Vinaya Gaduputi

Systemic Reactive Amyloidosis Associated with Castleman's Disease

We report this case of secondary amyloidosis associated with Castlemans disease. A 51-year-old man presented with systemic symptoms of generalized weakness, fatigue, unintended weight loss, anorexia and progressively worsening abdominal distension. On examination he was found to have an indurated right-sided submandibular mass and tense ascites. He was found to have multiorgan dysfunction with deranged liver function tests and renal failure. Ascitic fluid analysis revealed evidence of spontaneous bacterial peritonitis. Biopsy of the submandibular mass revealed angiofollicular lymph node hyperplasia consistent with a diagnosis of Castlemans disease. A subsequent liver biopsy showed extensive deposition of amyloid protein. Bone marrow biopsy also showed the presence of amyloid and increased kappa light chain-restricted plasma cells. The patient was not considered a candidate for chemotherapy or solid organ transplantation in view of active sepsis and poor physical condition. Secondary systemic amyloidosis complicating Castlemans disease is very rare. Untreated secondary systemic amyloidosis often has a rapidly fatal course, such as seen in our patient.

Perioperative Management of Direct Oral Anticoagulants (DOACs): A Systemic Review

Direct oral anticoagulants (DOACs) are in wide use among patients requiring both short- and long-term anticoagulation, mainly due to their ease of use and the lack of monitoring requirements. With growing use of DOACs, it is imperative that physicians be able to manage patients on these medications, especially in the perioperative period. We aim to provide guidance on the management of DOACs in the perioperative period. In this review, we performed an extensive literature search summarizing the management of patients on direct-acting anticoagulants in the perioperative period. A total of four direct-acting oral anticoagulants were considered appropriate for inclusion in this review. The drugs were dabigatran etexilate mesylate (Pradaxa), rivaroxaban (Xarelto), apixaban (Eliquis), and edoxaban (Savaysa). Management of patients on DOACs in the perioperative period involves an assessment of thromboembolic event risk while off anticoagulation compared to the relative risk of bleeding if such drug is continued. DOACs may not need to be discontinued in minor surgeries or procedures, and in major surgeries, they may be discontinued hours prior depending on drug pharmacokinetics and renal function of the patients.

Abdominal Aortitis Associated with Crohn Disease

Bronx Lebanon Hospital Center, Bronx, New York, USA Correspondence: Dr Hassan Tariq, Bronx Lebanon Hospital Center, 1650 Selwyn Avenue, Suite 10C, Bronx, New York 10457, USA. Telephone 718-900-1234, e-mail htariq@bronxleb.org Received for publication July 31, 2013. Accepted September 19, 2013 Case Presentation A 26-year-old woman who was diagnosed with Crohn disease when she was 12 years of age presented with a two-week history of nausea, vomiting, worsening diarrhea and bilateral lower abdominal pain. The patient had a protracted history of Crohn disease treated with mesalamine, tapering short courses of corticosteroids for exacerbations and then 6-mercaptopurine therapy initiated three years before this presentation. Nine months before the patient presented, she was also started on subcutaneous adalimumab and maintained on a dose of 40 mg every other week. Her white blood cell count was 10×109/L (65.5% segmented neutrophils, 28.9% lymphocytes, 4.8% monocytes), with a hemoglobin level of 123 g/L and a platelet count of 164 ×109/L. An abdominal computed tomography scan revealed multifocal areas of mural thickening with narrowing in the colon (Figure 1), long-segment minimal thickening with narrowing of the upper abdominal aorta and maximal luminal narrowing in an infrarenal aortic segment (Figure 2). These findings were suggestive of aortitis, which is very rarely associated with Crohn disease.

A fascinating presentation of hepatic hydrothorax.

We report this case of a 43-year-old woman with hepatitis-C cirrhosis who presented with a large right sided pleural effusion complicated by hypoxic respiratory failure and altered mentation necessitating dependence on mechanical ventilation. The pleural effusion spontaneously resolved upon initiation of mechanical positive pressure ventilation and recurred almost immediately after weaning the patient off the ventilator. The pre-ventilation, ventilation and post-ventilation chest X-ray films in chronological order present a striking visual demonstration of fluid dynamics and pathophysiology of hepatic hydrothorax, thereby obviating the need for a dedicated diagnostic test. We also report this case to highlight the treatment strategies for this often intractable complication.

Gastric schwannoma—a rare benign mimic of gastrointestinal stromal tumor

Abstract Schwannomas most commonly manifest as acoustic neuromas in the vestibulo-cochlear nerve (CN VIII). These may occur unilaterally as primary tumors, or bilaterally secondary to neurofibromatosis type 2. More rarely, they present in extra-cranial sites, including the gastrointestinal tract. Gastrointestinal schwannomas are believed to arise from Auerbach’s plexus in the muscularis propria, and are classified as mesenchymal tumors. Here, we report a rare case of a 49-year-old woman who had surgical resection of a gastric mass which was eventually diagnosed as gastric schwannoma.

