Intermittent Abdominal Cramping Research Articles

Hemoperitoneum Due to Dissection and Rupture of the Superior Mesenteric Artery in a Patient With COL3A1 Mutation.

Introduction: Vascular Ehlers-Danlos syndrome (vEDS) is an autosomal dominant disorder that results from mutations in the collagen type III gene. It is a risk factor for medium-sized artery aneurysms, dissections, and ruptures. We report a case of hemoperitoneum due to medial dissection and rupture of the superior mesenteric artery related to vEDS. Methods: A full body CT scan and full three cavity autopsy was performed in a 47-year-old man with a history of an intermittent abdominal cramping for one week rand complex past medical history that included a sigmoid bowel perforation at age 20, and previous popliteal artery pseudoaneurysm rupture. Histology and genetic testing were performed. Results: The postmortem computed tomography and autopsy showed a significant hemoperitoneum due to a ruptured dissection of the superior mesenteric artery and branches, and multiple splanchnic artery dissections with renal and small bowel infarctions. Genetic testing revealed a heterozygous COL3A1 gene variant associated with Ehlers-Danlos syndrome. Death was attributed to hemoperitoneum due to medial dissection and rupture of the superior mesenteric artery due to arteriopathy. Discussion: The relatively young age and medical history correlate with the autopsy findings and genetic testing towards the conclusion of an arteriopathy consistent with vEDS.

DEVELOPMENT OF A NOVEL DRUG DELIVERY SYSTEM (DDS) TO DELIVER DRUGS DIRECTLY TO THE COLONIC MUCOSA TO IMPROVE EFFICACY AND REDUCE SYSTEMIC EXPOSURE FOR THE TREATMENT OF ULCERATIVE COLITIS (UC)

Abstract The clinical remission rate in moderate to severe ulcerative colitis (UC) and Crohn’s Disease (CD) has plateaued at ~15-20% despite the approval of multiple therapeutics. Research has shown that an inadequate amount of drug at the disease site in the colon may be responsible for limited clinical benefit. The Drug Delivery System (DDS) is an ingestible electronic targeted delivery device containing a localization system to autonomously identify colon entry based on gastrointestinal (GI) anatomy, independent of the variable GI physiological conditions deliver a bolus dose of a liquid drug formulation to the colon mucosa to improve efficacy and reduce systemic toxicity. Here, we aim to evaluate the safety, tolerability, and functionality of a single dose of the DDS using gamma scintigraphy images as a reference in both normal healthy volunteers (NHV) (PM-601) and subjects with active UC (PM-602) in a fasted state. A total of twelve NHV (N=12) and seven subjects with an endoscopically confirmed history of UC and active UC (N=7) status, defined as having a Mayo score ≥ 2 or elevated fecal calprotectin protein or high sensitivity C-reactive protein within one month of the screening visit, were enrolled and dosed in these studies. Each subject fasted overnight and was dosed with a single DDS device before resuming a normal diet at 4 hours post-dose. Each device was filled with radioactive marker indium-111 DTPA and co-administered with water to which technetium-99m DTPA was added to monitor device GI transit and payload release in the GI tract. The GI transit of the device and delivery location of the radioactive payload were confirmed by serial scintigraphy imaging and compared with the localization data recovered from the devices. GI transit metrics showed a more variable GI motility and frequent bowel movements were observed among active UC subjects compared to NHV (Table 1). The DDS device was well tolerated in both NHV and active UC subjects. One subject with active UC (PM-602) experienced mild intermittent abdominal cramping following device administration possibly related to the device, which resolved on the same day. No other device-related AEs were reported in these studies. The results from these two studies demonstrated a total of 17 out of 19 DDS devices (90%) successfully identified colon entry and 15 out of 19 DDS devices (79%) delivered the radio payload into the colon regardless of variable GI transit time, the level of inflammation, or the presence of blood in the stool (Table 1 & 2). The dispersion of the radiotracer adequately covered the colon from the site of release throughout the remainder of the colon. These results demonstrated that the DDS device was well-tolerated and functioned as intended to deliver radiotracer throughout the colon regardless of variable GI motility, disease, and inflammation status.

