Tariq A. Hammad

Posterior Reversible Encephalopathy Syndrome Secondary to CSF Leak and Intracranial Hypotension: A Case Report and Literature Review

Posterior Reversible Encephalopathy Syndrome (PRES) is a clinical neuroradiological condition characterized by insidious onset of neurological symptoms associated with radiological findings indicating posterior leukoencephalopathy. PRES secondary to cerebrospinal fluid (CSF) leak leading to intracranial hypotension is not well recognized etiology of this condition. Herein, we report a case of PRES that occurred in the setting of CSF leak due to inadvertent dural puncture. Patient underwent suturing of the dural defect. Subsequently, his symptoms resolved and a repeated brain MRI showed resolution of brain lesions. The pathophysiology and mechanistic model for developing PRES in the setting of intracranial hypotension were discussed. We further highlighted the importance of tight blood pressure control in patients with CSF leak and suspected intracranial hypotension because they are more vulnerable to develop PRES with normal or slightly elevated bleed pressure values.

Hypertriglyceridemia-Induced Pancreatitis in Psychiatric Patients: A Case Report and Review of Literature.

Hypertriglyceridemia is a known cause of 2%-7% of cases of acute pancreatitis. Although there are numerous potential causes, the use of atypical antipsychotics has been linked to elevated triglycerides and pancreatitis. Here, we present the case of a 42-year-old male patient with a diagnosis of schizoaffective disorder who presented to our hospital with acute pancreatitis due to hypertriglyceridemia, which was exacerbated after he was started on quetiapine.

Acute Cholangitis following Biliary Obstruction after Duodenal OTSC Placement in a Case of Large Chronic Duodenocutaneous Fistula

Over-the-Scope Clip system, also called “Bear Claw,” is a novel endoscopic modality used for closure of gastrointestinal defect with high efficacy and safety. We present a patient with history of eosinophilic gastroenteritis and multiple abdominal surgeries including Billroth II gastrectomy complicated by a large chronic duodenocutaneous fistula from a Billroth II afferent limb to the abdominal wall. Bear Claw clip was used for closure of this fistula. The patient developed acute cholangitis one day after placement of the Bear Claw clip. Acute cholangitis due to papillary obstruction is a potential complication of Bear Claw placement at the dome of the duodenal stump (afferent limb) in patient with Billroth II surgery due to its close proximity to the major papilla.

Rifaximin for the prevention of spontaneous bacterial peritonitis and hepatorenal syndrome in cirrhosis: A systematic review and meta-analysis

Prophylactic antibiotics have been recommended in patients with a previous history of spontaneous bacterial peritonitis (SBP). Recently, there has been interest in the use of rifaximin for the prevention of SBP and hepatorenal syndrome (HRS). We conducted a meta-analysis to evaluate this association of rifaximin. We searched several databases from inception through 24 January 2017, to identify comparative studies evaluating the effect of rifaximin on the occurrence of SBP and HRS. We performed predetermined subgroup analyses based on the type of control group, design of the study, and type of prophylaxis. Pooled odds ratios (ORs) were calculated using a random effects model. We included 13 studies with 1703 patients in the meta-analysis of SBP prevention. Pooled OR [95% confidence interval (CI)] was 0.40 (95% CI: 0.22–0.73) (I2=58%). On sensitivity analysis, adjusted OR was 0.29 (95% CI: 0.20–0.44) (I2=0%). The results of the subgroup analysis based on type of control was as follows: in the quinolone group, pooled OR was 0.42 (95% CI: 0.14–1.25) (I2=55%), and in the no antibiotic group, pooled OR was 0.40 (95% CI: 0.18–0.86) (I2=64%). However, with sensitivity analysis, benefit of rifaximin was demonstrable; pooled ORs were 0.32 (95% CI: 0.17–0.63) (I2=0%) and 0.28 (95% CI: 0.17–0.45) (I2=0%) for the comparison with quinolones and no antibiotics, respectively. Pooled OR based on randomized controlled trials was 0.41 (95% CI: 0.22–0.75) (I2=13%). For the prevention of HRS, the pooled OR was 0.25 (95% CI: 0.13–0.50) (I2=0%). Rifaximin has a protective effect against the development of SBP in cirrhosis. However, the quality of the evidence as per the GRADE framework was very low. Rifaximin appeared effective for the prevention of HRS.

Diagnosis of Splenic Lymphoma by Endoscopic Ultrasound Guided Fine Needle Aspiration: A Case Report and Review of the Literature

Introduction. Splenic tumor is usually found as an incidental finding on CT of abdomen. Traditionally, ultrasound (US) or computed tomography (CT) guided biopsies were employed for the purpose of sampling; however they have been reported to have a complication rate of 5.3%. Endoscopic ultrasound-fine needle aspiration (EUS-FNA) has been recently utilized for the purpose of sampling splenic tumors. In literature there are 7 reported instances where splenic lymphoma was diagnosed using EUS-FNA. We present a case of follicular B cell lymphoma of the spleen diagnosed using EUS-FNA. Case Report. 58-year-old female presented to her primary care physician for left upper quadrant abdominal pain for one week. Physical exam was significant for left upper quadrant tenderness. Her laboratory tests were within normal limits. She underwent CT scan of abdomen which revealed approximately 5 cm × 5 cm mass in spleen. EUS-FNA of the spleen revealed a large hypoechoic, heterogeneous, well-demarcated mass measuring 54.7 mm × 43.0 mm. Fine needle aspiration was performed, and the sample was submitted for cytology and flow cytometry. Flow cytometry revealed a lambda monotypic population of B cells displaying dim CD19 and CD10. Diagnosis of B cell non-Hodgkin low grade follicular lymphoma was made. Conclusion. Endoscopic ultrasound with fine needle aspiration is a very rare but safe, reliable method of diagnosis of splenic lymphomas.

