.9 mm 3 in Dnmt3a +/-, p=0.0017, n=53,55) at end point. Histopathological analysis revealed marked immune infiltration, extensive ulceration and dysplasia of colonic epithelium, and more frequent adenocarcinoma formation with occasional submucosal invasion (histology score 20.2±4.4 in WT vs 24.6±6.9 in Dnmt3a +/-, p=0.03, n=10,9). To uncover signaling pathways deregulated by experimental Dnmt3a-driven CH, we surveyed the auto- and paracrine stimulatory loops by multiplex cytokine/chemokine assays and profiled transcriptomes of colon tumors by bulk RNA-seq. These studies identified gene signatures commonly associated with colon carcinogenesis including accentuated epithelial-to-mesenchymal transition (gene set enrichment analysis (GSEA) NES=2.42, padj=0.0096), Wnt/b-catenin (NES=2.07, padj=0.0096), and Vegf/angiogenesis (NES=1.83, padj=0.0096). Elevated proliferation (Ki67) and increased vascularization (CD31) were validated by immunohistochemistry. These aspects of tumor pathophysiology along with the composition and functional characteristics of the tumor-infiltrating leukocytes derived from animals with and without hematopoietic-specific Dnmt3a partial loss are being further investigated. Preliminary data showed bone marrow-derived macrophages (BMDMs) from Dnmt3a +/- chimera exhibit impaired ability to phagocytose syngeneic MC38 colon tumor cells, compared to WT.Our study provides new insights into the non-tumor-cell-autonomous mechanisms of carcinogenesis effected by alterations in the hematopoietic system and into the interplay between the immune system and the aggressive phenotype of colorectal cancer. Our findings may aid the development of novel therapeutic options to improve outcomes in solid tumor patients with CH. [Display omitted] DisclosuresBowman: Mission Bio: Honoraria, Speakers Bureau. Levine: Ajax: Membership on an entity's Board of Directors or advisory committees; Isoplexis: Membership on an entity's Board of Directors or advisory committees; Gilead: Honoraria; Prelude: Membership on an entity's Board of Directors or advisory committees; Auron: Membership on an entity's Board of Directors or advisory committees; Mission Bio: Membership on an entity's Board of Directors or advisory committees; C4 Therapeutics: Membership on an entity's Board of Directors or advisory committees; Celgene: Research Funding; Zentalis: Membership on an entity's Board of Directors or advisory committees; Imago: Membership on an entity's Board of Directors or advisory committees; Amgen: Honoraria; Lilly: Honoraria; QIAGEN: Membership on an entity's Board of Directors or advisory committees; Morphosys: Consultancy; Astellas: Consultancy; Janssen: Consultancy; Incyte: Consultancy; Roche: Honoraria, Research Funding.

Esophageal Stricture: Not Your Usual Culprit?

