Nonspecific Constitutional Symptoms Research Articles

MITRAL STENOSIS PRESENTATION REVEALING ALARGE LEFT ATRIAL MYXOMA

Introduction: Cardiac myxoma (CM) is the most frequent benign primary cardiac tumor. Around 75% of myxomas originate in the left atrium 20% arise from the right atrium while the remaining 5% are born from both the atria and the ventricle. Atrial myxomas can result in many symptoms: heart failure, systemic or pulmonary embolism, arrhythmias, and conductive disorders, or also constitutional symptoms (such as fever, and weight loss). It largely relies on the tumors size, location, and architecture. It can obstruct the blood flow, mimicking mitral stenosis. The surgical management is the cornerstone of this entity. Case Report: A 63-year-old female with a past medical history of diabetes and arterial hypertension was admitted to our department for palpitations and acute heart failure symptoms.The physical examination revealed an irregular pulse with a tachycardia of 150 bpm. The blood pressure was at 118/80 mmHg. It also revealed lower limb edema, lung crackles, and ascites with a mitral stenosis murmur. EKG showed atrial fibrillation at 150HR . Transthoracic echocardiography found dilated atriums with a large mass in the left atrium causing mitral pseudo stenosis . Discussion: Myxomas are primary cardiac tumors that originate from multipotent mesenchymal cells. They can occur at any age but mostly between 30 and 60 years. The incidence of myxoma in women is 2 to 4 times higher than in men. Clinically, atrial myxomas vary from asymptomatic especially with small tumor size, to non-specific symptoms (dyspnea, lower limb and pulmonary oedema, angina, syncope, and palpitation) and constitutional symptoms such as fever, fatigue, and weight loss. The diagnosis of atrial myxoma based on its presentation is challenging. echocardiography is usually the modality of choice which helps identify the location of the mass whether itÂ’s intra or pericardial, its size, attachment and mobility. Furthermore, it differentiates atrial myxoma from any thrombus or vegetation. Once a presumptive diagnosis of myxoma has been made on imaging studies, prompt resection is required because of the risk of embolization or cardiovascular complications, including sudden death. Conclusion: Myxoma continues to be a significant challenge for emergency physicians due to its non-specific symptoms and overlap with other conditions. The discrepancy between mild symptoms and the serious consequences the condition carries, necessitates high index of suspicion and thorough investigation to timely diagnose it among a long list of differentials.

#99 Clinical characteristics and outcomes of PTLD after kidney transplant: a single center experience

Abstract Background and Aims Post-Transplant Lymphoproliferative Disorder (PTLD) is a serious and potentially fatal complication of immunosuppression in kidney transplantation. Given the rarity of this entity, a high index of suspicion is necessary. We aimed to review the incidence, clinical presentation, histological subtypes, treatment, patient and graft survival of PTLD in kidney transplant patients in our unit. Methods Observational retrospective study, including adults diagnosed with PTLD between 1998 and 2023 in a Kidney Transplantation Center. Results Of 1390 kidney transplant recipients, 4 (0.3%) developed PTLD with a mean age of 52 ± 12.5 years. All cases were late-onset, occurring one year after transplantation with a median time from transplantation to diagnosis of 16.7 ± 7.3 years (range: 5-22 years). Of these, none had EBV donor/recipient mismatch. Two patients had prior rejection episodes (one patient, acute T cell-mediated rejection and the other patient, acute T cell-mediated rejection and active antibody mediated rejection). Clinical presentation was variable. Non-specific constitutional symptoms such as fever, fatigue and night sweats were present in all patients. Organ-specific symptoms were also present: lumbar pain in one patient with bone involvement, and delirium and lethargy in two patients with central nervous system involvement. Laboratory analyses revealed an increase in serum LDH in all patients. The primary sites of involvement were central nervous system (50%), lymph nodes (25%) and bone (25%). At PTLD diagnosis, immunosuppression included: tacrolimus (100%), mycophenolate mofetil (75%), low-dose of steroids (50%) and everolimus (25%). Regarding histologic classification, 75% were monomorphic and 25% polymorphic. In the monomorphic group, all patients had Diffuse Large B Cell Lymphoma (CD20 positive). In the polymorphic group, the patient had a Mixed Cellularity Classic Hodgkin Lymphoma (CD20 negative). Immunosuppression therapy was reduced in all patients with discontinuation of mycophenolate mofetil and tacrolimus. In the patient who was taking everolimus, the dose was increased due to the potential clinical antitumor effects of mTOR inhibition. Additional therapies included, rituximab in monotherapy or in combination with chemotherapy (R-CHOP) in the monomorphic group. Palliative measures were selected for one patient of this group due to advanced disease. The patient with Mixed Cellularity Classic Hodgkin Lymphoma (CD20 negative) did chemotherapy with ABVD. None of the patients underwent surgery or radiation therapy. Two patients needed dialysis. Three patients died in the first four weeks after PTLD diagnosis, all due to infectious complications. Patient survival was 25% one year after diagnosis. Conclusions Although the incidence of PTLD was low following kidney transplantation, its impact was significant in kidney graft and overall patient survival. Given the poor prognosis, new therapies combining high efficacy and low toxicity are an urgent unmet medical need in this field.

