Robert Spira

Intravenous Immunoglobulin in the Treatment of Severe Clostridium Difficile Colitis

Intravenous immunoglobulin (IVIG) has been utilized in patients with recurrent and refractory Clostridium difficile colitis. It is increasingly being used in patients with initial clinical presentation of severe colitis. Herein, we report a case of severe C. Difficile colitis successfully treated with IVIG with a review of the medical literature to identify the optimal timing and clinical characteristics for this treatment strategy.

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.

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.

A Rare Case Presentation of a Perforated Giant Sigmoid Diverticulum

Giant sigmoid diverticulum (GSD) is a rare complication of diverticulosis. These lesions arise from herniations of the mucosa through the muscle wall which progressively enlarge with colonic gas to become large air-filled cysts evident on plain X-ray and CT scans. We present a rare case of a 72-year-old female presenting with abdominal distention, abdominal tenderness, and fever who developed a type 1 giant sigmoid diverticulum (pseudodiverticulum) that subsequently formed an intra-abdominal abscess and an accompanying type 2 diverticulum as well. The patient was treated with surgical resection of the diverticulum with a primary anastomosis and abscess drainage. The patients postoperative course was uneventful. This case helps to support the need for the consideration of GSD in patients aged 60 and older with a history of diverticulosis and presenting with abdominal discomfort and distension.

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.

Enterogenous cyst of the small bowel causing intussusception in an adult: Case report and review of literature

Small bowel intussusception is a rare congenital disease entity, mostly manifesting before the age of two with abdominal pain and acute intestinal obstruction. In adults, colon intussusception is a rare event causing approximately 1% of all acute intestinal obstructions and they can occur idiopathically in adults or due to an intraluminal tumor mass. We report a case of an enterogenous cyst causing intussusception and iron deficiency anemia in an adult treated by surgical excision and resection of the small bowel.

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.

Follicular Lymphoma Presenting as an Isolated Colonic Polyp

Follicular lymphoma (FL) is the most common form of indolent lymphoma and accounts for 20–25 % of all lymphomas [1]. The gastrointestinal (GI) tract is the predominant site for primary extranodal non-Hodgkin lymphomas (NHL) and is 5–10 % of all extranodal diseases. Primary gastrointestinal NHL is found in the colon and is 6–20 % of all cases with 1–3.6 % being follicular lymphomas [2]. There has been only one other reported case of a follicular lymphoma presenting as an isolated polyp. We present another case of this same occurrence and include a brief review of this rare event. Case Presentation