Question: A 60-year-old woman with past medical history of ATTR amyloidosis and status post heart and liver transplantation presented with complaints of progressive esophageal dysphagia to solids and liquids. She was on tacrolimus, mycophenolate mofetil (MMF), and prednisone. Other pertinent medications included trimethoprim sulfamethoxazole and valganciclovir for infection prophylaxis. Physical examination and laboratory data were unremarkable. Esophagogastroduodenoscopy (EGD) with histopathologic examination of biopsies from the middle third of the esophagus showed the findings presented in Figure A and B. Despite high-dose proton pump inhibitor therapy and repeated dilations, symptoms were unchanged and little progress was made in maintaining an increase in luminal diameter. What is the most likely diagnosis? Look on page 400 for the answer and see the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. The EGD demonstrates a long, benign-appearing, intrinsic moderate stenosis with extensive fibrotic stricturing in the middle one-third of the esophagus (8 mm inner diameter × 4 cm in length) (Figure A). The stenosis was dilated with a through the scope dilator to 11 mm. Esophageal biopsies demonstrated extensive ulceration with fibrinopurulent exudate and inflamed granulation tissue (Figure B). No fungal or viral infection or malignancy was seen. The patient underwent placement of a percutaneous gastrostomy tube. Over the next year, despite continuous high-dose proton pump inhibitor therapy, she continued to experience dysphagia and required monthly dilations. After ruling out an infectious etiology, MMF was suspected as the possible culprit. Immediately upon withdrawal of MMF, the patient reported significant clinical improvement. A follow-up EGD 4 months later showed a widely patent esophageal lumen with only mild mucosal variance characterized by flattening and scarring in the mid esophagus. MMF has well-known gastrointestinal (GI) adverse effects, including nausea, vomiting and diarrhea. Although the entire GI tract is susceptible to MMF-related toxicity, the colon and, less commonly, the small bowel are the most affected areas.1Nguyen T. Park J.Y. Scudiere J.R. Montgomery E. Mycophenolic acid (CellCept and Myofortic) induced injury of the upper GI tract.Am J Surg Pathol. 2009; 33: 1355-1363Crossref PubMed Scopus (59) Google Scholar A variety of mucosal changes can be seen in the lower GI tract, ranging from inflammatory bowel disease–like changes to features akin to graft-versus-host disease. Upper GI tract toxicities of MMF have included features ranging from those compatible with nonsteroidal anti-inflammatory drug use with topical irritation and damage to ulcerative esophagitis, reactive gastropathy, and duodenal ulceration.2Panarelli N.C. Drug-induced injury in the gastrointestinal tract.Semin Diagn Pathol. 2014; 31: 165-175Crossref PubMed Scopus (24) Google Scholar MMF-related esophageal strictures are rare.3Kim J.J. Mulki R.H. Sebastian K.M. Recalcitrant esophageal stricture secondary to mycophenolate mofetil.Case Rep Gastrointest Med. 2020; 2020: 8817801PubMed Google Scholar This case highlights an uncommon cause of a refractory esophageal stricture that should be considered as a potential etiology for dysphagia, especially in a transplant recipient, when more common etiologies have been excluded or when esophagitis is refractory to proton pump inhibitor therapy.

An Atypical Autoinflammatory Disease Due to an LRR Domain NLRP3 Mutation Enhancing Binding to NEK7

The NLRP3 inflammasome is a vital mediator of innate immune responses. There are numerous NLRP3 mutations that cause NLRP3-associated autoinflammatory diseases (NLRP3-AIDs), mostly in or around the NACHT domain. Here, we present a patient with a rare leucine-rich repeat (LRR) domain mutation, p.Arg920Gln (p.R920Q), associated with an atypical NLRP3-AID with recurrent episodes of sore throat and extensive oropharyngeal ulceration. Unlike previously reported patients, who responded well to anakinra, her oral ulcers did not significantly improve until the PDE4 inhibitor, apremilast, was added to her treatment regimen. Here, we show that this mutation enhances interactions between NLRP3 and its endogenous inhibitor, NIMA-related kinase 7 (NEK7), by affecting charge complementarity between the two proteins. We also demonstrate that additional inflammatory mediators, including the NF-кB and IL-17 signalling pathways and IL-8 chemokine, are upregulated in the patient’s macrophages and may be directly involved in disease pathogenesis. These results highlight the role of the NLRP3 LRR domain in NLRP3-AIDs and demonstrate that the p.R920Q mutation can cause diverse phenotypes between families.

Clinical presentation of simple and combined or syndromic arteriovenous malformations

ObjectiveArteriovenous malformations of the lower extremities (AVMLE) can present as simple or complex combined or syndromic forms (eg, Parkes Weber Syndrome). We aimed to characterize the differences in clinical presentation and natural history of these potentially life- and limb-threatening congenital vascular malformations. MethodsWe conducted a retrospective analysis of a consecutive series of patients with AVMLE who presented to a tertiary referral center in Switzerland between 2008 and 2018. Clinical baseline characteristics, D-dimer level, and course were summarized and differences between simple, non-syndromic and combined or syndromic AVMLE determined. Odds ratios (ORs) and 95% confidence intervals (CIs) were estimated using logistic regression models. ResultsOverall, 506 patients were prospectively enrolled in the Bernese Congenital Vascular Malformation Registry, 31 (6%) with AVMLE. There were 16 women and 15 men, with a mean age of 18 years at first diagnosis (range, 1 month to 72 years). Simple AVMLE was present in 22 (71%) and combined or syndromic AVMLE with limb overgrowth in 9 patients (29%), respectively. Common symptoms and signs were pain (n = 25; 81%), swelling (n = 21; 68%), and soft tissue hypertrophy (n = 13; 42%). Among combined or syndromic patients, three patients died from wound infection with sepsis or disseminated intravascular coagulation with bleeding complications (intracranial hemorrhage and bleeding from extensive leg ulcers). Combined or syndromic patients presented more often with bleeding (67% vs 5%; P < .001), malformation-related infection (44% vs 5%; P = .017) and leg length difference (56% vs 14%; P = .049). D-dimer levels were elevated (mean, 17,256 μg/L; range, 1557-80,000 μg/L) and angiographic appearance showed complex, mixed type of AVMs, including interstitial type IV, in all patients with combined or syndromic AVMLE. ConclusionsPatients with congenital simple AVMLE most often present with benign clinical features and rarely with complications related to hemodynamic changes. Patients with combined or syndromic AVMLE often face serious outcomes dominated by complications other than direct high-flow-related heart failure.

