Syed A. Ali

Upper Gastrointestinal Bleeding Revealing the Stomach Metastases of Renal Cell Carcinoma

IntroductionRenal cell carcinoma (RCC) constitutes 3% of all adult malignancies and often presents insidiously. Consequently, 25–30% of patients have metastases at the time of diagnosis.DiscussionGastrointestinal (GI) bleeding from RCC metastases is an uncommon and underrecognized manifestation of this disease. We hereby report a rare case of RCC with stomach metastasis which heralded the primary manifestation of the disease. This case highlights the importance of maintaining vigilance for unusual causes during endoscopy in cases of upper GI hemorrhage.

Ohio river valley fever presenting as isolated granulomatous hepatitis: a case report.

Histoplasmosis is endemic to the midwestern and east central states in the United States near the Mississippi and the Ohio River valleys. Ninety-nine percent of patients exposed to histoplasmosis develop only subclinical infection. Liver involvement as a part of disseminated histoplasmosis is well known; however, isolated hepatic histoplasmosis without any other stigmata of dissemination is extremely rare and the literature is limited to only two case reports. We present a rare case of isolated granulomatous hepatitis due to histoplasmosis in a 35-year-old female with dermatomyositis receiving low-dose prednisone and methotrexate. There was no evidence of fungal dissemination elsewhere. High clinical suspicion is critical for early diagnosis and treatment.

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.

Successful endoscopic management of a bleeding ulcer in a giant epiphrenic diverticulum.

1. Hacking CP, Taylor CJ, Nathanson LK. Common bile duct polyp mimicking choledocholithiasis: a case report with laparoscopic transcystic management. Surg Laparosc Endosc Percutan Tech 2008;18:290-3. 2. Levy AD, Murakata LA, Abbott RM, et al. Benign tumors and tumorlike lesions of the gallbladder and extrahepatic bile ducts: radiologic-pathologic correlation. Armed Forces Inst Pathol Arch 2007;22:387-413. 3. Lin RL, Janniger CK. Pyogenic granuloma. Cutis 2004;74:229-33. 4. Lee CK, Dong SH, Jung SH, et al. Pyogenic granuloma of the common bile duct in a patient with choledochoduodenostomy. Endoscopy 2007; 39:E282-3. Division of Gastroenterology and Hepatology (J.T., C.M.W., S.V.), Department of Pathology (N.J.), University of Alabama at Birmingham, Birmingham, Alabama, USA.

Corrosive injury to the GI tract in adults: a practical approach

Corrosive injury to the GI tract still poses great challenges with regards to the initial evaluation triage, as well as the optimization of medical management. Although relatively uncommon in the adult population, these injuries can cause significant morbidity and serious sequelae of complications, such as esophageal strictures and cancer. Prompt recognition of the process and aggressive measures towards the stabilization of the patient are key to a favorable outcome.

Hypokalemic Rhabdomyolysis Due to Watery Diarrhea, Hypokalemia, Achlorhydria (WDHA) Syndrome Caused by Vipoma

Mild hypokalemia is common and encountered in a multitude of diseases, but severe hypokalemia leading to rhabdomyolysis is relatively rare. The watery diarrhea, hypokalemia, achlorhydria (WDHA) syndrome caused by vasoactive intestinal polypeptide (VIP)-producing tumors, is an extremely rare cause of hypokalemic rhabdomyolysis and the literature is limited to one case report. We report a second case of an adult who presented with rhabdomyolysis due to severe hypokalemia. Further evaluation revealed that he had a VIP-producing pancreatic neuroendocrine tumor (NET), which was the cause of his hypokalemic rhabdomyolysis. Although rare in occurrence, a high index of suspicion is of paramount importance for establishing the correct diagnosis and treatment.

Screening Veterans Affairs Patients with Iron Deficiency for Celiac Disease

Letters to the Editor are welcomed. They may report new clinical or laboratory observations and new developments in medical care or may contain comments on recent contents of the Journal. They will be published, if found suitable, as space permits. Like other material submitted for publication, letters must be typewritten, double-spaced, and must not exceed two typewritten pages in length. No more than five references and one figure or table may be used. See “Information for Authors” for format of references, tables, and figures. Editing, possible abridgment, and acceptance remain the prerogative of the Editors.

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.

Successful primary endoscopic treatment of suprapancreatic biliary stricture after blunt abdominal trauma.

An 87-year-old man presented with a 3-day history of diffuse abdominal pain. He had no medical history of abdominal pain. He was afebrile. His blood pressure was 95/63 mm Hg, and his radial pulse rate was 100 beats per minute. Abdominal palpation revealed right lower quadrant tenderness. Laboratory test results revealed a hemoglobin concentration of 7.1 g/dL (normal range 12-16 g/dL) and a blood urea nitrogen level of 38.0 mg/dL (normal range 8-20 mg/ dL); all other blood test results were unremarkable. A CT scan of the abdomen and pelvis demonstrated a large heterogeneous pelvic mass with hemoperitoneum (A). After optimization, the patient was taken to the operating room where laparotomy confirmed the presence of a 10 8-cm solid tumor that was 220 cm from Treitz’s ligament and showed an exophytic growth pattern (B). The tumor had ruptured but there were no peritoneal metastases; partial resection of the ileum with the contained mass was performed. The resected tumor was red in color and had areas of bleeding with numerous blood clots (C). Histologic ex-