Small Bowel Obstruction Caused by Metastasis of Nasal Cavity Basal Cell Adenocarcinoma

We report the case of a 68-year-old male with mechanical small bowel obstruction complicated by metastasis of nasal cavity basal cell adenocarcinoma (BCAC). The initial presentation included intermittent abdominal cramping pain and postprandial vomiting. We performed diagnostic laparoscopy under the impression of small bowel obstruction and noticed a tumor located at the terminal ileum. Tumor excision and end-to-end intestinal anastomosis were performed, and pathology reports confirmed the diagnosis of metastatic BCAC. A literature review revealed that small bowel metastatic tumors are rarely caused by BCAC, and that distant metastases of BCAC are also rare. Being aware of this rare disease may lead to an earlier correct diagnosis of small bowel obstruction due to a metastatic tumor.

S1793 Aeromonas Spp. Enteritis in the Course of Recurrent Immune Checkpoint Inhibitor Colitis

INTRODUCTION: The role of Aeromonas spp. as a gastrointestinal pathogen is debated.1 Here we present an Aeromonas infection in a patient with recurrent immune checkpoint inhibitor (ICI) colitis. CASE DESCRIPTION/METHODS: A 61-year-old Caucasian female with Stage IV Melanoma and history of recurrent ICI colitis presented with 6 days of watery diarrhea, nausea and vomiting. The patient had recently completed 2nd induction of Ipilimumab, an anti-CTLA-4 immunotherapy agent, while being on vedolizumab concurrently with oral budesonide for previous episodes of nausea and vomiting. She endorsed intermittent abdominal cramping and decreased PO tolerance but denied fevers, bloody diarrhea, hematemesis. On exam, abdomen was benign and non-tender. Serology labs were unremarkable. Stool studies were significant for positive lactoferrin and elevated calprotectin to 432 μg/g. Patient was started on solumedrol 40 mg IV BID empirically. GI multiplex PCR panel was negative including C. Difficile. Stool culture was positive for pan-susceptible Aeromonas spp. Patient was started on a 7-day course of Ciprofloxacin 500 mg BID and prednisone taper resulting in improved PO tolerance, resolution of diarrhea and decreased nausea and vomiting on discharge. DISCUSSION: Aeromonas spp. infections, although rare, most typically present with gastrointestinal symptoms. It has been implicated as an opportunistic pathogen in inflammatory bowel disease; however, its role in patients with ICI colitis remains unclear.2 Our patient had presented with similar symptoms and negative stool cultures several months prior and was treated for ICI colitis. This diagnosis was confirmed by colonoscopy showing active cryptitis and apoptotic bodies. In the current presentation, it is unclear what the primary cause of her symptoms was. Concurrent administration of both antibiotics and steroids improved her symptoms possibly suggesting a combination of Aeromonas spp. infection and ICI colitis which has never been reported previously in literature. Further studies with larger cohorts of patients with ICI colitis are warranted to investigate the pathogenicity and role of Aeromonas infection.

2099 E. coli Sepsis Following FMT in an IgA Deficient IBD Subject

INTRODUCTION: Fecal microbiota transplant (FMT) has been demonstrated to be an effective treatment option for recurrent C. difficile infections (RCDI) with minimal serious adverse reactions reported. Although the results of FMT for RCDI are promising, the screening process (for both donors and recipients) remains largely unregulated by the FDA. CASE DESCRIPTION/METHODS: A 19 y.o. male with a history of primary IgA deficiency, growth hormone deficiency, asthma, and ulcerative colitis presented to his gastroenterologist with his 3rd C. difficile infection in a 4 month period. FMT was performed via colonoscopy using commercially sourced stool. 10 days later, the patient presented to the ER with explosive bloody diarrhea, up to 20 BMs per day. He was also positive for leukocytopenia, tachycardia, intermittent subjective fevers, chills, night sweats, and abdominal cramping. Stool studies were positive for EPEC, ETEC, and Shiga toxin-producing E. coliO157:H7. Patient was not given antibiotics and received supportive care for 17 days until discharge. He has a good prognosis and has not experienced a recurrence of CDI since the FMT 3 months ago. Unbeknownst to his Gastroenterologist, the patient had a history of mostly asymptomatic, total primary IgA deficiency that was diagnosed in the Czech Republic. DISCUSSION: This appears to be the first reported instance of an individual with Primary IgA Deficiency undergoing FMT and also the first reported instance of FMT-introduced E. coli O157:H7 infection. The patient’s complete lack of IgA appears to be the main catalyst for his disastrous response to FMT. While barrier defects secondary to IBD and the concomitant use of immunosuppressive medications (Xeljanz and Entyvio) can increase susceptibility to infections, studies have shown FMT does not carry an increased risk of serious adverse effects in immunocompromised patients (including IBD patients on immunosuppressive therapy). This patient was not screened for immunodeficiencies prior to receiving FMT. The FDA has issued guidelines, but does not currently mandate which pathogens the stool must be screened for, or which comorbidities the recipient must be screened for. Given the understood importance of IgA in mucosal immunity against E. coli, and the outcome presented in this study, we suggest that rigorous screening of the recipient's medical history for immunodeficiency, and/or potentially running a basic Immunoglobulin panel, should be considered prior to performing FMT.

