Tenderness In Left Lower Quadrant Research Articles

A rare case of early abdominal pregnancy (EAP)

Introduction: Abdominal pregnancy comprises 1% of ectopic pregnancies and is challenging to manage due to the associated significant morbidity and mortality. Abdominal pregnancy may be classified according to gestation and implantation site. Ultrasound imaging is the mainstay of diagnosis. Confirmatory tests include magnetic resonance imaging (MRI) and diagnostic laparoscopy. Case Report: A 36-year-old patient, amenorrheic for 9–10 weeks, presented to the early pregnancy unit complaining of a one-day history of abdominal pain associated with an episode of vomiting. She denied vaginal bleeding and examination revealed left lower quadrant tenderness. Ultrasound imaging demonstrated a live abdominal pregnancy around 12 weeks’ gestation implanted on the left uterine surface. Following appropriate counselling, she opted for surgical management and consented to the termination of pregnancy. She underwent diagnostic laparoscopy which confirmed that the gestational sac was arising from the left lateral uterine angle and was densely adherent to the omentum and bowel. The procedure was converted to laparotomy to enable safe adhesiolysis and excision of the entire gestational sac. Postoperatively, she represented on day 12 with abdominal pain, fever and bleeding. Computed tomography of abdomen and pelvis (CT-AP) suggested left ureteric injury and she underwent retrograde double J urethral stent (JJ stenting) of the left ureter. Fortunately, the same healed with conservative management. Conclusion: Abdominal pregnancy is rare and poses challenges in diagnosis and management. Once diagnosed, urgent surgical management is recommended given the high risk of complications including intra-abdominal bleeding and visceral injury. Therefore, each case requires a careful and considered treatment approach by a multi-disciplinary team.

Simultaneous portal vein thrombosis and splenic vein thrombosis in a COVID-19 patient: A case report and review of literature

BACKGROUND It is well-described that the coronavirus disease 2019 (COVID-19) infection is associated with an increased risk of thrombotic complications. While there have been many cases of pulmonary emboli and deep vein thrombosis in these patients, reports of COVID-19 associated portal vein thrombosis (PVT) have been uncommon. We present a unique case of concomitant PVT and splenic artery thrombosis in a COVID-19 patient. CASE SUMMARY A 77-year-old-male with no history of liver disease presented with three days of left-sided abdominal pain. One week earlier, the patient was diagnosed with mildly symptomatic COVID-19 and was treated with nirmatrelvir/ritonavir. Physical exam revealed mild right and left lower quadrant tenderness, but was otherwise unremarkable. Significant laboratory findings included white blood cell count 12.5 K/μL, total bilirubin 1.6 mg/dL, aminoaspartate transferase 40 U/L, and alanine aminotransferase 61 U/L. Computed tomography of the abdomen and pelvis revealed acute PVT with thrombus extending from the distal portion of the main portal vein into the right and left branches. Also noted was a thrombus within the distal portion of the splenic artery with resulting splenic infarct. Hypercoagulable workup including prothrombin gene analysis, factor V Leiden, cardiolipin antibody, and JAK2 mutation were all negative. Anticoagulation with enoxaparin was initiated, and the patient’s pain improved. He was discharged on apixaban. CONCLUSION It is quite uncommon for PVT to present simultaneously with an arterial thrombotic occlusion, as in the case of our patient. Unusual thrombotic manifestations are classically linked to hypercoagulable states including malignancy and hereditary and autoimmune disorders. Viral infections such as Epstein-Barr virus, cytomegalovirus, viral hepatitis, and COVID-19 have all been found to increase the risk of splanchnic venous occlusions, including PVT. In our patient, prompt abdominal imaging led to early detection of thrombus, early treatment, and an excellent outcome. This case is unique in that it is the second known case within the literature of simultaneous PVT and splenic artery thrombosis in a COVID-19 patient.

Left side perforated appendicitis with intestinal non-rotation: a case report

BackgroundAcute appendicitis is the most common cause of acute abdominal pain, requiring emergency surgery. Symptoms and signs of acute appendicitis usually occur in the right lower quadrant. However, approximately one-third of cases have pain unexcepted location due to its various anatomical locations. Acute appendicitis is a very rare cause of left lower quadrant pain; if it occurs, situs inversus (SI) and midgut malrotation (MM) are uncommon anatomic anomalies that complicate its diagnosis and management.Clinical presentationHere we present a 23-year-old Ethiopian male patient who presented with epigastric and left paraumbilical abdominal pain, fever, and vomiting of a day duration. On examination at admission, the patient had left lower quadrant tenderness. Later, with the help of imaging studies, the patient was diagnosed with left-side acute perforated appendicitis with intestinal nonrotation, and he was operated on and discharged improved after 6 days of hospital stay.ConclusionPhysicians should be aware that acute appendicitis in patients with intestinal mal-rotation may be present with left-side abdominal pain. Although it is extremely rare, acute appendicitis should always be considered in the differential diagnosis of left-side abdominal pain. An increase in awareness of this anatomical variant is essential for physicians.