Macrophage activation syndrome with acute hepatitis in a patient with adult-onset immunodeficiency with anti-interferon gamma antibodies: a case report

BackgroundMacrophage activation syndrome is a rare disorder leading to unregulated immune activity manifesting with nonspecific constitutional symptoms, laboratory abnormalities, and multiorgan involvement. We report the case of a patient who presented with acute hepatitis secondary to macrophage activation syndrome diagnosed by liver biopsy and successfully treated with intravenous immune globulin, anakinra, and rituximab.Case presentationA 42-year-old Laotian woman with adult-onset immunodeficiency with anti-interferon gamma antibodies presented with a fever, headache, generalized myalgia, dark urine, and reduced appetite in the setting of family members at home with similar symptoms. Her laboratory workup was notable for evidence of acute hepatitis without acute liver failure. After an unrevealing comprehensive infectious and noninvasive rheumatologic workup was completed, a liver biopsy was performed ultimately revealing the diagnosis of macrophage activation syndrome. She was successfully treated with intravenous immune globulin, anakinra, and rituximab.ConclusionThis case highlights the importance of maintaining macrophage activation syndrome on the differential of a patient with acute hepatitis of unknown etiology in the correct clinical context and the value of a liver biopsy in making a diagnosis when noninvasive testing is unrevealing.

A case report on systemic lupus erythematosus

The abstract encapsulates the complex landscape of systemic lupus erythematosus (SLE), an autoimmune disease impacting multiple organ systems, characterized by immunosuppression and immunomodulation. SLE is recognized as a quintessential connective tissue disorder arising from immune system dysfunction and an overabundance of diverse autoantibodies. Clinical manifestations of SLE encompass nonspecific constitutional symptoms, including fever, exhaustion, anorexia, weight loss, and arthralgias. Additionally, signs of generalized inflammation like hepatosplenomegaly and lymphadenopathy may manifest at disease onset or during flare-ups. The adaptive immune response in SLE is underpinned by the critical role of B lymphocytes in generating autoantibodies, presenting autoantigens, and activating autoreactive T cells. Treatment strategies for SLE primarily involve biologics and therapeutic options approved by the FDA for refractory cutaneous, articular, and renal disease. Belimumab, infliximab, rituximab, abatacept, and tocilizumab represent some of these approved medications. The management of SLE during remission emphasizes the cautious use of prednisone to mitigate flare-ups, considering potential adverse psychiatric effects associated with steroid medication.[14]

18 F-FDG PET/CT in Renal Allograft Tuberculosis Mimicking as Posttransplant Malignancy.

The most common complications after the renal transplant are infections and malignancies, including posttransplant lymphoproliferative disorders. Tubercular infection in renal allograft recipients is a relatively rare entity. However, nonspecific constitutional symptoms often delay diagnosis, leading to significant morbidity and mortality. We present the 18 F-FDG PET/CT findings in a patient with renal allograft tuberculosis who had clinical and imaging suspicion of posttransplant lymphoproliferative disorder or renal cell carcinoma. Histopathology from the renal lesion revealed tuberculosis.

Takayasu arteritis in a young male patient: a case report and review of literature.

Takayasu arteritis is a systemic inflammatory disorder that causes harm to the large and medium arteries and their branches. It is primarily prevalent in Asia, Africa, and Latin America, with the incidence rate in Asia being reported to be 100 times higher than in Europe and North America. Females in their second or third decades of life are most commonly affected by this condition. In our case, a 26-year-old male patient was diagnosed with Takayasu arteritis after he experienced a headache and left upper limb weakness. The initial presentation of Takayasu arteritis includes nonspecific constitutional symptoms like fever, malaise, weight loss, and anorexia. Unfortunately, due to the delayed diagnosis of the disease, patients often experience claudication, absence of pulses, hypertension, myocardial infarction, and cerebrovascular accidents. An early and accurate diagnosis of Takayasu arteritis is vital to reduce the economic, social, and psychological burdens associated with the disease.

