Joseph R. DePasquale

Radiofrequency ablation for the treatment of radiation proctitis: a case report and review of literature

Radiation proctitis is a frequent complication of pelvic radiation for cancer. This condition can present acutely within several weeks of radiation, or chronically many months or years after radiation, leading to rectal bleeding and transfusion-dependent anemia. Various medical and endoscopic therapies have been described to treat this condition; however, some patients fail to respond to the current standard therapies. Here we present a case of refractory radiation proctitis, with suboptimal response to other therapies, treated successfully with a novel method, radiofrequency ablation.

Pleural Empyema due to Group D Salmonella

Non-typhi Salmonella normally presents as a bacteremia, enterocolitis, and endovascular infection but rarely manifests as pleuropulmonary disease. We present a case of a 66-year-old female with underlying pulmonary pathology, secondary to an extensive smoking history, who presented with a left-sided pleural effusion. The causative agent was identified as being group D Salmonella. Decortication of the lung was performed and the patient was discharged on antibiotics with resolution of her symptoms. This case helps to support the inclusion of Salmonella group D as a possible etiological agent of infection in the differential causes of exudative pleural effusions.

Acute diverticulitis in the young: a 5-year retrospective study of risk factors, clinical presentation and complications.

Aim  Acute diverticulitis in the young is considered to follow an aggressive course, but there is a paucity of data on factors that could determine a complicated course.

Replacement Gastrostomy Tube Causing Acute Pancreatitis: Case Series with Review of Literature

CONTEXT Percutaneous endoscopic gastrostomy (PEG) feedings are generally considered safe with few serious complications. Acute pancreatitis is a rare complication associated with replacement percutaneous endoscopic gastrostomy tubes. CASE REPORT We report two cases of acute pancreatitis induced by migrated replacement percutaneous endoscopic gastrostomy tubes. CONCLUSIONS Migration of a balloon into the duodenum can result in external manipulation of the ampulla of Vater thereby disturbing the flow of pancreatic secretions leading to acute pancreatitis. Recognition of this complication is important and should be included as potential etiology of acute pancreatitis in patients receiving percutaneous endoscopic gastrostomy feedings. Periodic examination and documentation of the distance of the balloon from the skin should be performed to document the position of the tubes or any inadvertent migration of the tubes. The use of Foley catheters as permanent replacement tubes should be considered medically inappropriate.

Reversal of liver cirrhosis in autoimmune hepatitis.

Liver cirrhosis is generally considered irreversible but there are reports in which there is documented reversal of fibrosis/cirrhosis in various clinical conditions like Wilsons disease, hemochromatosis, primary biliary cirrhosis and autoimmune hepatitis. The subgroup of patients with autoimmune hepatitis that will have reversal of cirrhosis is not known. We present two cases with documented liver cirrhosis that had reversal of cirrhosis after treatment with immunosuppressive agents. We postulate that patients presenting with acute hepatitis and no other fibrogenic factors have higher chances of reversal of liver cirrhosis as compared to those presenting as chronic liver injury.

Use of Bristol Stool Form Scale to predict the adequacy of bowel preparation - a prospective study.

Inadequate bowel preparation continues to be a substantial problem for colonoscopy. The seven‐point Bristol Stool Form Scale (BSFS) has been associated with delayed colonic transit in adults. We evaluated the utility of the BSFS to identify patients more likely to present with an inadequate preparation.

Multiple Gastrointestinal Complications of Crack Cocaine Abuse

Cocaine and its alkaloid free base “crack-cocaine” have long since been substances of abuse. Drug abuse of cocaine via oral, inhalation, intravenous, and intranasal intake has famously been associated with a number of medical complications. Intestinal ischemia and perforation remain the most common manifestations of cocaine associated gastrointestinal disease and have historically been associated with oral intake of cocaine. Here we find a rare case of two relatively uncommon gastrointestinal complications of hemorrhage and pancreatitis presenting within a single admission in a chronic crack cocaine abuser.