Young Man With Abdominal Cramps and Bloody Stools

A 35-year-old man presented with left side abdominal cramps and bloody stools that persisted for 1 week. Physical examination revealed a body temperature of 38.5 °C (101.3 °F), normoactive bowel sounds, and left lower quadrant tenderness. A standing abdominal radiograph showed a nonspecific small bowel gas pattern and a smooth radiolucent descending colon without haustration (Figure 1), indicating a typical lead pipe sign. Ultrasonography of the left side of the abdomen revealed a straight, smooth-walled descending colon filled with blood-like heterogeneous echogenic materials (Figure 2 and Video E1).

S1729 Drug-Induced Pancreatitis: Meth, Cannabis, or Meth-Laced Cannabis?,

Introduction: Drug-induced pancreatitis (DIP) is a rare entity with a 0.1 to 2% incidence of acute pancreatitis cases. Methamphetamine is a serotonergic drug used as a stimulant. It has infrequently been observed to cause pancreatic and hepatic damage due to its keen vasoconstrictive properties. Cannabis in its recreational form has also been linked with drug-induced pancreatitis. We report a 36-year-old female who presented with findings of acute pancreatitis revealing a drug-induced etiology. Case Description/Methods: The patient is a 36-year-old previously healthy female who presented with diffuse, sudden in onset abdominal pain, radiating to the back, aggravated with food without alleviating factors of 3 days duration. She reported nausea on the first day of her pain along with a single episode of nonbilious vomiting that had self-subsided. Social history was remarkable for smoking marijuana since her teenage years unremarkable for alcohol and tobacco use. She reported resorting to street, methamphetamine laced marijuana, the past month. The patient was vitally stable with a physical exam remarkable for epigastric and left lower quadrant tenderness with negative peritoneal signs. Laboratory tests showed elevated lipase, amylase, and CRP with normal liver function tests, hematocrit, BUN, bilirubin, triglycerides, and phosphocalcium balances. Ultrasound was done corroborating the absence of obstruction. Computed tomography (CT) abdomen was subsequently performed showing irregular contour of the pancreatic margins, blurring of peripancreatic fat planes, soft-tissue stranding, and trace-free fluid at the pancreatic body and tail without bile duct dilatation. Serological survey for mumps virus, cytomegalovirus (CMV), epstein barr virus (EBV), and human immunodeficiency virus (HIV) was negative. Anti-nuclear antibodies (ANA), neutrophil anti-cytoplasmic antibody (ANCA), and serum Ig G4 were also negative. She was diagnosed with mild acute pancreatitis with the culprit agent being methamphetamine-laced cannabis. The patient was followed up 3 months after agent cessation with marked symptomatic improvement and unremarkable lab work. Discussion: This case highlights that methamphetamine might also be the precipitating cause of pancreatitis in street marijuana-associated pancreatitis cases. Drug-induced pancreatitis is often challenging because there are no unique clinical characteristics to distinguish drugs from other etiologies, let alone the possibility of identifying one potential drug versus another.

S2983 Drug-Induced Liver Injury Due to Chronic Kratom Use

Introduction: Kratom (Mitragyna speciosa) is an herb with opiate and stimulant like properties. It is marketed as an herbal supplement. It can be exploited as a recreational drug and is popular for self-treatment of opiate withdrawal and pain. It was previously unknown what pathological changes could occur with chronic Kratom use. New evidence suggests that Kratom can cause a drug induced liver injury (DILI). There is little published evidence of the toxic effects of Kratom, yet there is increasing self-treatment of opioid withdrawal and reports of adverse events and lethal overdoses. We describe a case where chronic use of Kratom caused severe DILI. Case Description/Methods: A 39-year-old male with no significant medical history presented to the emergency department with sharp abdominal pain and diarrhea. Physical exam revealed jaundice, scleral icterus, and left lower quadrant tenderness. Initial labs were AST 791 units/L ALT 1841 units/L, total bilirubin 7.4 mg/dL, alkaline phosphatase 449 units/L and INR of 1.2. A CT demonstrated scattered porta hepatis lymph nodes. The patient reported no medication or recreational drug use. He underwent extensive testing including viral hepatitis panel, stool studies, toxicity screen, anti-smooth and anti-mitochondrial antibodies which all produced negative results. Magnetic resonance cholangiopancreatography and right upper quadrant ultrasound were unremarkable. A liver biopsy revealed grade-III inflammatory activity with significant eosinophilia, highly suspicious for drug interaction. On hospital day 5, the patient admitted to several months of kratom consumption. His AST level peaked at 1190 units/L, ALT peaked at 2261 units/L, total bilirubin peaked at 20.2 mg/dL and alkaline phosphatase continually declined. Given the strong correlation with his biopsy results, the likely etiology of this liver injury was determined to be hepatocellular toxicity due to chronic Kratom use. The patient symptomatically improved and in outpatient follow-up there was normalization of liver function after discontinuation of Kratom. Discussion: Kratom’s mechanism and scope of toxicity is not well understood. It remains legal in our state, Georgia, but is banned in some other states and countries around the world. As it remains commercially available, policy regarding this substance should be reviewed closely and studies should be conducted to evaluate its toxicity. Fortunately, this case demonstrates reversible toxic effects to the liver.