Unusual Clinical Presentation of Hemobilia with Recurrent Vasovagal Episodes

Hemobilia is caused by the abnormal connection between a blood vessel and the bile duct, which is usually iatrogenic and caused by hepatobiliary procedures. The classic triad of hemobilia includes biliary colic, obstructive jaundice, and gastrointestinal bleeding. We present the case of an 80-year-old man who had laparoscopic cholecystectomy complicated by hemobilia. He had an unusual presentation of hemobilia in the form of transient vasovagal episodes in addition to abdominal pain and hematochezia.

Gastrointestinal manifestations associated with systemic sclerosis: results from the nationwide inpatient sample

Background Systemic sclerosis (SSc) is a multisystem disease associated with significant morbidity and increased mortality. The prevalence of different gastrointestinal (GI) manifestations has been investigated in multiple, but mainly small, retrospective studies. In this study, we investigated the prevalence and risk for a broad spectrum of GI disorders and malignancies in a large sample of inpatients with SSc in the United States. Methods We conducted a retrospective analysis using the 2010-2011 Healthcare Cost and Utilization Project – Nationwide Inpatient Sample (HCUP-NIS). SSc patients were identified by ICD-9-CM code 710.1. Non-SSc patients (“controls”) were matched to cases 4:1 by age and sex. We examined demographics, clinical characteristics, and a range of GI conditions. Results From 15,824,031 total patients, 13,633 cases of SSc were matched to 54,532 controls. The prevalence of GI manifestations among SSc patients was 59.24% compared to 29.96% for controls (P<0.0001). Significantly elevated GI manifestations in SSc patients included dysphagia (4.3% vs. 1.9%, P<0.0001), esophageal reflux (34.8% vs. 15.4%, P<0.0001), Barrett’s esophagus (1.7% vs. 0.3%, P<0.0001), constipation (6% vs. 4.6%, P<0.0001), diarrhea (4.5% vs. 2.4%, P<0.0001), fecal incontinence (0.4% vs. 0.2%, P<0.0001), and celiac disease (0.2% vs. 0%, P<0.0001). Some GI disorders were significantly lower in SSc patients, including cholelithiasis (1.6% vs. 2.1%, P<0.0001) and GI malignancies (1% vs. 2.2%, P<0.0001). Conclusions Our results emphasize the established association between SSc and esophageal disorders, such as dysphagia and reflux disease. Our analysis indicated a significant positive association between SSc and celiac disease, and a negative association between SSC and cholelithiasis.

Metastatic Renal Cell Cancer to Thyroid Diagnosed by Endoscopic Ultrasound Guided Fine Needle Aspiration Technique

Medical literature about the role of endoscopic ultrasound (EUS) in identifying thyroid lesions is limited. We present a case of secondary thyroid cancer from renal cell carcinoma (RCC) metastasis, diagnosed by thyroid EUS-fine needle aspiration (FNA) approach that was done for staging of esophageal adenocarcinoma, in a patient with 11-year history of complete right nephrectomy for RCC. An 81-year-old female patient underwent EUS for the evaluation of a newly discovered distal esophageal cancer. A hypoechoic, round, and well-demarcated mass that measured 26.9 mm × 21.9 mm was noticed in the right lobe thyroid gland. Therefore FNA was performed. The cytological results were consistent with metastatic RCC. In conclusion, EUS-FNA of thyroid nodule is a feasible and safe technique that can be used to evaluate any suspicious thyroid nodule. This case emphasizes the importance of carefully examining the thyroid gland during routine upper esophageal EUS examinations in the presence of history of nonthyroidal cancer.

Rare Esophageal Migration of AXIOS Stent Used for Walled-off Pancreatic Necrosis Drainage

The AXIOS stent (Boston Scientific, Marlborough, MA) is a novel lumen-apposing self-expandable metallic stent designed for enteric drainage of nonadherent lumens. Efficacy and safety of using the AXIOS stent for pancreatic fluid drainage have been consistently shown in several studies. Although it is less common with this novel stent, stent migration still may happen. We present a case of AXIOS stent migration into the esophagus.

Multiple Myeloma Causing Gastric Polyposis

A 71-year-old white man with Durie-Salmon stage IIIB multiple myeloma diagnosed 1 year prior presented with obstructive jaundice. He had received multiple cycles of chemotherapy. Abdominal computed tomography scan showed a 2.5-cm pancreatic head mass with mild biliary and pancreatic duct dilatation. The patient was scheduled for endoscopic ultrasound (EUS) with fine-needle aspiration (FNA) and endoscopic retrograde cholangiopancreatography for biliary drainage. Endoscopic examination of the stomach revealed multiple large, pedunculated, and sessile polyploid lesions seen diffusely throughout the stomach, some of which were ulcerated (Figure 1). EUS examination of these lesions revealed hypoechoic mucosal and submucosal masses within an isoechoic rim. No communication with the muscularis propria was noted. Biopsies and FNA of the gastric polyps were consistent with plastocytoma (Figure 2). EUS exam of the pancreas showed a 35.6 mm x 27.9 mm hypoechoic and poorly demarcated pancreatic/parapancreatic mass. FNA of this mass was consistent with metastatic multiple myeloma. Biliary drainage was performed using a 10-French x 10 cm plastic biliary stent. Given the overall prognosis and progression of the disease, the patient was referred for hospice care, where he died 2 months later.