Francis J. Podbielski

External iliac artery dissection secondary to endofibrosis in a cyclist

Endofibrosis of the external iliac artery is an uncommon disease affecting primarily young, otherwise healthy, endurance athletes. Thigh pain during maximal exercise with quick resolution postexercise is characteristic of the so-called cyclists iliac syndrome. We report an unusual case in which the typical endofibrotic plaque was accompanied by dissection of the external iliac artery. The patient was treated surgically with excision of the affected artery segment and placement of an interposition graft. This case highlights an unusual finding in association with external iliac artery endofibrosis and provides an opportunity to briefly review the literature on the subject.

Aortoesophageal Fistula Secondary to Reflux Esophagitis

Aortoenteric fistula is a rare cause of massive upper gastrointestinal bleeding and is in the overwhelming majority of cases due to erosion of a suture line of a prosthetic vascular graft into the bowel. We report the case of a massive fatal gastrointestinal hemorrhage from an aortoenteric fistula secondary to erosion from reflux esophagitis. Proper management requires expedient radiographic and endoscopic evaluation, and even with appropriate management mortality remains extremely high.

Ischemic Colitis Secondary to Ergotamine Use: A Case Study

A 48-year-old woman with a history of chronic migraines, initially admitted for inpatient management of intractable migraine headaches, developed new onset abdominal pain, hypotension, and diarrhea on hospital day number ten. In our institution’s headache unit, patients are treated by a multidisciplinary approach, including individualized drug therapy based on diagnosis and previous response to therapy. Given the patient’s hypotension and clinical appearance, she was transferred to the intensive care unit and treated for septic shock and metabolic acidosis. A bedside colonscopy revealed diffuse ischemic colitis. Final pathology after colon resection showed widespread, transmural necrosis of the colonic wall. We review the pathophysiology of ergotamine use and its potential association with ischemic colitis.

In situ aortic thrombosis secondary to intra-abdominal abscess

Summary Background: Abdominal aortic mural thrombus is uncommon in the absence of aneurysm or atherosclerosis. Case Report: We report the case of a 46-year-old man who presented to our institution with perforated appendicitis for which he initially declined surgery. Four days after admission he ultimately consented to appendectomy and abdominal washout. Follow-up imaging to evaluate for intra-abdominal abscess revealed mural thrombus of the infra-renal abdominal aorta extending into the left iliac artery. This thrombus was not present on the admission CT scan. The patient had no clinical signs of limb ischemia. Conservative treatment with therapeutic anticoagulation resulted in resolution of the thrombus. Conclusions: While portal, mesenteric, and major retroperitoneal venous thrombosis are well associated with major intra-abdominal infection and inflammatory bowel disease, aorto-iliac arterial thrombus formation in the absence of associated aneurysm, atherosclerosis or embolic source is exceedingly rare. We are unaware of other reports of in-situ aorto-iliac arterial thrombus formation secondary to perforated appendicitis.

Eosinophilic granuloma of the lung and rib.

Langerhans-cell histiocytosis is characterized by abnormal proliferation of Langerhans cells, and frequently associated with cigarette smoking. A 24-year-old man who underwent excisional biopsy of a pulmonary nodule and segmental rib resection was found to have the eosinophilic granuloma variation of Langerhans-cell histiocytosis.

Esophageal Cancer and Dysphagia in the HIV-Positive Patient

Over the past 30 years, improvements in management and heightened awareness have contributed to increased survival among HIV-positive patients and the conversion of the disease from an acute, fulminant illness into a chronic condition [1, 2]. Mortality from end-stage AIDS or from HIV-related illnesses has precipitously decreased. In fact, recent data suggest that the 6-month cumulative mortality from a serious, non-AIDS event is more than twice the mortality for an AIDS event in HIV-positive patients [3]. This suggests the need for vigilance on the part of clinicians for serious events unrelated to a coexisting diagnosis of HIV/AIDS. Dysphagia, a common complaint among HIV-positive patients with a variety of HIV-related causes, illustrates this point [4, 5]. Most frequently, dysphagia in these patients is related to infectious esophagitis; however, other causes such as strictures, medication-induced injuries, and cancer must be considered [2, 4, 6]. HIV-positive patients are at increased risk for a variety of malignancies including lymphoma, Kaposi sarcoma, and cervical cancer. A relationship to esophageal cancer has also emerged, though it does not reach statistical significance in all studies [7–11]. The patient presented in this report had typical symptoms of AIDS-related dysphagia, but his workup revealed esophageal adenocarcinoma, a non-AIDS defining cause for these symptoms and a relatively common cause in the general population. Case Report

Spontaneous Rupture of a Saccular Intrahepatic Artery Aneurysm

Hepatic artery aneurysms are the second most common visceral aneurysm but are still relatively uncommon. Over the last century, methods for treating these lesions have evolved substantially. The presented case covers the presentation, diagnosis, and treatment of a 65-year-old woman with an aneurysm of the intrahepatic portion of the hepatic artery. This case demonstrates the variety of techniques available for managing these lesions and the importance of both a thorough knowledge of the available treatments and the flexibility to switch among them when necessary.

Extraluminal amyloidoma of the pelvic cavity causing large bowel obstruction.

Amyloidosis is a group of diverse disorders that fall into several major categories: primary, secondary, dialysis-associated, and hereditary forms. Clinically, amyloidosis may be categorized as localized or systemic. The gastrointestinal tract is among the most common places for deposition of amyloid, but large, localized amyloid deposits are an uncommon occurrence and rarely cause extraluminal bowel compression resulting in obstruction as was seen in the case presented in this clinical scenario.

Small Bowel Ischemia in a Sickle Cell Patient

We report a case of small bowel ischemia secondary to sickle cell disease. Acute bowel ischemia is an uncommon presentation of patients with sickle cell disease. Historically, only a handful of cases have been reported. We also provide a summary of the literature relevant to sickle cell patients with acute bowel ischemia.

Esophageal adenocarcinoma with solitary renal metastasis.

Esophageal cancer is a less common malignancy of the gastrointestinal tract and continues to have a dismal prognosis despite screening programs for high-risk patients. Patients frequently present with advanced disease, and 5-year survival is 18.1 % on average [1]. Of esophageal cancers in the USA, 59 % are adenocarcinomas, while squamous cell lineages represent another 34.5 % [1]. Metastases are common at the time of presentation with 18–50 % of patients having distant or unresectable disease [1–3]. Despite poor overall survival, surgical resection remains a mainstay of curative therapy for esophageal cancer [4]. Most esophageal tumors are responsive to chemotherapy or combined chemoradiotherapy, and thus neoadjuvant therapy is recommended for patients with node-positive disease and those found to have T3 tumors on preoperative endoscopic ultrasonography. This treatment results in down-staging the primary tumor and eventual resection [2]. In practice, 40– 63 % of patients who undergo curative esophagectomy ultimately develop recurrence of their disease [4–7]. The median time to recurrence is 11–12 months [4, 5]. The pattern of esophageal cancer recurrence and metastasis is of interest given the emphasis on surgical treatment of these patients and the ongoing controversy as to whether an interventional approach to recurrence offers any survival benefit compared to symptomatic treatment [4, 5]. Visceral metastases and recurrences, including the kidney, are common [3, 6, 8–11]. Most metastases, however, are small, multiple, and bilateral [7, 9, 11, 12]. Solitary, isolated metastases from any cancer to the kidney are rare [12, 13]. There have been occasional reports of renal metastases from esophageal squamous cell carcinoma, but not from esophageal adenocarcinoma as is reported in this case [7, 9, 11, 14].