715. A 79 year old Female with Bloody Diarrhea and Hypovolemic Shock: Keep the Differential Diagnosis Open

BackgroundSchistosomiasis is considered one of the neglected tropical diseases which is rarely seen in USA. We are reporting herein a case of intestinal schistosomiasis presented as bloody diarrhea and hypovolemic shock at Monmouth Medical Center, New Jersey.Methods: Case ReportA 79 year old female presented with bleeding into her colostomy bag and associated left lower abdominal pain for one day duration. She has a history of colon cancer diagnosed 25years ago, which was treated with chemotherapy and a left hemicolectomy with colostomy formation. On admission, her blood pressure was 78/51 mm Hg. She looked pale and her abdominal examination revealed tenderness in left lower quadrant. Laboratory findings showed hemoglobin of 5.3 g/dl. CT abdomen showed extensive colitis. She was resuscitated and treated with Piperacillin-Tazobactum for 6 days with minimal improvement. Stool for ova and parasites were negative. EGD was unremarkable with no evidence of acute bleeding. Colonoscopy showed severe ulcerative colitis in the distal 30cm of colon. Pathology revealed ischemic and necrotic tissue with numerous calcified schistosoma eggs in the colon (Figure 1). After furthering questioning, the patient mentioned that she travelled to South China 8months prior to presentation. Patient was then treated with Praziquental for one day for possible Schistosomiasis Japonicum, given the regional distribution. The patient showed marked clinical improvement and was discharged home later.Figure 1: Histopathology image showing calcified schistosoma eggs in colon ResultsIntestinal Schistosomiasis is a parasitic disease which peaks at age 15-20yrs, older patients usually have less parasitic burden. Symptoms include diarrhea, abdominal pain, dyspepsia and malnutrition. Heavily infected patients can have hemorrhagic diarrhea, obstruction and ischemic colitis. Definitive diagnosis requires egg identification. Treatment is relatively safe and effective, especially in the developed countries where the resistance to Praziquantel (PZQ) has not been reported yet.ConclusionEven though the worms that cause the disease are not found in USA, this case highlights the importance of recognizing Schistosomiasis especially in New Jersey, due to the high traveling immigrant population, as early recognition and treatment reduces morbidity and mortality.Disclosures All Authors: No reported disclosures

1663 Do Not Risk Your Colon: Beware of Hydrogen Peroxide Enema

INTRODUCTION: Hydrogen peroxide is an oxidizing agent widely available in a variety of medical and household products. There are few reported cases of chemical colitis due to hydrogen peroxide enema used for constipation. We present an interesting case of chemical colitis due to hydrogen peroxide enema used by the patient for alcohol detoxification after reading on the internet. CASE DESCRIPTION/METHODS: A 33-year-old male with a history of alcohol abuse presented with complains of abdominal pain and hematochezia that started after self-administration of enema with 3% hydrogen peroxide diluted with saline for alcohol detoxification. On the abdominal exam, he had left lower quadrant tenderness. Vital signs were stable. CBC revealed mild anemia with hemoglobin (Hb) of 13 g/dl while BMP was unremarkable. CT scan of abdomen and pelvis showed mucosal thickening, edema and subtle pericolonic stranding changes of the rectosigmoid colon to proximal descending colon and no free air. Gastroenterology was consulted and the patient underwent flexible sigmoidoscopy which showed diffuse moderate inflammation in the rectum, sigmoid colon, descending colon and splenic flexure secondary to colitis. The patient was managed conservatively with bowel rest, fluid resuscitation and empiric antibiotics. Hemoglobin remained stable and he was discharged once he was able to tolerate diet and his symptoms resolved. DISCUSSION: Chemical colitis is the inflammation of the large intestine caused due to chemicals introduced into the colon after accidental contamination of endoscopes or administration of enemas containing various chemicals like hydrogen peroxide. Hydrogen peroxide produces highly reactive oxygen radicals which damages colonic mucosa. Diagnosis can be challenging if pertinent history is not obtained as patients with chemical colitis present with non-specific GI symptoms that mimic inflammatory colitis. Given readily availability of hydrogen peroxide and information on the internet to the public, patients should be educated about the dangers of hydrogen peroxide enema. Physicians should also be aware of these dangerous and life threatening ways their patients can attempt to relieve constipation or detoxification. It is very important to recognize this entity as it is entirely preventable.