S2556 A Case of Pancreatic Gastrinoma Diagnosed by Endoscopic Ultrasound

Introduction: Gastrinomas are a rare neuroendocrine tumor that predominantly secretes gastrin and leads to peptic ulcer disease, acid reflux, and malabsorption. Diagnosis is usually made by gastrin levels and secretin stimulation test (SST). Here, we present a case of gastrinoma diagnosed by endoscopic ultrasound (EUS). Case Description/Methods: 49 year old female with chronic pancreatitis secondary to alcohol presented for syncopal episode. She noted melena for the last 4 days, with a similar episode 2 years ago found to have “bad stomach ulcers”, but with no follow-up. She was transfused blood and started on PPI upon arrival. Upper endoscopy showed thickened gastric folds and extensive ulceration from duodenum to jejunum suggestive of gastric acid hypersecretion. Further work up showed gastrin 436 and gastric acid pH 1-2. Due to concern for outpatient follow-up, octreotide scan was done which was negative. We proceeded to EUS with the patient’s consent, which showed atrophic pancreas with calcification throughout, and a 2-3 cm focal parenchyma devoid of calcification suspicious for mass from which fine needle aspiration (FNA) was performed. Pathology confirmed a well-differentiated neuroendocrine tumor. Patient was continued on PPI and referred outpatient for surgical resection. Discussion: The screening criteria of gastrinoma is fasting gastrin level > 1000 pg/mL and gastric pH < 2. SST can confirm diagnosis for those without active severe manifestations due to risks of stopping PPI in these patients. For localization, Ga-68 dotatate PET CT is the most sensitive test while octreotide scan has lower sensitivity and specificity. If these are unsuccessful, EUS and exploratory laparotomy may be considered. In this case, our patient was difficult to diagnose. Her clinical and endoscopic findings were highly suggestive of gastrinoma, however her initial tests were inconclusive and an SST was unable to be performed due to her acute presentation. With our endoscopy team, a suggestive pancreatic lesion was biopsied and confirmed the diagnosis. EUS is a relatively low risk procedure that allows for FNA as an alternative to diagnose gastrinomas. Studies have found that EUS has high sensitivity for detection and localization, particularly for pancreatic tumors, and can detect even small tumors. Therefore, EUS can be an effective and safe method to diagnosis that can lead to definitive treatment.Figure 1.: (a) Numerous large, circumferential duodenal ulcers on EGD. (b) Ulcer extension to the jejunum on EGD. (c) Atrophic calcified pancreas with focal area devoid of calcifications between pancreatic neck and body on EUS. (d) H&E showing polygonal cells with round, regular nuclei. (e) Synaptophysin positivity for neuroendocrine differentiation supporting gastinoma.

