Salma Akram

Acute buried bumper syndrome.

Buried bumper syndrome (BBS) is an uncommon complication of percutaneous endoscopic gastrostomy (PEG) tube placement. This unusual phenomenon occurs when the internal bumper of a PEG tube erodes and migrates through the gastric wall and becomes lodged anywhere between the gastric wall and the skin. If not removed and treated appropriately, it can lead to life-threatening complications. It is considered to be a late complication, with most cases occurring from months to years later. We present an unusual case of a very rapid development of BBS, along with a brief review of contributing factors and treatment recommendations.

Platypnea orthodeoxia: a ‘laid-back’ case of dyspnoea

A man with end-stage liver disease who presented with shortness of breath. He exhibited clinical platypnea (worsening shortness of breath on sitting up) and orthodeoxia (oxygen desaturation on sitting up). Follow-up investigations led to the diagnosis of hepatopulmonary syndrome.

Successful Endoscopic Transpapillary Management of Intrahepatic Pancreatic Pseudocyst

CONTEXT Intrahepatic pancreatic pseudocyst extension is a rare but complex clinical entity requiring multimodality approach for management. There is no consensus regarding the optimal strategy for the treatment of intrahepatic pancreatic pseudocyst and the literature is limited to a few case reports. Most of the published cases were managed by surgical or percutaneous drainage. CASE REPORT We hereby report a case of intrahepatic pancreatic pseudocyst extension which failed to resolve by percutaneous drainage. Endoscopic transpapillary drainage was utilized which led to complete resolution of the intrahepatic pancreatic pseudocyst. CONCLUSION The excellent results obtained in our patient suggest that it should be considered as primary treatment and may obviate the need for more aggressive and potentially morbid procedures.

Dermatitis Herpetiformis: Rare Cutaneous Manifestation of Colon Adenocarcinoma

A previously healthy mildly obese 72-year-old Caucasian male with well-controlled type II diabetes presented with a 2-month history of a pruritic papulovesicular rash on the extensor surface of the forearms. Skin punch biopsy showed subepidermal multilocular bullous lesions with edema and neutrophils (Fig. 1). Direct immunofluorescence showed dense granular deposits of IgA in the basement membrane and at the tips of dermal papillae, consistent with the diagnosis of dermatitis herpetiformis (DH) (Fig. 2). The patient did not have any gastrointestinal symptoms, and celiac disease serology including anti-endomysial antibodies and anti-tissue transglutaminase IgA and IgG were negative. The patient did not have any significant improvement in skin lesions on dapsone and gluten-free diet. Six months later, the patient presented with acute onset of right-sided abdominal pain, generalized weakness, anorexia, 25-lb weight loss, and several episodes of melena with iron deficiency anemia. A CT scan of the abdomen showed focal colonic wall thickening and a 5.5-cm hepatic flexure pericolonic fluid collection containing air, which was suggestive of focal perforation with a pericolonic abscess. Multiple enhancing liver lesions were noted which were suspicious for metastatic disease. Lymphadenopathy was noted in the right upper abdomen, involving the portacaval, periportal, and celiac axis regions. The largest lymph node, located in the portacaval region, measured up to 3.2 cm. Colonoscopy 3 years prior was normal. Carcinoembryonic antigen level was elevated at 414. Due to risk of perforation, colonoscopy was delayed pending image-guided biopsy. Biopsy of the liver lesions revealed poorly differentiated adenocarcinoma. Subsequent colonoscopy showed a 9-cm friable, ulcerated, partially obstructing mass extending from the hepatic flexure to the proximal transverse colon (Fig. 3). Endoscopic mucosal biopsies were consistent with poorly differentiated adenocarcinoma. Immunohistochemistry was positive for CK7, mucin, and CK20 and negative for CDX2, TTF-1, chromogranin, synaptophysin, PSA, and PAP. The patients clinical condition deteriorated rapidly, and he passed away 1 month following the diagnosis of metastatic colon cancer.

Screening Veterans Affairs Patients with Iron Deficiency for Celiac Disease

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Giant ulcerated lipoma of the colon causing iron deficiency anemia successfully treated with endoscopic ultrasound-assisted resection.

Colonic lipomas are frequently small and asymptomatic. Giant colonic lipoma (GCL) is an uncommon finding at endoscopy, and ulceration with occult blood loss leading to iron deficiency anemia (IDA) is even rarer. The choice of therapeutic procedure to treat symptomatic GCLs has been controversial. We hereby report a case of an ulcerated GCL that presented with occult bleeding and IDA. IDA resolved after the GCL was removed successfully combining endoloop ligation and snare cautery technique under endoscopic ultrasound (EUS) guidance. With the advent of EUS, endoscopic resection of submucosal tumors can be performed relatively safely by providing a viable and useful alternative to surgery.

Biliary Obstruction and Pancreatitis Caused by Diffuse Nodular Hyperplasia of Brunner’s Gland

IntroductionBrunners gland hyperplasia (BGH) of the duodenum is an uncommon finding at endoscopy and is usually asymptomatic. Symptomatic BGH presenting with biliary obstruction and pancreatitis is extremely rare and the literature is limited to a few case reports.CaseWe report an unusual case of diffuse BGH of duodenum involving the ampulla of Vater that led to this clinical presentation. Biopsies revealed BGH and successful endoscopic therapy utilizing sphincterotomy and plastic stent placement led to complete recovery.ConclusionAlbeit its uncommon clinical presentation, it can become challenging in terms of diagnosis and management. A high index of suspicion is of paramount importance for establishing the correct diagnosis and treatment.

Xanthogranulomatous cholecystitis mimicking gallbladder cancer

Xanthogranulomatous cholecystitis (XGC) is a benign, uncommon variant of chronic cholecystitis characterised by focal or diffuse destructive inflammatory process of the gallbladder (GB). Macroscopically, it appears like yellowish tumour-like masses in the wall of the GB. This article reports on a 74-year-old woman with XGC mimicking GB cancer.

Malignant Polyp in a Colonic Diverticulum: a Rare Cause of Diverticular Hemorrhage

Colonic diverticula and colonic polyps are two of the most common causes of lower gastrointestinal (GI) hemorrhage [1, 2]. Colonic polyps or carcinoma can arise from the normal mucosa near or within a diverticulum [3]. Case reports describe colonic tumors found within a diverticulum, e.g., colon polyps [4], carcinoids [5], lymphoma [6], and adenocarcinoma [3, 7–13]. Rarely adenocarcinoma in a diverticular colonic abscess has been reported [14, 15]. None of the cases has presented as hematochezia or been associated with diverticular bleeding. We report a case of malignant colon polyp within a diverticulum presenting as diverticular hemorrhage.