1636 Diverticulitis Complicated by Fusobacterium Nucleatum Brain Abscesses

INTRODUCTION: Diverticulitis is one of the manifestations of diverticular disease in which the colonic wall diverticula get inflamed. About 25% of patients with acute diverticulitis can develop complications including local abscess formation, fistulation, contained micorperforations or macroperforations leading to generalized peritonitis. Rarely, it can disseminate forming distant abscesses. We are reporting a case of diverticulitis complicated by brain abscesses. CASE DESCRIPTION/METHODS: A 55-year-old male presented to the ED with a 4-day history of lower abdominal pain. Physical examination showed left lower quadrant tenderness. Vital signs were all within normal limits. Lab testing was significant for elevated WBC at 17,000 cells/microliter. CT abdomen/pelvis showed sigmoid diverticulitis with a phlegmon and a focus of contained microperforation with extraluminal free air (Figure 1). He was discharged home on a 3-week course of oral amoxicillin/clavulanic acid with improvement of his symptoms. Three months later, he presented to the hospital with decreased vision in his left eye. Physical examination showed left hemianopsia. He was febrile at 38.4C. Lab testing was significant for WBC 27.3 cells/microliter. MRI brain revealed multiple supratentorial ring-enhancing lesions in both cerebral hemispheres with a dominant lesion within the right occipital lobe measuring 3.3 × 2.8 × 3.0 cm (Figure 2a,b). CT abdomen showed sigmoid diverticulosis without diverticulitis and blood cultures were negative. He underwent right parietal lobe craniotomy and drainage of the larger occipital lobe abscess, with cultures growing Fusobacterium nucleatum. He was started on IV ceftriaxone and oral metronidazole and was discharged home. On follow up, he finished 9 weeks of the aforementioned antibiotics followed by 1 month of oral moxifloxacin with follow up imaging showing resolution of his abscesses. DISCUSSION: In literature, there are only a few reported cases of brain abscesses secondary to diverticulitis. The isolated organisms were of gut flora with Streptococcus milleri and Enterococcus faecium species reported. Fusobacterium nucleatum is an anaerobic oral flora that is involved in periodontal disease, preterm deliveries and diverticular disease. Our patient did not have any periodontal disease and the source was assumed to be diverticulitis. Treatment usually involves IV antibiotics and drainage of the abscesses. Prognosis seems to be overall good with combination approach seem to be effective in ensuring recovery.

2753 Got the GIST: Multidisciplinary Management of an Acute Bleeding Gastrointestinal Stromal Tumor

INTRODUCTION: Gastrointestinal stromal tumors (GISTs) account for 1%-3% of all gastrointestinal tumors. They most commonly arise in the stomach followed by the jejunum/ileum. Presentation varies from incidental discovery during autopsy or endoscopy to acute gastrointestinal (GI) bleeding or bowel obstruction. We report a case of this rare neoplasm in a patient with an acute GI bleed, treated endoscopically with hemostatic spray and ultimately with arterial embolization and surgical resection. CASE DESCRIPTION/METHODS: A 67-year-old female with a family history of colorectal cancer presented to the emergency department for hematemesis and left lower quadrant abdominal pain for 1 day. Physical examination was notable for left lower quadrant tenderness to palpation. Initial laboratory data showed a hemoglobin of 12.8 g/dL from 14.4 g/dL 8 months prior. A CT scan of the abdomen demonstrated a 3.2 × 4.1 cm well-circumscribed mass along the lesser curvature of the stomach arising from the gastric wall. Overnight, she had an episode of large volume hematemesis and became tachycardic and hypotensive. Her hemoglobin dropped to 7 g/dL. An esophagogastroduodenoscopy (EGD) showed LA Grade D esophagitis and a submucosal ulcerated gastric tumor on the lesser curvature of the stomach to which Hemostatic powder spray was applied. She initially refused surgical intervention and remained hemodynamically stable for ∼12 hours after EGD. She then had multiple episodes of hematemesis with hypotension despite blood transfusions. She underwent embolization to the left gastric artery after which hemostasis was achieved. She then decided to proceed with surgical resection of the gastric mass. Pathology confirmed the diagnosis of GIST, spindle-cell type with strongly positive stains for DOG-1 and CD117. DISCUSSION: GISTs are rare tumors that originate from mesenchymal stem cells. Although 40% of gastric GISTs present with GI bleeding, there are no clear guidelines on the management of these lesions. Therapeutic endoscopy and arterial embolization are effective methods used in the management of GISTs with acute bleeding. Hemostatic spray, an inorganic powder that concentrates clotting factors on bleeding surfaces, can be used adjunctively to other methods for the management of bleeding GISTs especially when traditional endoscopic techniques are challenging or when surgery is not an option. This case highlights the importance of a multidisciplinary approach in the management of these rare tumors.