Gastric Outlet and Duodenal Obstruction as a Complication of Migrated Gastrostomy Tube: Report of Two Cases and Literature Review

Percutaneous endoscopic gastrostomy (PEG) is a well-recognized procedure for providing enteral feeding and long-term enteral nutritional support. Although it is mostly well tolerated, complications, sometimes mechanical in nature, do occur. Rare, and often initially unrecognized, late complications of PEG tube placement are gastric outlet obstruction and duodenal obstruction. Simple adjustment of the gastrostomy tube will lead to the improvement of the patient’s clinical condition and prevent further complications. Physicians should be aware of and suspect gastric outlet and duodenal obstruction as rare late complications of PEG tube placement. Simple adjustment of the gastrostomy tube can resolve the problem without unnecessary medical tests and overly aggressive care. Here, we present two interesting cases of elderly women who developed mechanical obstruction after inadvertent migration of the gastrostomy tube.

A Rare Case of Adult Colonic Intussusception from Benign Etiology

Defined as the tunneling of one bowel segment into an adjacent bowel segment, intussusception is typically observed in pediatric populations. Here, we present the case of a 78-year-old man who, in a series of unlikely events, developed colonic intussusception due to a benign lead point pathology. Intussusception of the colon is an uncommon occurrence in adults. However, adult colonic intussusception, observed in the absence of a malignant lead point pathology, represents a true clinical anomaly.

Hypertriglyceridemia-induced pancreatitis: updated review of current treatment and preventive strategies

Hypertriglyceridemia (HTG) is an uncommon but well-established cause of acute pancreatitis (AP) comprising up to 7% of the cases. The clinical course of HTG-induced pancreatitis (HTGP) is highly similar to that of AP of other etiologies with HTG being the only distinguishing clinical feature. However, HTGP is often correlated with higher severity and elevated complication rate. At present, no approved treatment guideline for the management of HTGP is available, although different treatment modalities such as insulin, heparin, fibric acids, and omega 3 fatty acids have been successfully implemented to reduce serum triglycerides (TG). Plasmapheresis has also been used to counteract elevated TG levels in HTGP patients. However, it has been associated with complications. Following the management of acute phase, lifestyle modifications including dietary adjustments and drug therapy are essential in the long-term management of HTGP and the prevention of its relapse. Results from studies of small patient groups describing treatment and prevention of HTGP are not sufficient to draw solid conclusions resulting in no treatment algorithm being available for effective management of HTGP. Therefore, prospective randomized, active-controlled clinical studies are required to find a better treatment regimen for the management of HTGP. Until date, one randomized clinical trial has been performed to compare clinical outcomes of different treatment approaches for HTGP. However, further studies are required to outline a generalized and efficient treatment regimen for the management of HTGP.

Adenosquamous Carcinoma of the Colon

Overall, colorectal cancer is the third most commonly diagnosed cancer in both men and women, meaning that it is one of the more widely recognized preventable cancers. Instances of colorectal malignancies though are overwhelmingly attributable to adenocarcinoma. Colorectal cancers with components of squamous cell carcinoma represent a statistical anomaly. Here, we present the case of a 50-year-old male, who complained of abdominal pain and weight loss over a 3-month period of time. Biopsies from a colonoscopy ultimately revealed that this patient’s colon cancer consisted of both adenocarcinoma and squamous cell carcinoma, representing a truly exceptional pathology finding in a patient diagnosed with a colorectal cancer.

Symptomatic Gallstones in the Young: Changing Trends of the Gallstone Disease-Related Hospitalization in the State of New York: 1996 - 2010

Background The aim of the study was to evaluate if the gallstone-related hospitalizations in the young (< 20 years of age) have increased over time in both the Bronx County and New York State as a whole. Methods We retrospectively reviewed 15 years (1996 - 2010) of Statewide Planning and Research Cooperative System (SPARCS) data of New York State Department of Health. Patients with ICD-9 code diagnosis of 574 (cholelithiasis) among the first three discharge diagnoses were reviewed. Results Total number of all cause admissions to hospitals had increased from 2.44 million to 2.77 million (1996 - 2010). However, gallstone-related hospitalizations had decreased from 1.7% to 1.2%. It was noted that there was a 30% increment in the proportion of those below 20 years of age with gallstone disease requiring hospitalization over the same period. This young patient population contributed only 2.04% to all gallstone-related hospitalizations in 1996, whereas it had increased to 2.96% in 2010. This trend was more pronounced in women, Hispanics and in those who were residing in the Bronx County as compared to all other New York counties combined. Conclusion The gallstone-related hospitalizations in the young (< 20 years of age) have increased over time in both the Bronx County and New York State as a whole. This could be due to increasing prevalence of risk factors such as obesity, physical inactivity, diabetes and early pregnancy.