Effect of Platelet Rich Plasma on Corneal Alkali Burn Ulcer in Rabbits

Objective of this study to assess the efficacy of platelet rich plasma (PRP) in the treatment of extensive corneal ulcers in albino rabbits with two different administration techniques. A total of 24 rabbits were used in this study. After collecting intracardiac blood samples, platelet-rich plasma was obtained by double centrifugation. Alkali burns were inflicted on the central corneas of all rabbits using a sterile swab soaked in 1 M NaOH for 60s. Only Left eye in each rabbit was used. Animals were divided into 4 groups. GroupI (n=6) normal control group received PRP drop twice daily with 8-h intervals for 7 successive days. whereas group II (n = 6) did not receive any treatment and served as the control untreated group. The third group (n = 6) received only one-shot of subconjunctival PRP. The fourth group (n=6) received PRP drop twice daily with 8-h intervals for 7 successive days. Corneal histopathology was investigated for epithelial regeneration, presence of inflammation, and structural integrity of fibroblasts. Data were expressed as mean ± standard deviations. Data from experimental groups were statically analyzed using one-way ANOVA with Turkey’s post hoc multiple comparisons tests using the GraphPad Prism software version 5 (San Diego, CA, USA) and P

Primary Invasive Gastric Mucormycosis Presenting as Meleney's Gangrene

Mucormycosis is an uncommon but potentially lethal fungal infection in immunocompromised individuals. The natural history of the disease is vascular invasion followed by thrombosis and necrosis of infected tissues. It can affect any organ system. Gastrointestinal (GI) mucormycosis is quite rare. Here, we report a case of primary invasive gastric mucormycosis in a 45-year-old male with diabetes and ethanol-related chronic liver disease who presented with necrotizing fascitis of the left thigh, groin, and lower abdominal wall. At presentation, he was hemodynamically unstable, anuric, and febrile with a high blood glucose level. He was stabilized with aggressive debridement and critical care management. During hospitalization, he developed sudden episode of upper GI bleed. Gastroscopy revealed extensive ulcerations with thick mucus in the fundus and body of the stomach. Biopsy from the lesions and special stain examination was consistent with invasive gastric mucormycosis. Delayed presentation of our patient and rapid progression to fungemia resulted in mortality.

Extranodal natural killer T cell lymphoma of the oropharyx: case report

BackgroundT cell lymphoma of the upper aerodigestive tract is a rare entity usually presenting as midfacial ulcerative lesion. It is extremely rare to present as non-healing erosive lesion of the oropharynx.Case presentationA 29-year-old female patient presented with odynophagia and trismus for several months. An “inflammatory” oropharyngeal ulcer was diagnosed and she was treated with repeated courses of antibiotics and corticosteroids without response. Recently, she had some blood stained saliva and vomited fresh blood. When seen, she had extensive painful ulcer eroding the right side of the soft palate and right tonsillar area. The ulcer had a whitish floor and ragged border without any tendency to heal. A second biopsy was taken and proved the lesion to be extranodal natural killer T cell lymphoma (ENKTL). The patient was treated with a modified SMILE (steroid, methotrexate, ifosfamide, l-asparaginase, and etoposide) protocol.ConclusionsExtranodal natural killer T cell lymphoma can manifest first in the oropharynx. If left untreated it may lead to deep erosive lesion and major oral bleeding. SMILE chemotherapy protocol was used in our patient with good early response.

Endoscopic Prediction of Crohn's Disease Postoperative Recurrence.

The presence and severity of endoscopic recurrence after Crohn's disease intestinal resection predicts subsequent disease course. The Rutgeerts postoperative endoscopic recurrence score is unvalidated but has proven prognostically useful in many clinical studies. This study aimed to investigate the association between specific early endoscopic findings and subsequent disease course. In the setting of a randomized controlled trial (the POCER study), 85 patients underwent colonoscopy at 6 and 18 months after intestinal resection. Patients received 3 months of metronidazole, and high-risk patients received a thiopurine (or adalimumab if they were thiopurine intolerant). For endoscopic recurrence (Rutgeerts score ≥i2) at 6 months, patients stepped up to a thiopurine, fortnightly adalimumab with thiopurine, or weekly adalimumab. Central readers confirmed Rutgeerts, Simple Endoscopic Score for Crohn's Disease, Crohn's Disease Endoscopic Index of Severity scores, and 5 newly tested endoscopic parameters: anastomotic ulcer depth (superficial vs deep), number of ulcers (0, ≤2, >2), ulcer size (1-5 mm, ≥6 mm), circumferential extent of ulceration (<25%, ≥25%), and the presence or absence of stenosis. The POCER index, based on the 6-month postoperative findings, was then developed in relation to predicting the endoscopic outcome at 18 months. Of the 5 parameters, the combination of ulcer depth and circumference at the anastomosis at 6 months was associated with endoscopic recurrence at 18 months (odds ratio [OR], 1.6; 95% confidence interval [CI], 1.03-2.50; P = 0.035) with an area under the receiver operating characteristic curve of 0.62 (95% CI, 0.5-0.75). The combination of these 2 parameters formed the basis of the POCER index (range, 0-4 with 0 denoting no ulcers and 4 denoting deep ulceration with >25% circumferential involvement). The new index had a strong correlation with the Rutgeerts score measured at the same time points: Spearmans' r = .80 at 6 months and r = .77 at 18 months (P < 0.001 at both time points). A POCER index of ≥2 and a Rutgeerts score of ≥i2 both had a sensitivity of 0.41 for recurrence; however, the POCER index had a higher specificity (0.8 and 0.67, respectively). The POCER index at 6 months was associated with endoscopic recurrence at 18 months (OR, 1.5; 95% CI, 1.2-2.0; P = 0.002; area under the receiver operating characteristic curve of 0.70; 95% CI, 0.57-0.82), but the Rutgeerts score was not (OR, 1.2; 95% CI, 0.8-1.8; P = 0.402). The POCER postoperative index comprises 2 key endoscopic factors related to the anastomosis that are associated with subsequent disease progression. A higher score, comprising the adverse prognostic factors of deep or circumferentially extensive anastomotic ulceration, may help identify patients who require more intensive therapy.

