Jurgen Gerada

Severe pancreatitis following hot-snare polypectomy of a distal biliary inflammatory polyp during ERCP in a heart transplant recipient.

Biliary polyps are rare and have neverbeen described in transplant recipients.Herein, we describe a heart transplant re-cipient with adistal biliarypolypthat wascausing biliary obstruction who devel-oped severe pancreatitis following endo-scopic polypectomy, a complication pre-viously unreported.A 65-year-old heart transplant recipientfor stage 4 congestive heart failure pre-sented with 4 days of epigastric painand vomiting. Examination was unre-markable. Investigations revealed bili-rubin 18.6μmol/L, alkaline phosphatase(ALP) 155U/L, γ-glutamyltransferase(GGT) 183U/L, C-reactive protein (CRP)225mg/L and normal amylase. Magneticresonance cholangiopancreatography(MRCP) showed cholelithiasis and cho-ledocholithiasis with biliary dilatation.An endoscopic retrograde cholangiopan-creatography (ERCP) was performed, dur-ing which selective biliary cannulationwas achieved without prior pancreaticduct cannulation or contrast injection.Biliary stones were confirmed and biliarysphincterotomywasperformed.Followingcomplete stone extraction, a 5-mm distalcommon bile duct polyp prolapsed out ofthe sphincterotomized ampulla (

Infectious aortitis in a liver transplant recipient.

The development of an abdominal aortic aneurysm secondary to infectious aortitis following solid organ transplantation is a rare event that in the absence of surgical intervention, can lead to uncontrolled sepsis, catastrophic hemorrhage and death. Arterial allografts have been a viable surgical option for the past 30 years, although operative modalities have undergone a paradigm shift in recent years. We describe the first case in the literature of a liver transplant recipient who developed an infrarenal aortic aneurysm secondary to Salmonella bacteraemia, which was treated successfully with aortic allograft transplantation.

Accidental severe bronchial aspiration of barium uncovers diagnosis of bronchiectasis

A 77-year-old man, with a history of chronic obstructive pulmonary disease (COPD) and radiotherapy-treated laryngeal malignancy diagnosed 15 years prior, presented with a 1-year history of intermittent dysphagia. As a part of his investigations, a barium swallow was obtained; but during the initial phases of the procedure, the patient aspirated the contrast agent of barium sulphate. A chest radiograph (Fig. 1a), taken few minutes after the aspiration, showed barium within the different segments and subsegments of the bronchial tree bilaterally, and uncovered features, such as irregular dilatation of the bronchial tree, non-tapering of the bronchi, luminal filling defects and lack of bronchial side branches, characteristic of bronchiectasis. This incident precipitated an exacerbation of COPD with type II respiratory failure, requiring bronchodilators, intravenous antibiotics and non-invasive ventilation using a bilevel positive airway pressure machine. On recovery, direct laryngoscopy revealed post-radiotherapy changes but no evidence of tumour recurrence. A speech and language pathology assessment using a few millilitres of water revealed weak laryngeal elevation, and immediate aspiration of water on swallowing. Given the high risk of further aspirations, advice regarding the benefits and risks of nasogastric tube insertion or percutaneous endoscopic gastrostomy tube insertion were given to the patient, but he declined both procedures. Six months following discharge, he was readmitted with an episode of food aspiration. A chest radiograph (Fig. 1b) revealed residual barium in both lung bases. This event precipitated another exacerbation of the COPD and bronchiectasis, which caused the patient to succumb to the disease. As early as the 1920s, the concept of utilizing contrast agents to aid in the diagnosis of pulmonary diseases, in particular bronchiectasis, had transpired. This involved instilling the contrast medium within the bronchial tree, by means of a catheter introduced in the trachea, and followed by the acquisition of various radiographs; a procedure known as bronchography. The initial contrast agents that were used in this regard were mainly waterand oil-based solutions. Subsequently in 1950s, barium sulphate, an inert and non-toxic agent, became a popular bronchographic medium that produced similar images as the earlier contrast agents, until the mid-1970s, when computed tomography became the gold standard imaging study for the investigation of pulmonary diseases. Although the earlier contrast agents, as well as barium sulphate, were considered safe bronchographic media, reports of pneumonitis and even death had been described with both [1]. The instilled contrast agent was found to cause obstruction of the small bronchi, followed by atelectasis of lung tissue and pneumonitis [2]. COPD patients often developed exacerbations after such procedures, as seen in our case. To minimize these risks, after the acquisition of the radiographs, patients were asked to cough and expectorate as much contrast dye as possible in an attempt to clear the airways. However, this mechanism would have been ineffective in cases of extensive small airway filling or ‘alveolarization’ with the contrast medium, as the alveoli lies outside the range of the normal mechanisms (cough and ciliary action) for cleansing the bronchial tree. The case we present demonstrates bronchographic features of bronchiectasis following accidental aspiration of E. Gerada (&) J. Gerada Department of Medicine, Mater Dei Hospital, Msida MSD 2090, Malta e-mail: egerada@gmail.com

Crohn's disease manifesting as an isolated cecal polyp and secondary appendiceal obstruction with histologically normal bowel.

Dear Editor:Inflammatory colonic polyps usually arise on a backgroundhistory of an inflamed colon such as Crohn’s disease orulcerative colitis [1]. Similar inflammatory bowel disease(IBD)-related inflammatory polyps, occurring in the absenceof background IBD, have manifested themselves as eitherfiliform polyposis [2] or localized giant inflammatory polyps[3]. We hereby report a case of an isolated sessile cecal poleinflammatory polyp, with histological features of Crohn’sdisease, without a history or current evidence of backgroundIBD. To our knowledge, our case is the first case of such amanifestation of a common condition. Moreover, this polypalso caused secondary appendiceal obstruction, another find-ing previously unreported.A 33-year-old male, nonsmoker, presented with a 6-monthhistory of intermittent colicky right iliac fossa (RIF) pain,which spontaneously resolves after 2 days of rest. He did notreport any change in bowel habit, rectal bleeding, fever, orweight loss. His past medical history, surgical history, familyhistory, and social history were unremarkable. Examinationrevealed normal findings. No tenderness or masses were elic-ited on palpation of the abdomen. Laboratory investigationsrevealeda normal fullblood count and inflammatory markersduring pain-free periods but an elevated C-reactive protein(95mg/l)andhyperferritinemia(681ng/ml)wheninpain.Hehad normal renal, liver, iron, folate, and vitamin B

Giant gastric folds in a patient with hypoalbuminaemia.

A 70-year-old man presented with a 3-month history of persistent epigastric pain, 8 kg weight loss and lower limb swelling. Examination revealed a normal abdomen and bilateral lower limb oedema. Blood results were unremarkable except for hypoalbuminaemia (23 g/l) and peripheral eosinophilia (1.06×109/l). Urinalysis and CT of the abdomen were negative. An oesophagogastroduodenoscopy (OGD) revealed large gastric folds involving the fundus and the body of the …

Recurrent urinary tract infections in a patient with Crohn's disease.

A 62-year-old male smoker was diagnosed with ileo-colonic Crohns disease 1 year previously, which was complicated by an asymptomatic terminal ileal stricture diagnosed on contrast radiology. Clinical and biochemical remission were induced initially by steroids and then maintained by mesalazine (1 g three times a day) and azathioprine (2 mg/kg daily). Six months following diagnosis, the patient complained of recurrent urinary tract infections and haematuria, and was found …