Colonic intussusception caused by an ulcerating lipoma in an adult: A rare case report and literature review

Intestinal lipomas are rare nonepithelial tumors that are typically small in size and detected incidentally. Colonic intussusception is an uncommon complication of colonic lipoma. A 56 y old woman visited our emergency room with sudden onset of intermittent abdominal cramps. A CT scan showed a 5.0 cm, nodular, homogenous, hypodense structure in the hepatic flexure of the colon as the lead point of an intussusception. The hypodense structure was suggestive of a colonic lipoma, and the tumor was suspected to be the cause of the intestinal intussusception. Laparoscopic exploration was performed, and the pathology demonstrated a mature submucosal colonic lipoma. In addition to the case report, we discuss the role of imaging modalities in diagnosing neoplasms and for assessing the clinical behavior of lipomas when symptomatic.

Portal Hypertension and Unexplained Diarrhea in an 80-Year-Old Man

Question: An 80-year-old man was referred for evaluation of cirrhosis and chronic diarrhea of unknown etiologies. In the past year he had been diagnosed with ascites, esophageal varices, and splenomegaly. His history was notable for four loose, non-bloody stools per day, intermittent abdominal cramping, and thirty pound weight loss. He denied fever, night sweats, rash, itching, or flushing. Physical examination revealed cachexia, no jugular venous distension, and a distended abdomen with shifting dullness. There were no skin lesions. His only medications were loperamide and propranolol. Laboratory studies showed a white blood cell count 5.5 x 109/L [3.5-10.5 x 109/L], hemoglobin 11 g/dL [13.5-17.5 g/dL], platelets 93 x 109/L [150-450 x 109/L], ALT 111 U/L [7-55 U/L], AST 67 U/L [8-48 U/L], alkaline phosphatase 601 U/L [46-118 U/L], total bilirubin 0.9 mg/dL [0.1-1.0mg/dL], and INR of 3.3. An abdomen/pelvis CT demonstrated hepatosplenomegaly, ascites (Figure A), and punctate sclerotic bone lesions. Diagnostic paracentesis revealed a SAAG of 2.6 and total protein of 1.6 g/dL. Gram stain, bacterial culture, and cytology of the ascitic fluid were negative. Liver biopsy with hematoxylin and eosin staining showed nodules without surrounding fibrosis (Figure B). Serum tryptase was elevated at 243 ng/dL [<11.5 ng/dL]. What is the most likely cause of his diarrhea and portal hypertension?A.Congestive heart failureB.Felty’s syndromeC.Systemic mastocytosisD.Cirrhosis Look on page 819 for the answer and see the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image(s) to Practical Teaching Cases. The correct answer is C. The liver biopsy (Figure B) shows hepatocellular nodules less than 3 mm in diameter with hypertrophic hepatocytes (arrows). These nodules are not surrounded by fibrosis but rather compressed hepatocytes (arrowheads). A reticulin stain (Figure C) highlights the changes of nodular hyperplasia (arrows) and atrophic hepatocytes (arrowheads) which are diagnostic of nodular regenerative hyperplasia (NRH). Given the history of chronic diarrhea, sclerotic bone lesions, and elevated serum tryptase, a bone marrow biopsy was performed. This revealed a hypercellular marrow with 20% involvement by atypical mast cells. Together these findings support a diagnosis of SM and secondary NRH. Congestive heart failure (Answer A) has been associated with NRH but the lack of jugular venous distension on physical exam makes this unlikely. NRH was first described in a patient with rheumatoid arthritis, neutropenia, and splenomegaly (Felty’s syndrome); however, in this case, there is no personal history of rheumatoid arthritis and neutropenia which excludes Felty’s syndrome (Answer B). While cirrhosis (Answer D) may present with esophageal varices, portal hypertension and hypersplenism; liver biopsy would demonstrate fibrosis rather than nodular regenerative hyperplasia. Occasionally, NRH and cirrhosis may be difficult to distinguish, particularly on clinical grounds and radiographic imaging. The diagnosis of NRH is made by liver biopsy. SM is characterized by excessive mast cell accumulation in multiple tissues, most commonly the skin, central nervous system, musculoskeletal system and gastrointestinal tract. Gastrointestinal manifestations such as diarrhea and malabsorption are likely a result of GI mucosal infiltration by mast cells with concomitant release of prostaglandin mediators.1Capron J.-P. Lebrec D. Degott C. et al.Portal hypertension in systemic mastocytosis.Gastroenterology. 1978; 74: 595-597Abstract Full Text PDF PubMed Scopus (28) Google Scholar SM is a rare cause of portal hypertension which may develop from arteriovenous shunting secondary to histamine release, increased intrahepatic resistance due to mast cell infiltration of sinusoids, and the development of NRH.2Grundfest S. Cooperman A.M. Ferguson R. Benjamin S. Portal hypertension associated with systemic mastocytosis and splenomegaly.Gastroenterology. 1980; 78: 370-373Abstract Full Text PDF PubMed Scopus (35) Google Scholar In this case, portal hypertension was caused by the development of NRH. NRH of the liver is an uncommon condition characterized by the diffuse transformation of normal hepatic parenchyma into small, regenerative nodules with no fibrosis. It is associated with systemic diseases including rheumatologic disorders, vascular disorders, myeloproliferative disorders, and certain medications.3Reshamwala P.A. Kleiner D.E. Heller T. Nodular Regenerative Hyperplasia: Not All Nodules Are Created Equal.Hepatology. 2006; 44: 7-14Crossref PubMed Scopus (189) Google Scholar NRH develops as a consequence of portal venopathy and altered hepatic circulation. The nodular areas are believed to develop as hyperperfused hepatocytes become hypertrophic while hypoperfused hepatocytes become atrophic.3Reshamwala P.A. Kleiner D.E. Heller T. Nodular Regenerative Hyperplasia: Not All Nodules Are Created Equal.Hepatology. 2006; 44: 7-14Crossref PubMed Scopus (189) Google Scholar Portal hypertension and its complications are the predominant clinical manifestations of NRH. Occasionally, as in this case, NRH and cirrhosis may be difficult to distinguish on clinical grounds and radiographic imaging. This case illustrates the importance of the gastroenterologist having knowledge of systemic diseases known to be associated with NRH and how liver biopsy is essential for diagnosis. Exam 2: Portal Hypertension and Unexplained Diarrhea in an 80-Year-Old ManGastroenterologyVol. 154Issue 4Preview Full-Text PDF