Novel Insights for Patients with Multiple Basal Cell Carcinomas and Tumors at High-Risk for Recurrence: Risk Factors, Clinical Morphology, and Dermatoscopy.

Simple SummaryWe investigated 225 patients with 304 primary basal cell carcinomas (BCCs) and we conducted a retrospective, morphological, cohort study aimed at evaluating patients’ demographics and tumors’ clinical and dermatoscopic characteristics. Our main objectives were the detection of risk factors for multiple BCCs in individual patients and the description of clinical and dermatoscopic features of low and high risk for local recurrence tumors. The rising incidence of BCC and the occurrence of multiple tumors in individual patients poses BCC as a major issue for health systems. To the best of our knowledge, this is one of the first studies to attempt to unveil clinical and dermatoscopic features of low-/high-risk neoplasms beyond histopathology and take into equal account parameters, such as anatomic location and size of the lesion. We strongly support that profiling of multiple patients with BCCs and a thorough knowledge of high-risk tumors’ clinico-dermatoscopic morphology could provide physicians with important information towards prevention of this neoplasm.Introduction: Basal cell carcinoma (BCC) quite frequently presents as multiple tumors in individual patients. Neoplasm’s risk factors for local recurrence have a critical impact on therapeutic management. Objective: To detect risk factors for multiple BCCs (mBCC) in individual patients and to describe clinical and dermatoscopic features of low- and high-risk tumors. Materials & Methods: Our study included 225 patients with 304 surgically excised primary BCCs. All patients’ medical history and demographics were recorded. Clinical and dermatoscopic images of BCCs were evaluated for predefined criteria and statistical analyses were performed. Results: Grade II-III sunburns before adulthood (OR 2.146, p = 0.031) and a personal history of BCC (OR 3.403, p < 0.001) were the major predisposing factors for mBCC. Clinically obvious white color (OR 3.168, p < 0.001) and dermatoscopic detection of white shiny lines (OR 2.085, p = 0.025) represented strongly prognostic variables of high-risk BCC. Similarly, extensive clinico-dermatoscopic ulceration (up to 9.2-fold) and nodular morphology (3.6-fold) raise the possibility for high-risk BCC. On the contrary, dermatoscopic evidence of blue-black coloration had a negative prognostic value for high-risk neoplasms (light OR 0.269, p < 0.001/partial OR 0.198, p = 0.001). Conclusions: Profiling of mBCC patients and a thorough knowledge of high-risk tumors’ clinico-dermatoscopic morphology could provide physicians with important information towards prevention of this neoplasm.