Takayasu arteritis associated with autoimmune/inflammatory syndrome induced by adjuvants: a case-based review.

Takayasu's arteritis (TA) is a chronic granulomatous vasculitis that predominantly affects the aorta and its major branches. Despite advancements in the understanding of the pathogenic pathways of vascular inflammation, the etiology and predisposing factors of TA remain to be fully understood. In susceptible individuals, exposure to adjuvants may trigger, unlock or unmask an autoimmune disorder, presenting as non-specific constitutional symptoms or a fully developed autoimmune syndrome such as vasculitis. Here, we hypothesize that TA could be triggered by siliconosis, a subtype of the autoimmune/inflammatory syndrome induced by adjuvants (ASIA). ASIA, also known as Shoenfeld syndrome, encompasses a wide range of autoimmune and immune-mediated diseases resulting from dysregulation of the immune response after exposure to agents with adjuvant activity. This case report describes the development of large artery vasculitis, TA, in an individual one year following the placement of silicone breast implants. The patient initially presented with non-specific symptoms, and multiple imaging methods were employed, including ultrasound diagnostics, CT angiography, and 18-fluorodeoxyglucose positron emission tomography/CT. These techniques revealed vasculitic alterations in the carotid arteries and thoracic aorta. Initial treatment with glucocorticosteroids proved ineffective, prompting the addition of steroid-sparing immunosuppressive agents. Due to the distinct clinical symptoms, disease progression, implant-associated fibrosis, and resistance to therapy, the potential involvement of implants in the development of large-vessel vasculitis was considered, and a potential association with ASIA was postulated. Although there is limited evidence to support a direct link between adjuvants and the pathogenesis of TA, similarities in cellular immunity between the two conditions exist. The diagnosis of this complex and potentially debilitating condition requires a comprehensive clinical examination, laboratory evaluation, and instrumental assessment. This will aid in identifying potential contributing factors and ensuring successful treatment.

Enterococcus faecalis endocarditis resulting in annular rupture: a case report.

Enterococcus faecalis is the third most common organism to cause infective endocarditis and is associated with high rates of morbidity and mortality. E. faecalis infective endocarditis often presents with a subacute course and with nonspecific constitutional symptoms. Complications related to E. faecalis infective endocarditis are common and include embolic events, abscess formation and pseudoaneurysm formation. Contained annular rupture is a complication of E. faecalis infective endocarditis that, to the authors knowledge, has not been previously described in the literature. Herein, we present an unusual case of a 62-year-old male presenting with classical symptoms of E. faecalis infective endocarditis which resulted in an unusual complication of this condition, a contained annular rupture and the surgical management undertaken to correct this condition.

Extrarenal manifestations of systemic vasculitis in children

The observation data of 22 children with systemic vasculitis (SV) and morphologically verified nephritis is presented. Emphasis was put on extrarenal manifestations of SV in childhood, analysis of clinical, laboratory, immunological, morphological changes and factors influencing on the course and prognosis. It has been established that SV often manifests with general non-specific constitutional symptoms, involvement of the ENT and organs of vision, is characterized by multiple organ and generalized lesions, in 77% of cases in children is associated with anti-neutrophil cytoplasmic antibodies (ANCA). The presence of antibodies to myeloperoxidase (MPO) is noted in most patients with lesions of the skin, joints, lungs, and nervous system and is associated with an unfavorable renal prognosis. ENT and organs of vision, gastrointestinal tract involvement is equally often observed in both MPO and PR3 antibody positive.

Abstract 12847: Left Atrial Cardiac Angiosarcoma: A Systematic Review of Case Reports