Laparoscopic resection of a sigmoid colon lipoma in a young female patient: A case report and review of the literature.

Lipomas of the sigmoid colon are rare entities. The present case describes a 27-year-old Caucasian woman who underwent a laparoscopic sigmoidectomy following the detection of a giant lipoma. The young patient was referred to the Emergency Department of the University Hospital of Heraklion (Crete, Greece) in May 2013 after experiencing intermittent abdominal cramping during defecation, and altering episodes of diarrhea and constipation. In addition, the patient described the protrusion of a solid tissue mass shaped like a 'champagne bottle cork' from the anus following defecation. These symptoms had been present for 1 month prior to referral. Physical examination was unremarkable. An urgent colonoscopy revealed a polypoid lesion measuring 2.5 cm in diameter in the sigmoid colon, which was located ~12 cm above the anal ring, with a smooth surface and tissue fragility. Tissue samples were obtained and sent for histopathological analysis. Preoperative contrast-enhanced computed tomography was performed urgently and confirmed the presence of a solid mass in the sigmoid colon without enlargement of regional lymph nodes. Following adequate preparation, the patient underwent a laparoscopic sigmoidectomy with intracorporeal termino-terminal colorectal anastomosis, with the use of a circular stapler. The patient had a positive post-operative outcome without complications and was discharged on day 4 post-surgery in an optimal condition. Histopathological examination of the surgical specimen demonstrated a pedunculated lipoma shaped like a 'champagne bottle cork'. The tumor consisted of mature adipose cells. The overlying colonic mucosa showed hyperplastic crypts with regenerative changes. In the lamina propria mild inflammatory infiltration was observed. At 2 years post-surgery, the patient remains asymptomatic without any clinical evidence of recurrence.

