Muhammad Aziz

Current updates in management of Clostridium difficile infection in cancer patients

Abstract Background: Clostridium difficile infection (CDI) is a significant health burden, now recognized as the leading cause of acquired diarrhea in patients receiving antibiotic therapy. Complications of infection with this pathogen include severe diarrhea, causing electrolyte imbalances, dehydration, hemodynamic instability, toxic megacolon, shock, and death. Hence it is extremely paramount to stay updated on management options for this infection, especially in cancer patients. Review: This article presents an in-depth review of literature on the treatment modalities available for CDI in cancer patients. Relevant articles highlighting therapeutic and symptomatic management of CDI patients with underlying malignancy have been summarized. Conclusions: Despite the current options available, more studies are needed to assess the newer therapeutic options that are being employed for populations other than cancer patients.

Colitis and Pancreatitis in a Patient with Systemic Lupus Erythematosus: Due to Disease or to Drug?

A 37-year-old female with a history of developmental delay, left-sided focal epilepsy due to polymicrogyria, systemic lupus erythematosus (SLE), and stage 3 chronic kidney disease due to lupus nephritis was initially evaluated for diarrhea of 4 months duration. Due to the presence of cognitive issues, her history was obtained from her mother, her primary caregiver. She reported that her daughter had been having 5–6 loose bowel movements per day for 4 months, associated with a weight loss of 15 lbs over this time period, contrasting with the one formed bowel movement per day she had experienced prior to the onset of diarrhea. Moreover, she was stated to have had sharp epigastric pain and intermittent nausea and vomiting for 3 days prior to evaluation and was currently not able to tolerate any oral intake. The patient was hospitalized 1 month prior to the current admission and diagnosed with influenza B. At that time, she was neutropenic with a white blood cell count of 0.7 × 109/dl (4.5–11.0 × 109/dl) which on consultation with the hematology service was attributed to her acute viral infection. She was treated with oseltamivir and given one dose of filgrastim prior to hospital discharge. Other past medical history included hypertension, hypothyroidism, and avascular necrosis of the femur due to chronic steroid use. In her family history, her mother and father had diabetes. She denied any history of smoking, alcohol, or illicit drug use. Her lupus nephritis had been treated with mycophenolate mofetil (MMF) for over 2 years, but 2 months prior to admission this treatment was changed to mycophenolate sodium (MPS) by her rheumatologist who thought MMF might have caused her diarrhea. Since the medication switch did not relieve the diarrhea, she presented to the Emergency Department, where she was afebrile and tachycardic (115/min), with a blood pressure of 70/42 mm Hg and respiratory rate 18/ min with oxygen saturation of 100% on room air per pulse oximetry. Physical examination revealed signs of marked intravascular volume depletion with a dry oral mucosa; abdominal examination revealed hyperactive bowel sounds and tenderness to palpation in the epigastric and periumbilical regions, but no rebound tenderness. Rectal examination was unremarkable. Laboratory tests on admission showed a blood hemoglobin of 10.1 g/dl (12-16 g/dl), a white blood cell count—3.4 × 109 per liter (4.5–11.0 × 109 per liter), a platelet count—150,000 mm3 (150,000–400,000/mm3), and serum concentrations of sodium—129 mmol/L (134144 mmol/L), potassium—3.5 mmol/L (3.5–5 mmol/L), chloride—98 mmol/L (98–111 mmol/L), bicarbonate—10 mmol/L (20–30 mmol/L), BUN—52 mg/dl (7–31 mg/dl), creatinine-3.81 mg/dl (baseline 0.7–0.9 mg/ dl), and lipase—479 mg/dl (10–73 mg/dl); liver function tests were normal. A computerized tomographic (CT) scan of the abdomen performed on admission showed findings suggestive of acute pancreatitis and a hydropic gall bladder. An ultrasound scan of the abdomen showed a dilated gall bladder but no evidence of the presence of cholelithiasis or choledocholithiasis. The patient was aggressively resuscitated with intravenous fluids followed by improvement in her blood pressure, heart rate, electrolyte abnormalities, and kidney function. Other tests included stool culture, * Swathi Paleti spaleti@salud.unm.edu

Future of diagnosing neoplasia in Barrett’s esophagus: volumetric laser endomicroscopy

