Rita Slim

Isolated fever induced by mesalamine treatment

Adverse reactions to mesalamine, a treatment used to induce and maintain remission in inflammatory bowel diseases, particularly ulcerative colitis, have been described in the literature as case reports. This case illustrates an unusual adverse reaction. Our patient developed an isolated fever of unexplained etiology, which was found to be related to mesalamine treatment. A 22-year-old patient diagnosed with ulcerative colitis developed a fever with rigors and anorexia 10 d after starting oral mesalamine while his colitis was clinically resolving. Testing revealed no infection. A mesalamine-induced fever was considered, and treatment was stopped, which led to spontaneous resolution of the fever. The diagnosis was confirmed by reintroducing the mesalamine. One year later, this side effect was noticed again in the same patient after he was administered topical mesalamine. This reaction to mesalamine seems to be idiosyncratic, and the mechanism that induces fever remains unclear. Fever encountered in the course of a mesalamine treatment in ulcerative colitis must be considered a mesalamine-induced fever when it cannot be explained by the disease activity, an associated extraintestinal manifestation, or an infectious etiology.

Unusual etiology of epigastric pain.

BACKGROUND Epigastric pain is a common presenting complaint encountered in urgent care settings. Although peptic, biliary, and pancreatic pathologies are the most frequent findings, other rare diagnoses also can be found. OBJECTIVES We report an unusual case of acute epigastric pain in which abdominal ultrasound was of great support in revealing the diagnosis. CASE REPORT A 64-year-old man presented to the Emergency Department after rapid onset of acute epigastric pain. Abdominal ultrasound showed a multi-cystic heterogeneous mass between the stomach and the liver. Abdominal computed tomography scan confirmed the gastric origin of the mass and showed torsion signs. Urgent laparotomy was performed with tumor excision. The diagnosis of pedunculated exophytic gastric stromal tumor was made and long-term follow-up was arranged. CONCLUSIONS Acute presentation revealed the presence of the tumor, which was excised surgically.

Education and Imaging. Hepatobiliary and pancreatic: peliosis hepatis associated with multiple myeloma.

A woman, aged 64, was investigated because of crampy pains in the right upper quadrant of her abdomen over the preceding 2 weeks. She was known to have hypertension and diabetes. Various blood tests including liver function tests were normal. An abdominal ultrasound study showed multiple hypoechoic lesions in the liver. A computed tomography (CT) scan revealed several hypodense lesions in the liver that raised the strong possibility of liver metastases (Figure 1). Subsequent investigations including various tumor markers, upper and lower endoscopy, mammography and a gynecological examination were unhelpful. An ultrasound-guided liver biopsy showed normal liver parenchyma with areas of marked sinusoidal dilatation (Figure 2, S) typical of peliosis hepatis. The cavities contained hematopoietic cells (Figure 2, H) of granulocyte and erythrocyte lineages as well as megakaryocytes (Figure 2, M). These features indicated extramedullary hematopoesis and, because of this, serum protein immunoelectrophoresis and a bone marrow biopsy were performed. The serum contained a monoclonal band composed of lambda light chains while the bone marrow biopsy showed a proliferation of plasma cells that were also positive for lambda light chains. The diagnosis was that of light chain myeloma. Peliosis hepatis is an uncommon vascular disorder of the liver characterized by small or larger blood-filled cavities with a diameter of up to several centimeters. It was first described in the 1950s in association with tuberculosis. Since that time, associations with other disorders have been reported including drugs (anabolic steroids, oral contraceptives), infections (bartonellosis, HIV), organ transplantation and a variety of hematological and nonhematological malignancies (lymphoma, multiple myeloma, pancreatic cancer). Reasons for these associations remain unclear although the pathogenesis is thought to involve injury to endothelial and parenchymal cells followed by sinusoidal dilatation and the development of larger cavities. With imaging, peliosis hepatis can be difficult to differentiate from multiple abscesses, focal nodular hyperplasia and liver metastases. Using CT, findings suggestive of peliosis hepatis include early enhancement in the center of the lesion followed by centrifugal progression with homogeneous enhancement in the delayed phase. In most patients, a definitive diagnosis will only be made by liver histology. In the above case, histology not only revealed peliosis hepatis but also revealed extramedullary hematopoesis. The latter is a compensatory mechanism to produce blood cells outside the bone marrow when bone marrow production is impaired. This demonstration of extramedullary hematopoesis led to the diagnosis of light chain myeloma.