Background: Primary cardiac angiosarcoma is a rare endothelial cell tumor, most commonly (78-93%) found in the right atrium. However, rare instances of left atrial angiosarcoma have been noted with varied clinical presentation and fatal prognosis. Methods: A systematic search using PUBMED, SCOPUS and WEB OF SCIENCE was undertaken to identify case reports on left atrial angiosarcomas through June 2021. The data on patient demographics, presentation, diagnostics imaging, management, and outcomes were analyzed using descriptive statistics. Results: Of 19 case reports (Table 1) , left atrial angiosarcoma was more prevalent among females (63%, 12/19). The mean age of cases was 59.26± 12.21 years. Progressive exertional dyspnea (11/19, 58%) and chest pain (5/19, 26%) were the most common presenting symptoms. Myocardial ischemia was the initial presentation in 11% of cases (2/19), congestive heart failure in 26%(5/19) while cerebrovascular events were reported in 11% of cases (2/19). Transesophageal echocardiography and transthoracic echocardiography were the mainstay imaging modalities used for diagnoses. Most cases were diagnosed intraoperatively (16/19, 84.2%) with one case being diagnosed through skin biopsy of a cutaneous metastatic nodule (Table 2) . Surgical excision followed by chemotherapy was the treatment of choice in most cases. With 26% (5/19) metastatic prevalence, death was reported in 58% of the patients (11/19). Conclusions: Primary left atrial cardiac angiosarcoma remains an elusive diagnosis with nonspecific constitutional symptoms. Even with advanced diagnostic modalities, the tumor is mostly detected at an advanced and incurable stage with a grave prognosis and high mortality rate. A deeper understanding of the spectrum of clinical presentation with a high index of suspicion can help clinicians in early diagnosis, which is imperative to prolonged survival.

P06 Waldenström macroglobulinemia – beware the label of primary Raynaud’s Phenomenon

P06 Waldenström macroglobulinemia – beware the label of primary Raynaud’s Phenomenon

Cardiac Myxomas and Carcinomas: Is it Incidental or Consequential Finding?

Myxoma is the most common primary intracardiac neoplasm, ranging between 0.001% to 0.03% in the general population [1]. Cardiac myxomas are most frequently located in the left atrium in 80% of cases, with the remainder mostly originating from the right atrium [2]. Patients may present with various cardiovascular manifestations depending on the anatomical location (e.g., cardiac arrhythmia, embolization,..). It may also present with nonspecific constitutional sign and symptoms such as fever and weight loss [3,4]. The association between cardiac myxomas and other simultaneous tumors has previously been described in the case of carney complex. Carney complex is a rare autosomal dominant syndrome caused by abnormalities in the PRKAR1A gene [5]. Patients may present with skin pigmentations and a variety of endocrine and non-endocrine tumors [5]. However, multiple reports of cardiac myxomas in patients with synchronous primary tumors have been reported, speculating that cardiac myxomas may simultaneously be present with other primary cancers, not classified as the carney complex. A variety of malignancies have been documented that coincide with cardiac myxomas over the years. Meir et al., encountered a left atrial myxoma in the echocardiography of a 51-year-old woman presenting with fever after receiving first chemotherapy session for invasive lobular adenocarcinoma [6]. The association between breast adenocarcinoma and cardiac myxoma was also reported by Kataoka et al. and Özer et al. [7,8]. Nuño et al. and Hajsadeghi et al., described synchronous colorectal carcinomas with a cardiac myxoma [9,10].

Febrile Illness in 3 Adolescent Patients.

Febrile Illness in 3 Adolescent Patients.

Pediatric ANCA- Associated Vasculitis Presenting with Acute Postoperative Subglottic Stenosis: A Case Report

Introduction: Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) often present with nonspecific constitutional symptoms. However, there has been increasing recognition of a subgroup of young, female AAV patients who are at higher risk for isolated subglottic airway disease. Case Presentation: We report a rare case of a 17-year-old female with undiagnosed ANCA-associated vasculitis who presents with acute, life threatening subglottic stenosis requiring emergent intubation after routine surgery. Conclusion: Much of the research on ANCA-associated vasculitis have been based on adult cases, however many pediatric patients may not follow the same diagnostic and clinical presentations. Clinicians should be vigilant in recognizing a subgroup of vasculitis patients who are often young, female, and have a higher prevalence of subglottic stenosis. Symptoms should be promptly worked up and initiation of immunosuppressive therapy is necessary to prevent life threatening complications and end-organ damage. Keywords: ANCA-associated vasculitis, Subglottic stenosis, Granulomatosis with polyangiitis.

Atypical Large Vessel Vasculitis Presenting With Cholestatic Liver Abnormalities: Case-Based Review.