P195 Predictors of colectomy in patients with acute severe ulcerative colitis: single-center retrospective analysis

Abstract Background Acute severe ulcerative colitis is observed in 25% of patients1. Near 40% of this severe patients might undergo surgery2 and the mortality rate in this group of patients reaches 6.3%3. Untimely surgery leads to severe metabolic disorders, infectious postoperative complications, and increases the risk of death4,5. Eventually, the purpose of this study is identify predictors of colectomy in patients with acute severe ulcerative colitis. Methods A retrospective study included 74 patients with acute severe ulcerative colitis, who were treated at the clinic in 2017(Fig. 1). The patients were divided into the groups: group of colectomy - 54/74 (73%) and group of conservative treatment 20/74 (27%) (Fig 1). The predictors, like serum albumin, C-reactive protein, hemoglobin, endoscopic picture of «extensive ulcers», and clinical data were analyzed. The statistical analysis was performed using the software«Statistica 13.3» and «RStatistica». Results There were no difference by gender, age and duration of the disease in the groups. Mean of albumin and hemoglobin levels were significantly lower in the colectomy group. The endoscopy «extensive ulcers» was significantly more common in the operated patients (Tab 1). Also univariate, multivariate and ROC analyses were performed (Tab 2), (Fig 2). The risk of colectomy when endoscopy «extensive ulcers» combined with an albumin level&amp;lt;31 g/l and hemoglobin&amp;lt;107 g/l, was 100%. A nomogram for predicting the probability of colectomy was constructed (Fig 3). This logistic model has a statistically significantly high predictive value (AUC=0.93, p=0.006). Conclusion The endoscopic picture of «extensive ulcers» in combination with an albumin level of less than 31 g/l and hemoglobin less than 107 g/l are predictors of colectomy with high predictive value.

Congenital Insensitivity to Pain and Anhidrosis: A painful experience by a painless child

A three-year-old boy with congenital insensitivity to pain and anhidrosis (CIPA) was first presented with transphyseal separation of distal left humerus. Surgical treatment with closed reduction and k-wiring of transphyseal separation of distal humerus resulted in devastating surgical site infection and osteomyelitis. Multiple surgical debridement and application of external fixator to eliminate infection were futile. At the age of four years, he refused to bear weight as a result of left hip dislocation. Closed reduction and spica cast was unsuccessful, resulting in recurrent left hip dislocation. He has since not been able to walk. At the age of five years, the right hip was dislocated followed by ipsilateral subtrochanteric femur fracture. Appropriate treatments such as hip spica and titanium elastic nail were not possible due to extensive bruising and skin ulceration over the right thigh. This child ended up with a functionless left upper limb, bilateral hip dislocation and malunited right femur fracture. Conservative treatment and watchful neglect might be the ideal treatment for patients with CIPA.

Washed microbiota transplantation for the treatment of recurrent fungal infection in a patient with ulcerative colitis.

Washed microbiota transplantation for the treatment of recurrent fungal infection in a patient with ulcerative colitis.

Congenital Inferior Vena Cava Agenesis with Ulceration and Deep Vein Thrombosis.

This is one of the few case reports of congenital inferior vena cava atresia (IVCA) with extensive bilateral lower extremity ulcers. IVCA is a congenital anomaly characterized by poor venous return in the lower extremities with increased risk of deep vein thrombi (DVTs) and, rarely, non-healing ulcers. A 45-year-old woman with history significant for DVTs presented with extensive bilateral lower extremity ulcers, and a CT scan revealed congenital IVCA. Oedema management, DVT prevention, routine wound care and skin grafts resolved the ulcers. Congenital venous abnormalities should be included in the differential diagnosis of multiple unprovoked DVTs and non-healing ulcers. There are very few reports in the English literature describing inferior vena cava atresia with extensive bilateral lower extremity ulcers.We present our findings as well as new insights into the congenital causes of bilateral lower extremity ulcers and deep vein thrombi (DVTs).Especially for young adults with a history of multiple DVTs and non-healing ulcers, venous abnormalities should be included in the differential diagnosis and advanced imaging should be utilized.

P0696 / #465: WHEN DIVERTING COLOSTOMY PERFORM TO CRITICAL ILLNES FOR SEVERE PERIANAL OPEN WOUNDS?

