Frida Abrahamian

Carcinoma in situ arising in a tubular adenoma of ampulla of vater

alcohol abuse presented with coffee-ground emesis and melena. He denied abdominal pain, heartburn or dysphagia. Patient reported drinking Listerine (Up to 32 ounces daily). His abdominal exam was unremarkable. On Admission Hb 10.0 mg/dl, Hct 29, normal chem.-7, liver test, normal PT/PTT. Patient was placed on Pantoprazole 40mg IV QD. On EGD he was found to have a normal esophagus and multiple ulcers covered with exudate in the body and fundus. The duodenum was remarkable for patchy erythema as well as multiple erosions covered with exudate. There was multiple petechiae present in the proximal second portion of the duodenum. Pathology revealed moderately active chronic Gastritis with focal glandular regeneration and regenerative atypia. Mouthwash has been documented to produce stomatitis. The manifestations included erythema, petechiae, keratosis, tongue coating, geographic tongue type lesion and ulceration. A PubMed search did not yield any publications describing chemical gastritis caused by mouthwash. There are cases reporting fatal alcohol intoxication from the abuse of mouthwash. The use of mouthwashes and other sources of Ethanol by alcoholics is more prevalent in States where the sale of alcohol is prohibited on Sundays. Listerine is the mouthwash with the highest Ethanol content 26.9 %. Other brands range from 6 to 21 %. This case could illustrate the long term effects of Ethanol (from Listerine) on the upper gastrointestinal tract.

Shunt patency required for effective management of endotipsitis

Transjugular intrahepatic portosystemic shunt (TIPS) infections have been reported in up to 20% of newly placed shunts. All of the reported cases responded to antibiotics alone and did not require shunt revision to clear the infection. We report a case that required repeated shunt revision and ultimately a patent shunt in order to clear the infection. A 59 year-old female with advanced liver disease due to autoimmune hepatitis presented with a 2-wk history of fatigue, somnolence and fever. She had TIPS placement 20 months earlier for refractory ascites. She underwent revision of an occluded shunt 3 months later and was found to have good flow through the shunt 1-yr later. On presentation she was febrile, icteric and had ascites and a leukocytosis of 13,000. Blood cultures grew E. coli that was treated with ceftriaxone. Investigation for an alternative source of infection was negative and included CXR, urinalysis and culture, paracentesis, abdominal CT, and echocardiogram. Doppler ultrasound showed TIPS occlusion. She remained febrile for 10 days despite appropriate antibiotics. A shunt revision with balloon angioplasty was completed with good post-procedure flow. During the procedure the patient experienced high-grade fever and chills, tachycardia and tachypnea. She defervesced over the next 48-hrs. However, she again became febrile and the shunt was again found to be occluded. Antibiotic coverage was broadened, however, her fever continued. A second TIPS revision was performed, again with good post-procedure flow. She defervesced over the next 48-hrs and remained afebrile. Good flow was documented through the shunt 3 days later. Since histopathologic confirmation is not possible, endotipsitis, like endocarditis, is diagnosed on positive blood cultures, exclusion of other sources of infection, and imaging studies showing a thrombus. The infection is typically cleared with long-term antibiotics. This case illustrates symptoms of acute bacteremia during shunt manipulation, another criterion for diagnosis of shunt infection, and the need for shunt patency in order to clear the infection.

New approach in the management of proximally migrated stent with an obstructing anti-reflux valve

New approach in the management of proximally migrated stent with an obstructing anti-reflux valve

Unusual presentation of Churg-Straus syndrome as multiple non-perforating gastrointestinal ulcers

Achalasia is a primary esophageal motor disorder of unknown cause characterized by incomplete lower esophageal sphincter relaxation and esophageal aperistalsis. We present a case with a previously unreported complication of botox injection for achalasia. A 77 year-old male with history of achalasia presented with regurgitation of both liquids and solids. He had been treated three previous times for relief of achalasia symptoms. His last botox treatment was seven months ago and patient had been symptom free till now. Patient was not deemed a surgical candidate due to multiple medical problems. An EGD was performed and 1cc of botox was injected in all four quadrants at the gastroesophageal junction with a standard sclerotherapy needle. Upon awakening post procedure the patient started to complain of abdominal pain. Abdominal exam revealed distended abdomen and tympanic bowel sounds, along with mild diffuse abdominal tenderness. Stat abdominal x-ray revealed free air under the diaphragm and some mediastinal air. Cardiothoracic surgical consultation recommended surgical repair. Instead, we ordered a CT scan of the chest and abdomen, which showed no contrast extravasation into mediastinum, or abdomen but there was presence of large amount of intraand retroperitoneal air with pneumomediastinum. A gastrograffin and then barium swallow showed no extraluminal extravasation of contrast. The patient was started on IV antibiotics and was transferred to ICU for observation. Three days later a follow up esophagram still did not show any leakage of contrast, the patient was allowed to eat and was subsequently discharged. The patient did well 1 year on follow up with resolution of his air collections and achalasia symptoms. To our knowledge, this is the first case to report of microperforation of the esophagus secondary to botox injection leading to pneumoperitoneum. Conservative management should be considered in a patient with suspected microperforation of the esophagus prior to considering surgical repair.