Rahman Nakshabendi

Adverse Effects of Grape Seed Extract Supplement: A Clinical Case and Long-Term Follow-Up

ABSTRACT Grape seed extract (GSE) supplement use is becoming more popular today for its potential chemopreventive and chemotherapeutic role. We report a 49-year-old male who presented with recurrent nausea, vomiting, diarrhea, and acute weakness following GSE use. A thorough medical workup ensued and no causes were identified clinically, procedurally, or with imaging. Symptoms resolved after GSE discontinuation and the patient remained symptom-free 5 years later. This case illustrates the paucity of documented detailed clinical cases and lack of controlled trials detailing a thorough and reproducible adverse effect profile of GSE supplement.

African American ethnicity is not associated with development of Barrett's oesophagus after erosive oesophagitis

BACKGROUND Barretts oesophagus is the primary risk factor for oesophageal adenocarcinoma; erosive oesophagitis is considered an intermediate step with Barretts oesophagus development potential upon healing. Barretts oesophagus occurs in 9-19% following erosive oesophagitis but minimal data exists in African Americans. The study aim was to determine if ethnicity is associated with Barretts oesophagus formation following erosive oesophagitis. METHODS Retrospective review of endoscopies from September 2007 to December 2012 was performed. Inclusion criteria were erosive oesophagitis on index endoscopy, repeat endoscopy ≥6 weeks later and non-Hispanic white or African American ethnicity. Barretts oesophagus frequency following erosive oesophagitis by ethnicity was compared. RESULTS A total of 14,303 patients underwent endoscopy during the study period; 1636 had erosive oesophagitis. Repeat endoscopy was performed on 125 non-Hispanic white or African American patients ≥6 weeks from the index procedure. Barretts oesophagus occurred in 8% of non-Hispanic whites while no African American developed it on repeat endoscopy following erosive oesophagitis (p=0.029). No significant difference was seen between ethnic groups in any clinical parameter assessed. CONCLUSIONS African American ethnicity appears to result in decreased Barretts oesophagus formation following erosive oesophagitis. Further investigation to demonstrate factors resulting in decreased Barretts oesophagus formation among African Americans should be performed.

Giardiasis: a malignant mimicker?

SIMI 2015 A 27-year-old man, with no pertinent past medical history, presented with a 3-week history of severe nausea, vomiting, diarrhea, and abdominal pain. The pain was nonspecific and described as bloating. Associated symptoms included subjective fever and flatulence. The patient worked as a truck driver, traveling often, who had recently transported a shipment of river mulch. His mother was recently diagnosed with colon cancer and grandmother with lymphoma. The patient was afebrile, normotensive, and mildly tachycardiac on arrival. No cough, chest pain, alcohol use, weight change, sick contacts, or bleeding was reported. Physical examination revealed diffuse abdominal tenderness without peritoneal signs. Complete blood count showed a leukocytosis at 17.4 9 10 3 /lL. Folate, B12, and

Initial Presentation of a Pancreatic Mass

Question: A 55-year-old African American man with a medical history of chronic pancreatitis, pancreatic mass, alcohol abuse, hypertriglyceridemia, gastroesophageal reflux disease, and essential hypertension presented to the emergency department with severe abdominal pain radiating to his back that was associated with diaphoresis and weight loss. The initial workup demonstrated acute pancreatitis. Prior radiologic studies were reviewed to better characterize the pancreatic mass. More recent computed tomography and MRI scans demonstrated an enlarging, cystic and septated mass within the pancreatic head with marked dilatation of the patient’s pancreatic, and intrahepatic and extrahepatic biliary ducts (MRI; Figure A). Additionally, there was evidence of peripancreatic fat infiltration and multiple enlarged peripancreatic lymph nodes. Ultrasonography had also shown that the mass was displacing the patient’s duodenum.

Primary Histoplasma capsulatum Enterocolitis Mimicking Peptic and Inflammatory Bowel Disease

In immunocompromised patients, histoplasmosis may present as disseminated disease. We present a 52-year-old Caucasian male with symptoms of dyspepsia, postprandial epigastric pain, nausea, and nonbloody diarrhea. Upper and lower gastrointestinal endoscopies were suspicious for inflammatory bowel disease (IBD); however, biopsies were consistent with histoplasmosis, specifically in the duodenum.

Hepatobiliary and Pancreatic: Extrahepatic cavernous hemangioma presenting as a palpable abdominal mass