Clinicians usually easily recognize cranial manifestations of giant cell arteritis (GCA) such as new-onset headache, jaw claudication, scalp tenderness, and abrupt changes in visual acuity or blindness; however, when presented with an aberrant clinical course, the diagnosis becomes more elusive. In addition to temporal arteries and other extracranial branches of the carotid arteries, large vessel vasculitis (LVV) can also affect other blood vessels including coronary arteries, aorta with its major branches, intracranial blood vessels, and hepatic arteries.Over time, the scope of the symptoms typically associated with LVV has broadened and includes cases of fever of unknown origin accompanied with other constitutional symptoms that can mimic a range of neoplastic and infectious diseases. In up to half of patients with atypical LVV, liver enzyme level elevations with a cholestatic pattern have been observed. Alkaline phosphatase level and γ-glutamyl transferase level elevations tend to be more prevalent in those LVV patients with vigorous inflammatory responses, particularly in those with fever and other nonspecific constitutional symptoms. These patients also have more profound anemia and thrombocytosis. With the exception of rare instances of vasculitides and granulomas affecting the liver tissue, liver biopsy is generally of little help and primarily shows nonspecific changes of fatty liver.In this article, we review 3 patients who were eventually diagnosed with atypical LVV. The diagnosis was confirmed with temporal artery biopsy in 2 patients and with positron emission tomography/computed tomography in 1 patient. The common hepatic abnormality observed in all patients was the elevation of alkaline phosphatase level, which tended to respond rapidly to initiation of immunosuppressive treatment.

Association of Breast Implants with Nonspecific Symptoms, Connective Tissue Diseases, and Allergic Reactions: A Retrospective Cohort Analysis.

Given the rising media attention regarding various adverse conditions attributed to breast implants, the authors examined the association between breast implantation and the risk of being diagnosed with connective tissue diseases, allergic reactions, and nonspecific constitutional complaints in a cohort study with longitudinal follow-up. Women enrolled in a regional military health care system between 2003 and 2012 were evaluated in this retrospective cohort study. A propensity score was generated to match women who underwent breast implantation with women who did not undergo breast implantation. The propensity score included age, social history, health care use, comorbidities, and medication use. Outcomes assessed included International Classification of Diseases, Ninth Revision, diagnoses codes for (1) nonspecific constitutional symptoms, (2) nonspecific cardiac conditions, (3) rheumatoid arthritis and systemic lupus erythematosus, (4) other connective tissue diseases, and (5) allergic reactions. Of 22,063 women included in the study (513 breast implants and 21,550 controls), we propensity score-matched 452 breast implant recipients with 452 nonrecipients. Odds ratios and 95 percent confidence intervals in breast implant recipients compared to nonrecipients were similar, including nonspecific constitutional symptoms (OR, 0.77; 95 percent CI, 0.53 to 1.13), nonspecific cardiac conditions (OR, 0.97; 95 percent CI, 0.69 to 1.37), rheumatoid arthritis and systemic lupus erythematosus (OR, 0.66; 95 percent CI, 0.33 to 1.31), other connective tissue diseases (OR, 1.02; 95 percent CI, 0.78 to 1.32), and allergic reactions (OR, 1.18; 95 percent CI, 0.84 to 1.66). Women with breast implants did not have an increased likelihood of being diagnosed with nonspecific constitutional symptoms, connective tissue disorders, and/or allergic reaction conditions. Therapeutic, III.

Polymyalgia rheumatica: An updated review.

Polymyalgia rheumatica should be suspected in older patients with bilateral shoulder and hip stiffness that is worse in the morning and improves with use. An array of nonspecific musculoskeletal complaints, constitutional symptoms, and elevated serum inflammatory markers may be present, so other conditions should also be considered. Prolonged glucocorticoids with patient-tailored dosing and duration are the mainstay of treatment. Corticosteroid-sparing therapy with adjunctive methotrexate may benefit select patients.

Waldenström Macroglobulinemia: Clinical Presentation, Diagnosis, and Management.

Waldenström macroglobulinemia is a rare hematologic malignancy characterized by an IgM-associated lymphoplasmacytic lymphoma. Often, it is associated with an indolent disease course, and many patients are candidates for careful monitoring. As many patients present with advanced age and nonspecific constitutional symptoms, careful consideration should be given to treatment decisions, including when and how to treat for maximized clinical benefit with minimal toxicity. This article provides an evidence-based practical approach to appropriate monitoring of the asymptomatic patient and management of symptomatic patients who require treatment for this rare malignancy.