Resectional One Anastomosis Gastric Bypass/Mini Gastric Bypass as a Novel Option for Revision of Restrictive Procedures: Preliminary Results

Background Revisional surgery is becoming a common and challenging practice in bariatric centers. The aim of this study was to evaluate resectional one anastomosis gastric bypass/mini gastric bypass (R-OAGB/MGB) as a revisional procedure. Methods From January 2016 to February 2017, data on 21 consecutive patients undergoing R-OAGB/MGB for weight loss failure after primary restrictive procedures were prospectively collected and analysed. Results Mean age was 39 ± 12 years (18–65), and 11 (52.3%) were women. The mean operative time was 96.4 ± 20.9 min (range, 122–80), and the mean postoperative stay was 47.8 ± 7.4 hours (range, 36–73). There were no deaths and no procedure-related complications. The mean body mass index (BMI) decreased from 42.9 ± 6.5 at the time of R-OAGB/MGB to 28.5 ± 4 at the 12-month follow-up. At that time point, the mean percentage of BMI loss (%EBL) and the mean percentage of total body weight loss (%TWL) reached 81.6 ± 0.17% and 35 ± 0.01%, respectively. Conclusion R-OAGB/MGB was technically straightforward, effective, and safe in this at-surgical risk population. R-OAGB/MGB should be added to the armamentarium of revisional bariatric procedures considering its technical aspects and the potential advantage on weight loss.

Trimethoprim-sulfamethoxazole-induced hepatotoxicity in a renal transplant patient

Drug-induced liver injury (DILI) represents liver damage from various therapeutic drugs. Antimicrobials are among the most common causes of DILI. We report a case of hepatic toxicity due to Trimethoprim-sulfamethoxazole (TMP-SMX) in a patient who underwent renal transplantation. Diagnosis has been made after a careful history taking, exclusion of competing etiologies and reversal of biochemical abnormalities after withdrawal of the antibiotic. TMP-SMX liver toxicity is well known but remains unpredictable and is rarely reported.

Hepatobiliary and Pancreatic: Peliosis hepatis associated with multiple myeloma: Education and Imaging

A woman, aged 64, was investigated because of crampy pains in the right upper quadrant of her abdomen over the preceding 2 weeks. She was known to have hypertension and diabetes. Various blood tests including liver function tests were normal. An abdominal ultrasound study showed multiple hypoechoic lesions in the liver. A computed tomography (CT) scan revealed several hypodense lesions in the liver that raised the strong possibility of liver metastases (Figure 1). Subsequent investigations including various tumor markers, upper and lower endoscopy, mammography and a gynecological examination were unhelpful. An ultrasound-guided liver biopsy showed normal liver parenchyma with areas of marked sinusoidal dilatation (Figure 2, S) typical of peliosis hepatis. The cavities contained hematopoietic cells (Figure 2, H) of granulocyte and erythrocyte lineages as well as megakaryocytes (Figure 2, M). These features indicated extramedullary hematopoesis and, because of this, serum protein immunoelectrophoresis and a bone marrow biopsy were performed. The serum contained a monoclonal band composed of lambda light chains while the bone marrow biopsy showed a proliferation of plasma cells that were also positive for lambda light chains. The diagnosis was that of light chain myeloma. Peliosis hepatis is an uncommon vascular disorder of the liver characterized by small or larger blood-filled cavities with a diameter of up to several centimeters. It was first described in the 1950s in association with tuberculosis. Since that time, associations with other disorders have been reported including drugs (anabolic steroids, oral contraceptives), infections (bartonellosis, HIV), organ transplantation and a variety of hematological and nonhematological malignancies (lymphoma, multiple myeloma, pancreatic cancer). Reasons for these associations remain unclear although the pathogenesis is thought to involve injury to endothelial and parenchymal cells followed by sinusoidal dilatation and the development of larger cavities. With imaging, peliosis hepatis can be difficult to differentiate from multiple abscesses, focal nodular hyperplasia and liver metastases. Using CT, findings suggestive of peliosis hepatis include early enhancement in the center of the lesion followed by centrifugal progression with homogeneous enhancement in the delayed phase. In most patients, a definitive diagnosis will only be made by liver histology. In the above case, histology not only revealed peliosis hepatis but also revealed extramedullary hematopoesis. The latter is a compensatory mechanism to produce blood cells outside the bone marrow when bone marrow production is impaired. This demonstration of extramedullary hematopoesis led to the diagnosis of light chain myeloma.