2092 A Rare Case of Primary Colonic Lymphoma Mimicking Metastatic Adenocarcinoma in a Patient With Ulcerative Colitis

INTRODUCTION: Primary colorectal lymphoma (PCL) is uncommon and accounts for only 0.2-1% of all large intestine cancers. There is an increasing incidence in populations with Inflammatory bowel disease (IBD), Celiac disease, H. pylori and other autoimmune conditions. Here, we present a rare case of Ulcerative Colitis with primary Diffuse Large B Cell lymphoma (DLBCL) and liver metastasis. CASE DESCRIPTION/METHODS: Our patient is a 50 y/o male with left-sided ulcerative colitis presenting with a two- month history of severe left lower quadrant abdominal pain and constipation, without overt GI bleeding, diarrhea or weight loss. Examination was remarkable for left lower quadrant tenderness, without palpable mass. CT scan revealed multiple ill-defined liver masses concerning for metastasis with circumferential thickening in sigmoid colon with fat infiltration. Of note, patient had surveillance colonoscopy, few months prior to presentation which revealed marked erythema in the sigmoid colon, biopsies revealed acute on chronic inflammation without evidence of malignancy. Labs with normal CEA, AFP, CA 19- 9 levels. Repeat colonoscopy showed an ulcerated stricture with friable nodular mucosa in the sigmoid colon that was again biopsied in conjunction with biopsy of the liver lesions. Immunohistochemical staining of colon and liver lesions was positive for CD20 and negative for CK20, CK7 and CDX2, consistent with DLBCL. Patient was started on R-CHOP chemotherapy and is currently being monitored for response by Oncology. DISCUSSION: The risk of colorectal cancer significantly increases in IBD and surveillance is usually warranted. Although the suspicion of adenocarcinoma remains high in a UC patient with colonic mass and liver metastasis, PCL should also remain in the differential as correct pre-operative identification is crucial for the design of treatment. PCL is rare, with a male predominance in age 50-70 years and typically present with abdominal pain, lower GI bleeding, weight loss, palpable mass and rarely bowel obstruction. Diagnosis is aided by tissue biopsy and imaging. Multimodality approach involving both surgery and chemotherapy is the principal mode of treatment with radiotherapy in selected cases. Considering our patient’s clinical scenario, further speculations in routine CT scans to evaluate symptoms, alongside endoscopic surveillance for colorectal cancer in IBD, needs to be addressed.

A Case of Evanʼs Syndrome Triggered by Vedolizumab

Clinical trials have shown Vedolizumab to be a safe and highly effective therapy in treating inflammatory bowel disease. Its unique gut-specific mechanism of action has made it an attractive agent in recent years. However, Vedolizumab's side effect profile and long-term effects are not yet fully understood. We report a patient with ulcerative colitis (UC) presenting with epistaxis found to have a Vedolizumab-induced severe immune-mediated thrombocytopenia and hemolytic anemia, otherwise known as Evan's syndrome. Our patient is a 26 year-old man with a history of ulcerative pancolitis who presented with epistaxis and hematuria one week after his first Vedolizumab infusion. In terms of his UC history, he had been diagnosed with UC one year prior through colonoscopy and was initially managed with Mesalamine and Adalimumab with persistent symptoms of bloody diarrhea and abdominal pain. He was then switched to Vedolizumab and within five days, began experiencing severe epistaxis and scant hematuria. Physical exam was notable only for mild left lower quadrant tenderness. He was found to have a severe thrombocytopenia with a nadir of 7 K/μL. He had findings consistent with a hemolytic anemia with an indirect bilirubinemia, elevated LDH, and decreased haptoglobin. Direct Coomb's testing was positive and he was diagnosed with Evan's syndrome. He was treated with corticosteroids, intravenous immunoglobulin, and Rituximab. Both his UC symptoms and blood counts improved on treatment. He was eventually discharged on a Prednisone taper. All of his blood counts returned to normal four weeks after discharge. Evan's syndrome is a rare autoimmune disorder characterized by a Coomb's positive autoimmune hemolytic anemia and thrombocytopenia. It has been associated with several disorders and medications. However, to our knowledge, this is the first documented case of Vedolizumab-induced Evan's syndrome. This case highlights the potential for a paradoxical immunogenicity associated with the drug. Although there is excellent safety data on Vedolizumab, clinicians should be aware of this potentially rare but serious side effect. Rapid recognition and treatment of this uncommon disorder is essential. Ongoing post-market drug safety monitoring may help to fully understand all of the potential long and short term side effects of Vedolizumab.2099 Figure 1 No Caption available.