Giant Pedunculated Colonic Lipoma Causing Colo-Colic Intussusception and a Rectal Bleeding

Intussusception is less common in adults than in children. Intussusception in adults is associated with an identifiable etiology in 90% of cases. Lipoma of the large intestine is rare; with a reported incidence ranging between 0.2% and 4.4%. Small Lipomas are usually asymptomatic, but giant Lipomas are often presented as abdominal pain, vomiting, diarrhea, bleeding and Intussusception. We present a case of 45-year-old man in our emergency room with intermittent abdominal cramps, rectal bleeding for eight days. Physical examination showed tenderness in the left lower abdominal quadrant. Blood found in rectal examination. Colonoscopy in two periods revealed an ulcerative mass in the proximal of descending colon. A CT scan showed a coil spring appearance highly suspicious for Intussusception of the descending-colon, a laparotomy was performed. The Intussusception was found in the descending colon, with extended left hemicolectomy, en-bloc resection was performed with end-to-end anastomosis. After surgical resection, the histo pathologic examination of the specimen showed the configuration of pedunculatedlipoma with tip ulceration, measuring 9x5x 6 cm in diameter. Patient discharged on day five post-operative with good condition.

Acute appendicitis associated with an appendiceal carcinoid tumor

A 28-year-old man presentedwith acute periumbilical pain for 1 day. The pain had started in the periumbilical region and then shifted to the right lower quadrant with intermittent abdominal cramps. He visited the hospital and was admitted with the suspicion of acute appendicitis. He was afebrile and hemodynamically stable. No rebound tenderness or abdominal guarding was noted during the physical examination. The appendix could not be visualized by ultrasonography. A computed tomographic scan showed an edematous and dilated appendix with fecolith and one nodular lesion over the proximal part of the appendix (Fig. 1A, arrow). The patient underwent appendectomy, and the gross picture of the appendix showed a white solid mass (1.2 cm in greatest diameter; Fig. 1B, arrow). The postoperative histological examination (Figs. 1C and 2AeD) revealed a Grade 1 neuroendocrine tumor (NET G1; carcinoid). Over the past 2 decades the term “carcinoid tumor” has commonly been used for well-differentiated neuroendocrine neoplasms that have a relatively benign prognosis. According to the newest World Health Organization nomenclature and classification of neuroendocrine neoplasms of the digestive system, a typical carcinoid is classified as a Grade 1 neuroendocrine tumor (NET G1). Appendiceal neuroendocrine tumors are rare and one of more unusual histopathological findings (about 0.37%) when examining appendectomy specimens. Nonetheless, they are the

Chronic Diarrhea, Malabsorption, Villous Blunting, and Microscopy Colitis due to Common Variable Immunodeficiency Syndrome

Introduction: While the most common diagnosis associated with chronic diarrhea and villous atrophy is celiac sprue, Common Variable Immunodeficiency (CVID) can also present similarly. Here we present a case of enteropathy with CVID that had been treated as refractory celiac disease. Case Report: A 42-year-old female with history of iron deficiency anemia, B12 deficiency and chronic diarrhea presented with intermittent abdominal cramping and watery diarrhea. Her symptoms dated back to age 18 after a trip to Indonesia. She was diagnosed with IBS and treated without improvement. Upper endoscopy at outside hospital initially showed mild villous blunting in duodenum consistent with celiac sprue. Gluten free diet was started, and she had minimal response after 2 years. Celiac panel later showed normal endomycial IgA and tissue transglutaminase IgA/IgG with low immunoglobulin A. Further evaluation showed hypogammaglobulinemia which was consistent with CVID. IVIG and Budesonide were started without improvement of her GI symptoms. Prednisone was subsequently started, which led to significant improvement of her GI symptoms. Colonoscopy showed increased intraepithelial hyperlymphocytosis and preserved crypt architecture consistent with lymphocytic colitis. Conclusion: CVID is a rare disease which can mimic GI symptoms and pathology of celiac disease. Although villous atrophy is present in both CVID and celiac disease, milder intraepithelial hyperlymphocytosis, lack of intestinal plasma cells and diffuse follicular lymphoid hyperplasia are more common in CVID. Microscopic colitis has also been reported in CVID enteropathy. This case suggests that it is important to consider alternative diagnosis such as CVID in patients labeled as refractory celiac disease.