Demographics, Substance Use Behaviors, and Clinical Characteristics of Adolescents With e-Cigarette, or Vaping, Product Use–Associated Lung Injury (EVALI) in the United States in 2019

To date, limited information is available on the characteristics of adolescents with e-cigarette, or vaping, product use-associated lung injury (EVALI). To inform public health and clinical practice by describing differences in demographics, substance use behaviors, and clinical characteristics of EVALI among adolescents compared with adults. Surveillance data reported to the Centers for Disease Control and Prevention during the 2019 EVALI outbreak were used to calculate adjusted prevalence ratios (aPRs) with 95% CIs and to test differences between 360 hospitalized or deceased adolescents vs 859 young adults and 936 adults with EVALI (N = 2155). Demographics, substance use behaviors, and clinical characteristics. Included in this cross-sectional study were 360 hospitalized or deceased adolescents (age range, 13-17 years; 67.9% male) vs 859 young adults (age range, 18-24 years; 72.4% male) and 936 adults (age range, 25-49 years; 65.6% male) with EVALI. Adolescents diagnosed as having EVALI reported using any nicotine-containing (62.4%), any tetrahydrocannabinol (THC)-containing (81.7%), and both (50.8%) types of e-cigarette or vaping products. Informal sources for obtaining nicotine-containing and THC-containing e-cigarette or vaping products were more commonly reported by adolescents (50.5% for nicotine and 96.5% for THC) than young adults (19.8% for nicotine [aPR, 2.49; 95% CI, 1.78-3.46] and 86.9% for THC [aPR, 1.11; 95% CI, 1.05-1.18]) or adults (24.3% for nicotine [aPR, 2.06; 95% CI, 1.49-2.84] and 75.1% for THC [aPR, 1.29; 95% CI, 1.19-1.40]). Mental, emotional, or behavioral disorders were commonly reported; a history of attention-deficit/hyperactivity disorder was almost 4 times more likely among adolescents (18.1%) than adults (4.9%) (aPR, 3.74; 95% CI, 1.92-7.26). A history of asthma was more likely to be reported among adolescents (43.6%) than adults (28.3%) (aPR, 1.53; 95% CI, 1.14-2.05). Gastrointestinal and constitutional symptoms were more common in adolescents (90.9% and 97.3%, respectively) than adults (75.3% and 94.5%, respectively) (aPR, 1.20; 95% CI, 1.13-1.28 and aPR, 1.03; 95% CI, 1.00-1.06, respectively). Because of missing data, percentages may not be able to be calculated from data provided. Public health and clinical professionals should continue to provide information to adolescents about the association between EVALI and THC-containing e-cigarette or vaping product use, especially those products obtained through informal sources, and that the use of any e-cigarette or vaping product is unsafe. Compared with adults, it appears that adolescents with EVALI more frequently have a history of asthma and mental, emotional, or behavioral disorders, such as attention-deficit/hyperactivity disorder, and report nonspecific problems, including gastrointestinal and constitutional symptoms; therefore, obtaining a confidential substance use history that includes e-cigarette or vaping product use is recommended.

Enterocutaneous Fistula: A Simplified Clinical Approach.

A “fistula” is an abnormal connection between two epithelial surfaces. Fistulae are named based on the two surfaces or lumens they connect to. Fistulae form due to loss of wall integrity from an underlying insult, leading to the penetrance of an adjacent organ or epithelized surface. Common causes of small bowel fistulae include sequelae of surgical intervention, foreign body, bowel diverticula, Crohn's disease, malignancy, radiation, and infection. A histopathological analysis displays acute and/or chronic inflammation due to the underlying pathology.A thorough history and physical examination are important components of patient evaluation. Generally, patients will present with non-specific constitutional symptoms in addition to local symptoms attributed to the fistula. In rare instances, symptoms may be severe and life-threatening. Initial laboratory workup includes complete blood count, comprehensive metabolic panel, and lactate level. Radiologic imaging is useful for definitive diagnosis and helps delineate anatomy. In practice, computed tomography (CT) is the initial imaging modality. The addition of intravenous or enteric contrast may be helpful in certain situations. Magnetic resonance imaging (MRI) may also be used in special circumstances. Invasive procedures, such as endoscopy, can assist in the evaluation of mucosal surfaces to diagnose pathology such as inflammatory processes.Appropriate management should include optimizing nutritional status, delineating fistulous tract anatomy, skincare, and managing the underlying disease. A non-operative approach is generally accepted as the initial approach especially in the acute/subacute setting. However, operative intervention is indicated in the setting of failed non-operative management. Successful management of small bowel fistulae requires a multidisciplinary team approach.To conclude, a small bowel fistula is a complex clinical disease, with surgical intervention being the most common cause in developed countries. The non-operative approach should be trialed before an operative approach is considered.