Insight into Fecal Microbiota Transplant in an Immunocompromised Patient

Clostridium difficile infection (CDI) is a significant cause of morbidity and mortality. Fecal microbiota transplant (FMT) is effective for treatment of recurrent CDI, but has not been well studied in immunocompromised (IC) patients. New data shows that FMT may be safe in this population, but has not gained widespread acceptance. This is the case of a 67-year old male with recurrent CDI and immunocompromised state due to myelodysplastic syndrome transformed to acute myeloid leukemia, who was treated with FMT. This case contributes to the growing body of evidence on the outcomes of FMT on CDI in IC patients. The patient is a 67-year old male with past medical history significant for clostridium difficile colitis who was diagnosed with myelodysplastic syndrome with progression to acute myeloid leukemia. He developed diarrhea with ten loose, bloody bowel movements a day. Vitals on admission were unremarkable. On exam, he displayed left lower quadrant tenderness. Labs displayed WBC 1.43, hemoglobin 8.1, and platelets 126. He was treated initially with vancomycin, with the addition of metronidazole after minimal improvement. Stool studies were negative for infectious cause. Flexible sigmoidoscopy revealed the presence of pseudomembranes. Figures 1 and 2 show the heaped, necrotic epithelium characteristic of pseudomembranes in CDI. Due to the refractory CDI, the patient underwent FMT with improvement in his bowel movement frequency to three loose bowel movements a day. Conditioning therapy in preparation for stem cell transplant was initiated, but the patient suffered cardiorespiratory distress and died. FMT is an established treatment for recurrent CDI. One population in which FMT has not been well studied is in IC patients due to the high theoretical risk of complications. Recent studies have shown that FMT in IC patients results in resolution or decrease in diarrhea frequency with few adverse effects. Our patient met inclusion criteria for many of these studies with his history of immunosuppression and refractory CDI. After FMT, the patient's diarrhea frequency decreased from ten loose bowel movements to three a day. The patient was able to undergo conditioning therapy in preparation for stem cell transplant. Although our patient succumbed to cardiorespiratory distress, this case provides valuable insight into a patient population that is not normally treated with FMT and furthers the discussion on FMT in IC patients.1464_A Figure 1. Heaped, necrotic epithelium characteristic of pseudomembranes in clostridium difficile infection1464_B Figure 2. Magnification of Image 1

A Rare, Entirely Benign, Colonic Submucosal Lesion

A submucosal colonic lesion is described as any mass-like protrusion into the lumen that is covered by normal appearing mucosa. The differential diagnosis of such lesions is broad and management can be challenging as endoscopic exam provides limited diagnostic utility and proximal colonic lesions are not typically accessible by endoscopic ultrasound. Further, the literature is sparse on definitive evaluation and surveillance of such lesions. We present a case of a patient presenting with abdominal pain and hematochezia incidentally found to have a cecal submucosal lesion. A 26 year old male with history of Hashimoto's thyroiditis presented to GI clinic with two months of abdominal pain and rectal bleeding. He denied other symptoms. Abdominal exam revealed left lower quadrant tenderness. Labs were normal. Colonoscopy revealed a 20 mm submucosal cecal mass and internal hemorrhoids. Cecal mass was biopsied with pathology showing chronic inflammatory cells including focally increased eosinophils. While the abdominal pain was thought to be functional and hemorrhoids were the etiology of rectal bleeding, there remained some uncertainty about the relationship of his autoimmune background, symptoms and eosinophils seen on pathology. CT abdomen showed a “surgically removed appendix,” despite no history of appendectomy. Repeat colonoscopy with deeper biopsies revealed inspissated mucin or fecalith; no malignancy. Given the size of the lesion, there remained concern for inadequate sampling, thus he was referred for surgical evaluation and underwent laparoscopic right hemicolectomy with pathology consistent with appendicolith. A fecalith is a hard mass of feces associated with increased risk of appendicitis. In this case, the fecalith was golf tee shaped which formed over time and arose from the distal end of the appendix, compressing against the cecum producing a submucosal cecal mass. The fecalith made the appendix invisible on imaging, explaining the CT finding; it did not cause appendicitis due to its very gradual accumulation. In our case, both colonoscopies yielded an uncertain diagnosis on pathology, which led to the patient undergoing surgical resection. The concern was if there was a tumor deep to the fecalith causing his symptoms,This case highlights the importance for further management recommendations for patients with incidentally found submucosal lesions with an endoscopically inconclusive pathologic diagnosis.