An 89-year-old Caucasian female with history of total abdominal hysterectomy with unilateral oophorectomy presented with abdominal pain, cramps, nausea, and diarrhea. Her vital signs were normal and physical examination was unremarkable except for a palpable abdominal wall mass of ~10 cm in the right upper quadrant. The mass was non-tender and non-pulsatile. Lab testing including complete blood count, basic metabolic panel, urine analysis, Cancer antigen (CA) 125, CA 19-9, and occult blood were all within normal limits. Computed tomography (CT) of the abdomen with contrast showed re-demonstration of benign cavernous hemangioma in the dome of the liver consistent with previous imaging five years prior (Fig. 1a). A new mass was present at the abdominopelvic junction on the right measuring 13 × 9 × 10 cm (Fig. 1b). The low attenuated mass with regions of nodular enhancement abuts the liver as well as loops of bowel including the duodenum. A fat plane is present between parts of the mass and the adjacent liver. An ultrasound-guided biopsy via core needle technique with subsequent histological workup revealed a hypervascular peritoneal mass consistent with a benign cavernous hemangioma and no evidence of malignancy (Fig. 2). Hepatic hemangiomas are the most common benign mesenchymal hepatic tumors, with prevalence ranging from 0.5–20%. The majority are discovered at autopsy or incidentally during imaging. Most patients with hemangiomas are asymptomatic, with lesions greater than 4 cm more likely symptomatic. Abdominal hemangiomas have been described in numerous locations, including the gastrointestinal tract, retroperitoneum, skeletal muscle, and mesentery. They traditionally are diagnosed on CT, but with unclear demarcation of its origin, subsequent imaging modalities should be considered. This patient’s clinical presentation was suspicious for a malignant mass in the abdomen. With histology confirming a benign cavernous hemangioma, the suspicion of a exophytic tumor remained. However, CT of the abdomen with contrast demonstrated no clear connection with the liver and made identification of hepatic origin challenging. Pedunculated exophytic hemangiomas show a thin pedicle that contains a feeding artery and draining vein, and this pedicle connects the hemangioma to the liver. In contrast, usual exophytic hemangiomas just show contrast enhancement at the contact surface with the caudate lobe. This case does not show evidence of either traditional finding on contrast CT, thus, the origin of the benign cavernous hemangioma remains unclear. Magnetic resonance imaging has been shown to be an excellent modality for both benign and exophytic liver tumors, and would be an useful imaging modality in this case. The differential diagnosis of intraabdominal masses in the elderly population is extensive and must include hemangioma. Contributed by AC Berry,* R Nakshabendi and BB Berry *University of South Alabama, Medicine, Mobile, Alabama, University of Florida College of Medicine-Jacksonville, Medicine, Jacksonville, Florida, and Wheaton Franciscan Healthcare, Medicine, Milwaukee, Wisconsin, USA Figure 2 Fibrovascular tissue with large irregularly shaped and dilated blood vessels, and lined by a single layer of endothelial cells. a b

An Unusual Cause of Chronic Painless Hematochezia

Question: A 74-year-old Caucasian woman with a history of persistent hemorrhoids presented with painless intermittent hematochezia per rectum of 6 months’ duration. A thorough physical and digital rectal examination were unremarkable. Laboratory analysis on admission included hemoglobin of 9.9 g/dL and hematocrit of 30.3%. Previous colonoscopy 5 years before admission showed a tubular adenoma. She became symptomatically anemic and underwent a colonoscopy, showing a large rectal fungating mass extending between 10 and 15 cm in length, occupying >50% of the colon circumference (colonoscopy; Figure A, B). Biopsy and subsequent immunohistochemical (IHC) analysis of the rectal mass was completed (IHC analysis; Figure C). What is the most likely diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.

A plunging case of intermittent dysphagia.

Question: A 71-year-old woman with a history of gastroesophageal reflux disease and chronic intermittent dysphagia presented with progressively worsening dysphagia for solid foods over the past three days. The patient also complained of reflux, without weight loss, and has never had food impaction requiring bolus removal. Upon presentation, the patient denied any nausea, vomiting, abdominal pain. Laboratory results were unremarkable. Esophagogastroduodenoscopy (EGD) 6 months before admission was unremarkable. However, current endoscopy revealed a large, 4to 5-cm subepithelial lesion in the mid esophagus at around 30 cm from the incisors. The lesion appeared smooth with normal overlying smooth tissue and no obvious ulcerations (EGD; Figure A). As the scope passed, the lesion plunged into the stomach, shown with the scope retroflexed (EGD; Figure B). CT of the chest with and without contrast confirmed the presence of a large submucosal mass 5.5 cm in width in the distal esophagus. Biopsy was performed under endoscopic ultrasonography (EUS; Figure C) with subsequent histology demonstrating a spindle cell neoplasm, combined with immunohistochemical analysis positive for CD117 (C-Kit) and negative for HMB-45. No extraesophageal masses were identified. What is the diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.

Acute Right Lower Quadrant Abdominal Pain: An Uncommon Culprit

Gastroenterology Question: A 60year-old Caucasian man with a history of diverticulosis, diabetes mellitus type 2, and hypertension woke up in the middle of the night with right lower quadrant pain. The pain was dull, nonradiating, and not associated with bowel movement or urination. He had undergone a screening colonoscopy 6 months earlier showing diffuse diverticulosis of the colon, with no history of any diverticulitis. The patient was afebrile and physical examination revealed an obese male in no acute distress. Abdominal examination demonstrated tenderness and rebound in right lower quadrant of the abdomen, with minimal guarding. His laboratory results were unremarkable except for an elevated white blood cell count of 14.3 103/mL with 82% segmented neutrophils and mildly elevated serum alanine aminotransferase at 63 U/L. A computed tomography (CT) scan of the abdomen was performed (Figure A, sagittal view; Figure B, coronal view). A surgical consultation was obtained and the patient underwent abdominal laparoscopy that evening. What is the likely diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.

An unusual cause of lower gastrointestinal bleeding.

53-year-old Caucasian woman presented withcomplaints of abdominal pain, constipation,pyrosis, and occasional red blood in her stool for 6months’ duration. The abdominal pain was burning innature, worse with eating, and radiated from her chest toher back. Physical examination was unremarkable anddid not show any pigmentation of the skin or the eyes.Hemoglobin and hematocrit levels on admission were14.3 g/dL and 43.1%, respectively. Colonoscopy showedinternal hemorrhoids and a bi-lobed rectal polypmeasuring 1.5 cm, which was snared and retrieved(Figures A and B). Immunohistochemical analysis wasstrongly positive for S-100, melan A, HMB-45, and nega-tive for chromogranin, which is most consistent with thediagnosis of malignant melanoma (Figure C).After the skin and retina, anorectal malignant mela-noma is the third most common location of melanoma.Anorectal melanomas make up less than 3% of all mel-anomas, and less than 1% of all malignant tumors of theanorectum are melanoma.