Young Male with Cecal Mass and Family History of Skin Tumors

Purpose: Hereditary nonpolyposis colorectal cancer (HNPCC), or Lynch syndrome, is the most common inherited colon cancer syndrome, and accounts for about 3% of all colon cancers. We present an interesting case of a young patient with family history of skin tumors presenting with mechanical obstruction due to a cecal mass. Case: A 33-year-old male with no past medical history developed intermittent abdominal cramping, constipation, and a 40-pound weight loss over the past three months. He presented to the ER with worsening abdominal pain associated with nausea and vomiting. He denied hematochezia, and his last bowel movement was two days prior to admission. The patient had a family history of Muir-Torre syndrome. His maternal grandmother died of colon cancer at a young age, and his mother had multiple sebaceous skin tumors. On exam, his abdomen was distended and diffusely tender, with hypoactive bowel sounds. Computed tomography scan showed a large obstructing cecal mass with dilated distal ileum. The patient was taken to OR for emergent fecal diversion with loop ileostomy. Colonoscopy performed two days post-op revealed an occluding ulcerated cecal mass and a colonic mass at the hepatic flexure. Repeat laparotomy demonstrated a widely metastatic tumor, and the patient underwent cytoreductive surgery with total colectomy and intra-peritoneal chemotherapy. Pathology revealed metastatic high-grade mucinous adenocarcinoma. Conclusion: HNPCC syndrome is an autosomal dominant disorder in which patients are predisposed to colon and a variety of extra-colonic cancers (endometrial, ovarian, urologic, gastrointestinal, skin). Muir-Torre syndrome is a variant of HNPCC in which there is a strong family history of colon cancers in association with sebaceous tumors. Due to early-onset colon cancer, annual screening colonoscopy is recommended starting at age 25. It is important for clinicians to identify families at risk for HNPCC syndrome to initiate timely cancer surveillance. Conclusion: HNPCC syndrome is an autosomal dominant disorder in which patients are predisposed to colon and a variety of extra-colonic cancers (endometrial, ovarian, urologic, gastrointestinal, skin). Muir-Torre syndrome is a variant of HNPCC in which there is a strong family history of colon cancers in association with sebaceous tumors. Due to early-onset colon cancer, annual screening colonoscopy is recommended starting at age 25. It is important for clinicians to identify families at risk for HNPCC syndrome to initiate timely cancer surveillance.

Psychological stressors preceding vitiligo onset are associated with itch and intermittent abdominal cramping

Psychological stressors preceding vitiligo onset are associated with itch and intermittent abdominal cramping

Congenital Membrane Causing Duodenal Obstruction and Malpositioning of the Descending Colon

A congenital membrane without intestinal malrotation is a rare cause of duodenal obstruction. Here we present an 11-year-old girl who had suffered from intermittent abdominal cramping pain and vomiting for more than 5 years. The image studies, including a plain abdomen roentgenogram and sonogram, showed no definite diagnosis. The upper gastrointestinal series and small bowel series showed the contrast was static over the third portion of the duodenum and the descending colon pulled up toward the epigastric area. Laparoscopic exploration revealed a congenital membrane extending from the right-side paraduodenal peritoneum through the third portion of the duodenum to the descending colon, which had caused obstruction of the third portion of the duodenum and malpositioning of the descending colon. To the best of our knowledge, this is the first case report in the literature where a congenital membrane caused both duodenal obstruction and malpositioning of the descending colon.

Endoscopic Resection of Giant Infracted Colonic Inflammatory Fibroid Polyp Mimicking Colonic Neoplasm

Purpose: Inflammatory fibroid polyp (IFP) is an uncommon non-neoplastic lesion more frequently involving the stomach and the small intestine and they are rarely described in the esophagus or the colon. The colonic IFP are usually asymptomatic, however, when they become very large, they may present with colicky pain, weight loss, diarrhea, bleeding, anemia, and intussusceptions. We report a case of giant infracted colonic IFP causing chronic intermittent abdominal pain and hematochezia treated successfully with endoscopic resection. Case: Our patient is an 83 year old male with past medical history of diabetes mellitus, coronary artery disease and end stage renal disease treated with hemodialysis, presented with one week history of hematochezia, chronic intermittent abdominal cramps, and anemia. Physical exam was unremarkable. He was scheduled for colonoscopy which revealed a giant polypoid mass, nearly obstructing the lumen of the descending colon. The mass was pedunculated, had a wide stalk, and measured 7.0 cm in size. Biopsies obtained with forceps revealed acutely inflamed stroma with granulation tissue but no epithelium was present for evaluation. Serum CEA was 1.3. CT scan of abdomen was done and revealed hypodense and heterogeneous mass within the proximal descending colon with somewhat low internal density corresponding to fat density which may represent lipoma, however, malignancy could not be excluded. Surgical option was declined by the patient. Colonoscopy was repeated and endoscopic polypectomy was performed. The mass was removed in a piecemeal fashion on two sessions. Pathology reported a 7.0 x 4.0 x 3.0 cm polyp with extensive infarction and necrosis with some areas of benign inflammatory fibrosis with scattered eosinophils. Immunostain was positive for CD34 and negative for S 100 and desmin. Patient's symptoms resolved completely after polypectomy. Conclusion: Although large benign colonic polyps can be difficult to differentiate from malignant polyps prior to resection, (even with abdominal imaging and direct endoscopic visualization), carefully selected cases can be accurately and safely diagnosed and treated endoscopically. This report is distinct to demonstrate that endoscopic resection of a giant infracted and symptomatic colonic IFP still remains a safe and effective option of therapy when it is performed by experienced endoscopists at the tertiary centers. To our knowledge this is the largest reported pedunculated colonic inflammatory fibroid polyp successfully treated by endoscopic polypectomy.