Push Enteroscopy: A Useful Diagnostic Modality for Proximal Small-Bowel Mass Lesions

Small-bowel mass lesions (SBMLs) are responsible for obscure gastrointestinal bleeding (OGIB) in up to 10 % of cases [1–3]. The detection of SBMLs has been difficult due to limited visualization of the small bowel by esophagogastroduodenoscopy (EGD) and colonoscopy [1, 4]. Furthermore, imaging modalities including computerized tomography (CT) and small-bowel series fail to detect small-bowel neoplasms in up to 50 % of cases [1, 5, 6]. Consequently, malignant neoplasms of the small bowel are often diagnosed at a later stage of the disease compared to upper gastrointestinal and colorectal cancers [1]. Capsule endoscopy (CE) is now considered to be the method of choice for starting the diagnostic workup in patients with suspected small-bowel pathology [4, 7, 8]. However, CE has major limitations including the inability to obtain tissue samples and therapeutic incapability [1, 7, 9]. Prior studies have shown that CE fails to visualize the entire small bowel in up to 30 % of cases [1, 7, 9]. We report a case of a gastrointestinal stromal tumor (GIST) presenting as OGIB which initially was missed on CT scan and CE but subsequently diagnosed by push enteroscopy. Case Report

Isolated angioedema of the bowel due to C1 esterase inhibitor deficiency: a case report and review of literature

We report a rare, classic case of isolated angioedema of the bowel due to C1-esterase inhibitor deficiency. It is a rare presentation and very few cases have been reported worldwide. Angioedema has been classified into three categories. A 66-year-old Caucasian man presented with a ten-month history of episodic severe cramping abdominal pain, associated with loose stools. A colonoscopy performed during an acute attack revealed nonspecific colitis. Computed tomography of the abdomen performed at the same time showed a thickened small bowel and ascending colon with a moderate amount of free fluid in the abdomen. Levels of C4 (< 8 mg/dL; reference range 15 to 50 mg/dL), CH50 (< 10 U/mL; reference range 29 to 45 U/ml) and C1 inhibitor (< 4 mg/dL; reference range 14 to 30 mg/dL) were all low, supporting a diagnosis of acquired angioedema with isolated bowel involvement. Our patients symptoms improved with antihistamine and supportive treatment. In addition to a detailed comprehensive medical history, laboratory data and imaging studies are required to confirm a diagnosis of angioedema due to C1 esterase inhibitor deficiency.

Burkitt's lymphoma of the colon

CT demonstrated pancolitis, suggesting ischemia versus infection. Empiric intravenous ampicillin, ciprofloxacin, and metronidazole were initiated. An urgent colonoscopy limited to the sigmoid revealed a diffusely hyperemic mucosa with extensive subepithelial hemorrhage. Histology showed ulceration, acute inflammation, and submucosal hemorrhage. Cultures of the sigmoid biopsies grew Klebsiella oxytoca sensitive to ciprofloxacin. Other stool studies were negative, including C. difficile. After two weeks of ciprofloxacin, leukocytosis normalized, and the diarrhea and hematochezia completely resolved. The polycythemia resolved after fluid hydration. Four months later, a hypercoagulable state was ruled out as tests for antithrombin III, protein C and S deficiency, and factor V Leiden were normal. At that time, repeat colonoscopy revealed resolution of his colitis with biopsyproven eradication of K. oxytoca. This represents a case of acute Klebsiella oxytoca colitis, which should be considered in the differential diagnosis of infectious colitis. Only four published reports to date are identified in literature, all from Europe. These patients typically presented with diarrhea and/or hematochezia. Associations have been reported with the use of antibiotics, diclofenac, or fusidic acid. The colitis can be segmental or pancolonic. Diagnosis is usually made by biopsy culture. The treatment consists of supportive care and initiation of an appropriate antibiotic, such as a fluoroquinolone.