Spontaneous rectus sheath haematoma due to cough on apixaban

A 69-year-old woman on apixaban for 4 years due to her atrial fibrillation presented with severe left lower abdominal pain. She was discharged from the hospital 4 days prior after...

Epiploic Appendagitis: A Rare Cause of Acute Abdominal Pain

Epiploic appendagitis is a self limiting condition presenting as acute abdomen and is often misdiagnosed without CT abdomen. A 34-year-old Caucasian male presented to our emergency room with progressive left sided abdominal pain for 3 days. Pain was constant sharp 7/10, in the left lower abdomen with no radiation. Lying on his left side helped alleviate the pain, with no exacerbating factors. He denied any fever, chills, diarrhea, constipation, urinary symptoms, nausea, vomiting or blood in stools. He had no history of recent trauma or travel. He didn't have any significant past medical history except for laparoscopic appendectomy for uncomplicated appendicitis 10 years ago. On physical exam, blood Pressure 116/74 mmHg, Pulse 112/minute, Temperature 98.7°F (37.1 °C) (Oral), Respiratory rate 16/minute, Oxygen saturation 97% on room air. He had localized tenderness in left lower quadrant with no guarding or rigidity. Bowel sounds were normal. Rest of the physical exam was unremarkable. An emergent Computerized Tomography scan of the abdomen and pelvis with contrast showed a 2 cm, fat density, oval shaped lesion with peripheral enhancement (consistent with hyperemia) and perilesional fat stranding and edema, adjacent to the descending colon. These findings were consistent with Epiploic Appendagitis. Patient was reassured and was treated conservatively. The diet was advanced to general diet the following day. He had significant improvement in the symptoms after receiving the pain medication and was observed in hospital. He had no further complications and expressed complete resolution of the symptoms and was discharged to home the following day. At 1 month follow up he did not have any further abdominal symptoms or complications. Epiploic appendagitis is an ischemic infarction of an epiploic appendage caused by torsion or spontaneous thrombosis of the central draining vein. Patients are usually young and present with localized abdominal pain and tenderness on exam. It is often misdiagnosed as appendicitis, bowel infarction or diverticulitis.CT scan is the diagnostic test of choice and shows characteristic findings of paracolonic well-defined fat density lesion with periappendageal fat stranding and thickened peritoneal ring, as in our patient. Management is conservative with anti-inflammatory medications or short course of opiates. The condition is self-resolving and awareness can avoid unnecessary use of antibiotics and surgical interventions.Figure: CT abdomen showing Oval paracolonic lesion, fat density, peripheral enhancement and surrounding fat stranding.

Recurrent Mantle Cell Lymphoma Presenting as Colonic Mass

Mantle cell lymphoma (MCL) is a rare and aggressive subtype of B cell Non-Hodgkin's Lymphoma. MCL frequently involves extranodal sites and gastrointestinal tract is involved in 80% of cases. MCL is usually resistant to standard chemotherapy regimens and associated with high recurrence rate. Recurrent disease is very aggressive and resistant to treatment. We present a case of recurrent MCL involving the colon despite intensive chemotherapy. A 58 year old woman presented to our hospital with complaints of left sided abdominal pain and hematochezia since one day. Abdominal pain was described as severe and continuous with no radiation. She was diagnosed with MCL two years ago when she had axillary lymph node biopsy. She was treated with standard chemotherapy regimen and stem cell transplantation at that time. She had a relapse one year after initial treatment for which she was again treated with chemotherapy. On examination, no lymphadenopathy was noted. Abdominal examination was significant for left lower quadrant tenderness without guarding, rigidity or hepatosplenomegaly. Laboratory tests were normal. Computed tomography scan of abdomen showed ascending colon wall thickening. Colonoscopy showed mass like lesion in the ascending colon and polyps in the ascending colon as well as splenic flexure. The biopsy of all the three lesions showed atypical lymphocytes infiltrating the lamina propria. The tumor cells were positive for cyclin-D1, CD 5, CD 20, CD 43 and CD 79A consistent with the diagnosis of MCL. Patients with MCL and gastrointestinal involvement could be asymptomatic or may present with abdominal pain, obstruction, diarrhea, or hematochezia. The most common site of involvement in the GI tract is ileocecal region, but any other area may be involved from the stomach to the rectum. Involvement of the gastrointestinal tract may occur with or without the appearance of polyps. Even though there are no standard guidelines for endoscopic screening of gastrointestinal tract in asymptomatic patients, one should be aware of involvement of gastrointestinal tract in the early course of disease or recurrent disease. Although mantle cell lymphoma is initially responsive to chemotherapy, it eventually becomes refractory with median survival of 3 to 5 years. Patients with obstructive tumor masses require surgical therapy, but the mainstay of treatment is chemotherapy.Figure: A polypoid non-obstructing medium-sized mass. Polyp with normal looking mucosa was found at the splenic flexure.Figure: A frond-like/villous, fungating, infiltrative, polypoid and ulcerated nonobstructing large mass was found in the ascending colon.