Henoch-Schönlein Purpura With Intussusception: A Case Report

Gastrointestinal symptoms in Henoch-Schönlein purpura (HSP) are common and occur in about two-thirds of HSP patients. Surgical intervention is only required in a minority of cases. Intussusception is a rare complication and the most common surgical indication for HSP. We report a 3-year-old boy with HSP and clinical manifestations of palpable skin rash Lasting for 4 days, fever for 3 days, intermittent abdominal cramping pain, and left ankle arthralgia Lasting for several hours. Abdominal sonography revealed characteristic signs of intussusception including a doughnut sign and a pseudo-kidney sign in the right upper quadrant of the abdomen. After unsuccessful initial reduction by air enema, surgical reduction was arranged and manual reduction of the ileocecal intussusception without bowel resection was carried out.

Clinical diagnostic problems associated with cecal ameboma. Case report and review of the literature

Amebiasis is uncommon in developed countries. Its clinical presentation can be variable and non-specific, and the diagnosis can be easily overlooked. Among the wide variety of clinicopathologic manifestations of the intestinal amebiasis, amebomas occur rarely, resulting from the formation of annular colonic granulation tissue, usually in the cecum or ascending colon. This report describes the case of a 65-year-old female who presented with a painful mass in the right hypochondrium and intermittent abdominal cramping, associated with defecation difficulty. Radiologic examination depicted thickening of the cecal wall and its ring-like stenosis in association with a mesenteric reaction. Because of concentric thickening of the cecal wall and the mass-like appearance, a preliminary clinical diagnosis of cecal cancer was made, and the patient was referred to the Clinic for surgical treatment. Histologic examination of the surgical specimen after segmental colectomy confirmed the diagnosis of cecal ameboma. The authors conclude that multiple granulomas of amebic trophozoites can be better recognized after PAS staining, and that the pathognomonic feature of protozoa-ingested red blood cells was also seen in the surgical specimen.

Systemic Mastocytosis: A Rare Cause of Portal Hypertension

Purpose: We present a rare case of systemic mastocytosis masquerading as advanced liver disease. An 80-year-old Caucasian man was referred for evaluation of ascites and esophageal varices. His history was notable for frequent watery stools occurring on a daily basis and a thirty pound weight loss over the past year that had remained undiagnosed despite an extensive work-up. In the interim, he had been diagnosed with chronic liver disease of unclear etiology based on the presence of esophageal varices, ascites, and hypersplenism. He reported intermittent abdominal cramping but denied fever, night sweats, rashes, itching, or flushing. On exam, he appeared cachectic and his abdomen was distended with shifting dullness. An abdomen/pelvis CT showed hepatosplenomegaly, ascites, and punctate sclerotic bone lesions. Labs were significant for WBC 5.5 × 10(9)/L with 49% monocytes, hemoglobin 11 g/dL, platelets 93 × 10(9)/L, ALT 111 U/L, AST 67 U/L, alkaline phosphatase 601 U/L, total bilirubin 0.9 mg/dL, and INR of 3.3. Ascitic fluid analysis showed a SAAG of 2.6, total protein of 1.6 g/dL, and 350 cells with 88% monocytes. Gram stain, bacterial culture, and cytology of the ascitic fluid were negative. Liver biopsy revealed nodular regenerative hyperplasia. A bone marrow exam was hypercellular with 20% involvement by systemic mastocytosis. Tryptase immunostaining of the liver biopsy revealed mast cells within the portal areas. Additionally, a serum tryptase was 243 ng/dL (nl < 11.5) which confirmed the diagnosis. Conclusion: Systemic mastocytosis is a rare cause of portal hypertension. Possible mechanisms of portal hypertension in mast cell disease include increased blood flow in the splenic vein, splenic arteriovenous shunting secondary to histamine release, increased intrahepatic resistance secondary to mast cell infiltration, and nodular regenerative hyperplasia. In this case, portal hypertension was likely caused by nodular regenerative hyperplasia and infiltration of portal areas by mast cells. The diagnosis of systemic mastocytosis was considered only after realizing that the diarrhea could not be explained by the degree of portal hypertension and noting the presence of sclerotic bone lesions which prompted a bone marrow biopsy and tryptase measurement. This case highlights the fact that systemic mastocytosis should be considered in the differential of causes of portal hypertension in individuals with evidence of advanced liver disease even when the characteristic cutaneous manifestations of mast cell disease are absent.

