John Wysocki

Colo-renal fistula: An unusual cause of hematochezia.

A 76 year old woman with bloody stools and symptomatic anemia presented to the Emergency Department approximately 2 wk after computed tomography (CT)-guided cryoablation to a 4.5 cm renal cell carcinoma on her left posterior kidney. The patient was initially prepped for a colonoscopy to view possible causes of lower gastrointestinal bleeding. However, the patient had a CT with PO contrast that revealed a variation of a renoalimentary fistula. The patient was subsequently brought to the operating room, and it was discovered that a colo-renal fistula had formed, with transmural perforation of the posterior descending colon. A left nephrectomy, left colectomy with colostomy and Hartmanns pouch was performed.

Mixed Large Cell Neuroendocrine Carcinoma and Adenocarcinoma with Spindle Cell and Clear Cell Features in the Extrahepatic Bile Duct

Mixed adenoneuroendocrine carcinomas, spindle cell carcinomas, and clear cell carcinomas are all rare tumors in the biliary tract. We present the first case, to our knowledge, of an extrahepatic bile duct carcinoma composed of all three types. A 65-year-old man with prior cholecystectomy presented with painless jaundice, vomiting, and weight loss. CA19-9 and alpha-fetoprotein (AFP) were elevated. Cholangioscopy revealed a friable mass extending from the middle of the common bile duct to the common hepatic duct. A bile duct excision was performed. Gross examination revealed a 3.6 cm intraluminal polypoid tumor. Microscopically, the tumor had foci of conventional adenocarcinoma (CK7-positive and CA19-9-postive) surrounded by malignant-appearing spindle cells that were positive for cytokeratins and vimentin. Additionally, there were separate areas of large cell neuroendocrine carcinoma (LCNEC). Foci of clear cell carcinoma merged into both the LCNEC and the adenocarcinoma. Tumor invaded through the bile duct wall with extensive perineural and vascular invasion. Circumferential margins were positive. The patients poor performance status precluded adjuvant therapy and he died with recurrent and metastatic disease 5 months after surgery. This is consistent with the reported poor survival rates of biliary mixed adenoneuroendocrine carcinomas.

Leptospirosis with acute liver injury

A 61-year-old man with no significant medical history presented with fever, muscle pain, and weakness. He was found to be in multiorgan failure due to leptospirosis, a condition known as Weils disease. A timely workup, combined with early initiation of antibiotics, led to effective treatment for this patient.

An Uncommon Cause of Abdominal Pain and Fever in a Patient With Crohn’s Disease

Question: A 46-year-old man with a history of ileocolonic Crohn’s disease (CD) presented with worsening abdominal and back pain, fever, and headache. He was diagnosed with CD 16 years ago, when he presented with suspected perforated appendicitis and found to have free intraperitoneal perforation from Crohn’s ileitis for which he underwent ileocecal resection. He did well postoperatively for about 10 years. He developed recurrent CD and was treated with infliximab and azathioprine until 5 months ago, when he developed periumbilical abdominal pain and back pain. Computed tomography (CT) of the abdomen was unremarkable at that time. His treatment regimen was switched to adalimumab and later to certolizumab pegol, without improvement of his symptoms. One month ago, he had worsening pain, fever, unintentional weight loss, and a progressively worsening headache, which prompted hospital admission and further evaluation. Laboratory studies showed a white blood cell count of 7.8 10/L with 89% polymorphonuclear neutrophils and an elevated C-reactive protein (163 mg/L; normal, <8 mg/L). CT of the abdomen showed new stranding and nodularity of the omentum (Figure A, B) compared with the one from 5 months earlier. The radiographic impression included infection, malignancy, peritonitis, or other infiltrative processes. No definitive acute bowel pathology or masses were seen. An exploratory laparoscopy was performed that showed a nodular, adherent omentum, which was biopsied (Figure C). What is the diagnosis? What is the appropriate treatment? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.