X-Ray Quiz: A 32-Year-Old Female with Abdominal Pain

A previously fit 32-year-old woman was presented to the emergency department for left abdominal pain for two days. The pain is dull in character and is not accompanied by nausea, diarrhoea, fever, dysuria, or haematuria. She is a virgin with a regular menstrual cycle and her last menstrual period started 2 weeks ago. The physical examination revealed mild left lower quadrant tenderness only. The initial impression of her illness was urolithiasis and she underwent intramuscular piroxicam for analgesia. However, the urine analysis showed neither haematuria nor pyuria. Her pregnancy test was negative for pregnancy and hydronephrosis was not exhibited on the sonogram of her bilateral kidneys.

A Rare Case of Spontaneous Umbilical Hernia Rupture- Flood Syndrome

A 54-year-old female with alcoholic cirrhosis and massive ascites presented with acute leakage of ascitic fluid from umbilical hernia. Prior to presentation, patient reported progressive increase in abdominal distension due to increasing ascites over several years. She was recently evaluated by a dermatologist for pruritus. Skin examination at that time had revealed excoriated papules, likely due to insect bites or liver disease. 24 hours prior to current presentation, she had been scratching the region of her umbilical hernia, which resulted in a sudden gush of clear fluid. In the emergency department (ED), she denied, fever, chills, cough, vomiting or straining but reported soreness at the site of umbilical hernia. She was tachycardic and appeared icteric. Other vital signs were within normal ranges. Abdominal examination revealed distended abdomen and left lower quadrant tenderness on palpation. A large (10 x 10 cm) umbilical hernia containing bowel was noted which was draining serosanguinous fluid. She was diagnosed with flood syndrome- spontaneous rupture of umbilical hernia. Workup revealed macrocytic anemia with Hemoglobin of 11mg/dl, a platelet count of 100,000 and total bilirubin of 13mg/dl. Broadspectrum antibiotics were initiated and she underwent primary open surgical repair of umbilical hernia with JP drain placement. The drain was eventually removed after 6 days. She was transitioned to oral antibiotics and discharged to a nursing facility. At her 8 month follow-up, she was noted to be doing well with no recurrence.Figure 1Figure 2

Solitary Rectal Ulcer Syndrome with a Visible Vessel: An Uncommon Cause of Lower GI Bleeding

Solitary Rectal Ulcer Syndrome with a Visible Vessel: an Uncommon Cause of Lower GI Bleeding Introduction: Solitary rectal ulcer syndrome (SRUS) is a rare condition affecting both healthy and immunocompromised patients. Presenting symptoms are diverse but can include rectal bleeding in up to 25% of patients. Case: A 51 year old man with PMH including HIV on HAART, HCV cirrhosis, c.difficile colitis and solitary rectal ulcer syndrome (SRUS) presented to the emergency room with new onset hematochezia and clot passage for 3 days. He reported associated tenesmus and constant left lower quadrant abdominal pain. His medical history was notable for diverticulosis and left hemicolectomy with renanastamosis 15 years prior. He reported recent anal intercourse with 1 partner and had used an enema for constipation prior to symptom onset. On evaluation, the patient was tachcardic and hypotensive. Physical exam was significant for left lower quadrant tenderness without rebound, guarding, or masses. Rectal exam showed gross blood, with mild tenderness on inspection and no hemorrhoids or fissures. Lab work demonstrated hemoglobin of 7.7 g/dL, WBC count of 2.1K/mcL, platelets of 57K/mcL and INR of 1.5. He received IV fluid and blood products and was admitted for further workup. Colonoscopy revealed persistent sharp angular ulcerations in the rectum without erythema or colitis. A prominent visible vessel seen in an ulcer bed. A hemoclip was placed successfully. Ulcer histopathology demonstrated mucosal prolapse without architectural distortion. Stains were negative for viral pathogens. The patient's hemoglobin stabilized and he was advised to avoid rectal trauma.Figure 1Figure 2Discussion: Symptoms of SRUS can include bleeding, mucoid discharge, perineal and abdominal pain, feeling of incomplete defecation, constipation and overt rectal prolapse. The pathogenesis is poorly understood but may be related to trauma or shear forces during defecation in combination with mucosal ischemia. Treatment options include bulking agents, topical therapies, biofeedback, and surgery. Bleeding from SRUS has been reported, but visualization of a visible vessel is rare. Dieulafoy-like lesions have been described in the context of stercoral ulcers but to our knowledge, no case of a visible vessel has been reported in SRUS. Endoscopic hemoclip placement was successful for acute treatment in this patient with follow up colonoscopy showing ulcer improvement after 6 weeks.