Band ligation resection of duodenal carcinoid (with video)

A 51-year-old woman with a 10-year history of irritable bowel syndrome manifested by intermittent abdominal cramps, bloating, and watery diarrhea developed worsening symptoms and new-onset dyspepsia. EGD revealed a small nodule in the duodenal bulb, biopsy specimens of which revealed a carcinoid tumor. She was subsequently referred for endoscopic resection of the lesion (A). There were no clinical features to suggest carcinoid syndrome. Laboratory values were as follows: urinary 5-hydroxyindoleacetic acid screen was negative; serum calcium, alkaline phosphatase, alanine aminotransferase, and aspartate aminotransferase levels were normal; gamma-glutamyl transferase was 46 U/L (range, 13-40 U/L).

Colonic Lipoma With Intussusception

A 51-year-old woman was admitted to the hospital with a 20-day history of intermittent abdominal cramping. Her stools had decreased in volume and had become watery. Physical examination revealed no fever or palpable mass. Computed tomography in the axial plane showed an intussusception of the transverse colon due to a primary mass with dominant fatty density. The relationship of the intussusception to the mass was well delineated on oblique multiplanar reformation, and a diagnosis of colonic lipoma was considered. The patient's obstructive symptoms resolved spontaneously, and she was hesitant about undergoing surgery. However, recurrence of her symptoms a few days later prompted exploratory laparotomy, which revealed a long-stalked mass approximately 7 × 6 × 5 cm at the transverse colon near the hepatic flexure. Resection of the tumor revealed multiple yellowish lobules. Pathologic examination disclosed a lipoma with no evidence of malignancy. Colonic lipomas are relatively rare and frequently asymptomatic. Most gastrointestinal lipomas arise in the submucosa. The colon is commonly affected, followed by the small intestine and then the stomach. Large lipomas may be associated with complications such as intussusception or intestinal bleeding.1Kabaalioglu A Gelen T Aktan S Kesici A Bircan O Luleci E Acute colonic obstruction caused by intussusception and extrusion of a sigmoid lipoma through the anus after barium enema.Abdom Imaging. 1997; 22: 389-391Crossref PubMed Scopus (12) Google Scholar Colonoscopic biopsy is usually performed to confirm the nature of the tumor. However, inadequate tissue samples often indicate nonspecific colitis because of adjacent mucosal inflammation produced by the lipoma.2Zhang H Cong JC Chen CS Qiao L Liu EQ Submucous colon lipoma: a case report and review of the literature.World J Gastroenterol. 2005; 11: 3167-3169Crossref PubMed Scopus (52) Google Scholar Computed tomography clearly reveals the characteristic fatty densitometric features of lipomas.3Liessi G Pavanello M Cesari S Dell'Antonio C Avventi P Large lipomas of the colon: CT and MR findings in three symptomatic cases.Abdom Imaging. 1996; 21: 150-152Crossref PubMed Scopus (41) Google Scholar Most lipomas demonstrate homogeneous fatty density with a thin fibrous septa, depending on the tumor size. If prominent fibrous septa and nodularity are evident, the most imperative differential diagnosis is a well-differentiated liposarcoma, despite the few reports of gastrointestinal liposarcomas in the literature.4Pereira JM Sirlin CB Pinto PS Casola G CT and MR imaging of extrahepatic fatty masses of the abdomen and pelvis: techniques, diagnosis, differential diagnosis, and pitfalls.Radiographics. 2005; 25: 69-85Crossref PubMed Scopus (137) Google Scholar