Aims & Objectives: The aim of the present study was to analyze the outcome after performing a diversion colostomy in children with severe perianal lesion. Methods: We are presenting to case series whose diverting colostomy was opened for large perianal open wounds and sepsis. Results: Our first patient was 6-month girl whose diagnosed with meningococcemia had extensive necrotizing wounds in the perianal region, a colostomy performed (on the 40th day hospitalization) to prevent stool passage and skin irritation. In the follow-up of the patient, wound healing was observed and no additional problem was observed. It was learned that the patient’s colostomy was closed in the 5th month. Second patient was 7-moth girl, also she was diagnosed meningococcemia along with severe purpura fulminans then extensive necrotizing wounds in the perianal region, a colostomy performed (on the 23th day of admission). The patient is still in our hospital and has colostomy. The patient was in good general condition. Third patient’s disorder was dilated cardiomopathy and then total artificial heart support implanted because of failure. He had extensive sacral decubitus ulcer and a colostomy performed (on the 58th day of hospitalization). After healing of the patient’s wound, colostomy was closed in the 10th month hospitalization. We achieved successful results in 3 patients.Conclusions: In conclusion, the present study is the first to case series the use of diverting colostomy method for critically ill children sever and large open perianal wounds. Colostomy may be good treatment option for perineal severe tissue lost.

Ischemic proctitis 6\xa0months after laparoscopic sigmoidectomy: a case report

BackgroundIschemic colitis is a common disease; however, its pathophysiology remains unclear, especially in ischemic proctitis after sigmoidectomy. We present a rare case of ischemic proctitis 6 months after laparoscopic sigmoidectomy.Case presentationThe patient was a 60-year-old man with hypertension, type 2 diabetes, and hyperlipidemia. He was a smoker. He underwent laparoscopic sigmoidectomy for pathological stage I sigmoid colon cancer and was followed up without any adjuvant therapy. Six months after his surgery, he complained of lower abdominal discomfort, bloody stools, and tenesmus. Colonoscopy showed extensive rectal ulcers between the anastomotic site and the anal canal, which was particularly severe on the anal side several centimeters beyond the anastomosis. We provided non-surgical management, including hyperbaric oxygen therapy. The rectal ulcers had healed 48 days after the therapeutic intervention. He has not experienced any recurrence for 3.5 years.ConclusionsWhile performing sigmoidectomy, it is important to consider the blood backflow from the anal side of the bowel carefully, especially for patients with risk factors of ischemic proctitis.

Sudden Chest Pain Due to Esophageal Intramural Dissection

Sudden Chest Pain Due to Esophageal Intramural Dissection

A case of refractory pouchitis complicated by cytomegalovirus infection requiring administration of ganciclovir and infliximab

Pouchitis is a frequent complication of surgical treatment of ulcerative colitis (UC), and is typically treated using antimicrobials. If pouchitis is refractory to antimicrobials, screening for complications, such as cytomegalovirus (CMV) infection, is necessary. However, the optimal approach to management of pouchitis complicated by CMV infection is unclear. We report the case of a 41-year-old female patient with UC presenting with pouchitis associated with CMV infection; she had received subtotal colectomy/ileal pouch anal anastomosis (IPAA). She was admitted to hospital with persistent fever, epigastric discomfort, and watery diarrhea despite receiving antibiotics. Laboratory findings showed inflammation and reactivation of CMV infection accompanied by liver injury. The endoscopic findings showed inflammation of the pouch and ileal mucosa on the oral side with extensive and deep punched-out ulcers. Immunohistological staining of biopsy specimens from an ulcerated lesion demonstrated CMV infection. Therefore, we diagnosed the patient with pouchitis complicated by CMV infection. The patient was treated with ganciclovir and infliximab, which resolved her symptoms and led to the disappearance of CMV-positive cells. There has been no recurrence of pouchitis. CMV infection should be considered in patients with UC who develop refractory pouchitis.

Multiple Site Peripheral Arteriovenous Malformations: A Definitive Diagnosis Using Duplex Ultrasound

We present a case of a 70-year-old woman with extensive, multiple, dystrophic, necrotic, and bleeding ulcers on her forearm stump, shoulder, and chest wall. She had previously undergone a mid-forearm amputation due to a bleeding fungating ulcer from an arteriovenous malformation (AVM) on the dorsum of her right hand. Considering her history, AVM was suspected as the cause of the lesions. Due to significant renal impairment, duplex ultrasound (DU) was crucial in diagnosing and subsequent surgical management of her multifocal AVMs.