Esophageal adenocarcinoma (EAC) is one of the deadliest carcinoma faced by gastroenterologists. Any insult to esophagus that causes replacement of normal squamous epithelium with columnar intestinal epithelium is labelled as the initiating event of the metaplasia–neoplasia sequence. Barrett’s esophagus is the precursor to EAC. Currently, endoscopically obtained biopsies are used to detect neoplastic changes in patients with Barrett’s esophagus (BE); however, it is not cost effective and hence a better screening modality is needed. Volumetric laser endomicroscopy (VLE) has been under study for the past few years and has shown promising results to overcome the shortcoming faced in the biopsy samplings. It is a second-generation optical coherence tomography (OCT) that provides high-resolution cross-sectional imaging of the esophageal mucosa using near-infrared light. The principle is similar to endosonography, but image formation in OCT depends on variations in the reflection of light from different tissue layers rather than ultrasonic waves.

Pseudoephedrine Induced Ischemic Colitis: A Case Report and Review of Literature

Ischemic colitis due to medications is common, and a number of cases have been described with pseudoephedrine as the culprit agent. We present here an interesting case of a healthy female with no risk factors who developed pseudoephedrine induced ischemic colitis. This case serves to remind the healthcare providers about the utmost importance of obtaining a comprehensive history to aid with the diagnosis.

Pathological complete response in pancreatic adenocarcinoma with FOLFIRINOX

The report describes a patient who presented to our centre with abdominal pain and significant weight loss due to adenocarcinoma of the tail of the pancreas. The cancer was deemed as ‘resectable disease associated with morbid surgical outcomes’ due to the local involvement of the vessels and adjacent organs. Given the patient’s excellent performance status, the patient underwent neoadjuvant chemotherapy with folinic acid, fluorouracil, irinotecan and oxaliplatin to downstage the tumour for less morbid surgical resection. The patient underwent 12 cycles of chemotherapy with serial imaging which demonstrated positive response to treatment and surgical resection was performed. Surgical pathology revealed no residual tumour and imaging was negative for any extrapancreatic tumour metastasis. This is an unusual case as pancreatic malignancy is usually lethal with poor survival outcomes.

A Rare Case of Complete Esophageal Obstruction Following Esophageal Variceal Band Ligation (EVBL) for Esophageal Varices Performed by Esophagogastroduodenoscopy (EGD)

Patient: Female, 69 Final Diagnosis: Complete esophageal obstruction Symptoms: Nausea • vomiting Medication: — Clinical Procedure: — Specialty: Gastroenterology and Hepatology Objective: Rare disease Background: Esophageal variceal band ligation (EVBL) performed by esophagogastroduodenoscopy (EGD) is a routinely performed procedure for the treatment of esophageal varices that is undertaken to control bleeding and prevent further complications. This report is of a case of a rare complication of complete esophageal obstruction following EVBL. Case Report: A 69-year-old woman underwent EVBL for esophageal varices. She subsequently presented with complete obstruction of the esophageal lumen with ulceration, which was seen on repeat EGD. Following conservative management, EGD demonstrated scarring around the ulcerated region and a patent esophagus. Conclusions: This case report serves to remind physicians of the potential complications that may arise with the use of EVBL treatment for bleeding esophageal varices and to consider the use of a loop cutter, to grasp and remove the esophageal band to improve patient recovery.

Proximal Migration of Jejunostomy Extension Tube Causing Recurrent Aspiration

A 67-year old woman presented with worsening dyspnea, productive cough, and fever. She denied oral intake, and her symptoms were worse with tube feeds. Her medical history was significant for chronic obstructive pulmonary disease, gastric esophageal reflux disease (GERD), and severe oropharyngeal dysphagia status post percutaneous endoscopic gastrostomy (PEG) tube with jejunal extension placement one year prior. Physical exam was notable for bilateral end expiratory wheezes with right-sided basilar rales on auscultation of the lungs. PEG insertion site looked clean with no signs of infection or abnormal drainage. Chest x-ray showed right lower-lobe consolidation. Blood and sputum cultures were obtained and broad-spectrum empiric antibiotic coverage was initiated for a diagnosis of aspiration pneumonia.