Hepatobiliary and Pancreatic: Peliosis hepatis associated with multiple myeloma

A woman, aged 64, was investigated because of crampy pains in the right upper quadrant of her abdomen over the preceding 2 weeks. She was known to have hypertension and diabetes. Various blood tests including liver function tests were normal. An abdominal ultrasound study showed multiple hypoechoic lesions in the liver. A computed tomography (CT) scan revealed several hypodense lesions in the liver that raised the strong possibility of liver metastases (Figure 1). Subsequent investigations including various tumor markers, upper and lower endoscopy, mammography and a gynecological examination were unhelpful. An ultrasound-guided liver biopsy showed normal liver parenchyma with areas of marked sinusoidal dilatation (Figure 2, S) typical of peliosis hepatis. The cavities contained hematopoietic cells (Figure 2, H) of granulocyte and erythrocyte lineages as well as megakaryocytes (Figure 2, M). These features indicated extramedullary hematopoesis and, because of this, serum protein immunoelectrophoresis and a bone marrow biopsy were performed. The serum contained a monoclonal band composed of lambda light chains while the bone marrow biopsy showed a proliferation of plasma cells that were also positive for lambda light chains. The diagnosis was that of light chain myeloma. Peliosis hepatis is an uncommon vascular disorder of the liver characterized by small or larger blood-filled cavities with a diameter of up to several centimeters. It was first described in the 1950s in association with tuberculosis. Since that time, associations with other disorders have been reported including drugs (anabolic steroids, oral contraceptives), infections (bartonellosis, HIV), organ transplantation and a variety of hematological and nonhematological malignancies (lymphoma, multiple myeloma, pancreatic cancer). Reasons for these associations remain unclear although the pathogenesis is thought to involve injury to endothelial and parenchymal cells followed by sinusoidal dilatation and the development of larger cavities. With imaging, peliosis hepatis can be difficult to differentiate from multiple abscesses, focal nodular hyperplasia and liver metastases. Using CT, findings suggestive of peliosis hepatis include early enhancement in the center of the lesion followed by centrifugal progression with homogeneous enhancement in the delayed phase. In most patients, a definitive diagnosis will only be made by liver histology. In the above case, histology not only revealed peliosis hepatis but also revealed extramedullary hematopoesis. The latter is a compensatory mechanism to produce blood cells outside the bone marrow when bone marrow production is impaired. This demonstration of extramedullary hematopoesis led to the diagnosis of light chain myeloma.

Prospective Audit of Colonoscopy Practice in a Lebanese University Hospital

Background Colonoscopy has a great impact on diagnosis and management of the diseases of the colon. In general its a safe and accurate procedure. No evaluation has been done of any endoscopic practices in a country where the practice of medicine is totally private. Objectives Prospective audit of technical success and complication rates of both therapeutic and diagnostic colonoscopy. Setting One endoscopy unit of a Lebanese university hospital. Patients and design 407 consecutive colonoscopies were evaluated over a 6-month period. Data were recorded for age and sex of the patients, indication of the colonoscopy, presence of comorbidities, patients risk stratification, administrated dose of anesthetic drugs. Data concerning the procedure itself were also monitored. Intervention Completion rate as well as complications reported during or post colonoscopy. All patients were called back by phone 48 hours and 1 month later to identify any related post-procedural complication. Results 407 patients underwent colonoscopy. All patients were sedated with midazolam, propofol and fentanyl. The overall caecal intubation rate was 99.99%. 70 snare polypectomies and 29 cold forceps excision were performed as well as 5 coagulations with Argon Plasma Coagulation. The most important post-procedural complication was chemical colitis in 2 cases. Limitations Patients and endoscopists satisfaction was not evaluated. Its an audit of a single tertiary French affiliated hospital. It does not necessarily reflect whats really happening on a national level. Conclusion This audit enabled us to change some of our practices; i.e. rinsing method of endoscopes. It stimulated the team to keep a high performance level without neglecting the risk of potential complications.

An unusual internal pile

A 60 year old female underwent total colonoscopy for recurrent painless haematochezia. She reported no past medical history of abdominal or anorectal symptoms. Physical examination was unremarkable. …