ACG Case Reports Journal最新文献

We present the case of a 60-year-old African American man with sickle cell beta plus thalassemia who developed large-volume hematochezia during hospitalization for a vaso-occlusive crisis. Sickle cell disease is characterized by chronic hemolysis and vaso-occlusion that can affect the gastrointestinal tract, although clinically significant colonic ischemia remains rare. The patient had a history of diverticulosis and hemorrhoids but presented with acute lower gastrointestinal bleeding after dehydration and nonsteroidal anti-inflammatory drug exposure, both of which can impair mucosal perfusion. Colonoscopy revealed discontinuous ulcerations in the rectosigmoid colon, and histopathology confirmed ischemic colitis with thrombosed submucosal vessels, consistent with vaso-occlusive microthrombosis. This case underscores the importance of early endoscopic evaluation and recognition of ischemic colitis as a potential cause of overt gastrointestinal bleeding in patients with sickle cell disease.

Plug-Assisted Retrograde Transvenous Obliteration (PARTO) is increasingly used for bleeding gastric varices, particularly in patients at high risk of hepatic encephalopathy where Transjugular Intrahepatic Portosystemic Shunt may be unsuitable. Current American Gastroenterological Association guidelines state that PARTO and Balloon-Occluded Retrograde Transvenous Obliteration are more effective than Transjugular Intrahepatic Portosystemic Shunt in preventing rebleeding and have lower hepatic encephalopathy rates. We report a case of multifocal ischemic stroke after technically successful PARTO. The temporal relationship and a patent foramen ovale suggest paradoxical embolism. This first reported case highlights a previously unrecognized but critical risk of PARTO warranting consideration during patient selection and counseling.

Noncirrhotic portal hypertension (NCPH) accounts for approximately 10% of all cases of portal hypertension, with liver cirrhosis being the most common underlying etiology. One of the potential causes of NCPH is pancreatitis, due to the close anatomical relationship between the mesenteric vessels-particularly the splenic vein-and the pancreas, as well as the proinflammatory state associated with this condition. This case report describes a 61-year-old man with a history of necrotizing acute pancreatitis who developed spontaneous bacterial peritonitis secondary to prehepatic NCPH.

Hemospray (TC-325), a powder-based hemostatic spray, is increasingly used for upper gastrointestinal bleeding but can rarely cause endoscope retention. A 74-year-old woman with chronic kidney disease, atrial fibrillation on warfarin, mechanical heart valves, and prior gastric ulcers presented with melena and large-volume hematemesis causing hemodynamic instability. Laboratory findings revealed hemoglobin 7.3 g/dL and international normalized ratio 7. Esophagogastroduodenoscopy showed multiple bleeding arteriovenous malformations in the cardia and fundus, treated with a synthetic self-assembling peptide gel and subsequently with hemospray applied in retroflexion. Withdrawal of the endoscope was initially unsuccessful due to powder adhesion, but aggressive water irrigation enabled removal after 90 minutes. The patient stabilized with transfusions and octreotide, with no recurrent bleeding. This case underscores the risk of endoscope retention when Hemospray is applied retroflexed and suggests aggressive irrigation as a potential remedy. Further studies are needed to optimize Hemospray dosing and evaluate self-assembling peptide-powder interactions.

Pancreatic tuberculosis is a rare disease. It mimics both benign and malignant conditions of the pancreas. We describe the case of a man who presented with repetitive epigastric pain and elevated pancreatic enzymes, leading to a presumptive diagnosis of alcohol-induced pancreatitis. Imaging revealed pancreatic pseudocyst, omental thickening, multiple loculated ascites, and bilateral pleural effusions. Despite supportive management for pancreatitis, the patient's symptoms worsened. Further evaluation raised the suspicion of tuberculosis. He was started on antituberculosis therapy. There was complete resolution of his symptoms, pseudocyst and ascites on follow-up imaging. Early suspicion and management of pancreatic tuberculosis may lead to excellent outcomes.

Endoscopic procedures such as esophagogastroduodenoscopy and colonoscopy are commonly performed under propofol-based anesthesia due to its rapid onset and recovery. However, delayed emergence is a rare but clinically significant concern, especially in patients with neurological disorders such as narcolepsy. We report a 28-year-old woman (body mass index: 35.8) who exhibited delayed emergence approximately 10 hours after esophagogastroduodenoscopy and colonoscopy for evaluation of iron deficiency anemia. She received lidocaine 80 mg IV, followed by propofol 900 mg IV over 45 minutes. Postprocedure, she remained sedated despite unremarkable laboratory and neurologic imaging, including head computed tomography angiogram and perfusion studies. She was monitored in the ICU and gradually regained consciousness without intervention. Before discharge, she disclosed a history of narcolepsy, unrecognized preoperatively. This case underscores the importance of thorough preoperative screening for sleep disorders, as narcolepsy can alter anesthetic sensitivity and prolong sedation, necessitating close collaboration between gastroenterologists and anesthesiologists.

Chylous ascites is a rare complication of cirrhosis-related portal hypertension, accounting for less than 1% of ascites cases. We report a 76-year-old diabetic woman with prior breast cancer and cirrhosis secondary to metabolic dysfunction-associated fatty liver disease presenting with abdominal distension, bloating, and dyspnea. Paracentesis revealed pink milky chylous fluid with triglycerides of 269 mg/dL. Malignancy was excluded by cytology and positron emission tomography-computed tomography. Treatment with a medium-chain triglyceride diet, fat-soluble vitamins, diuretics with albumin, octreotide (200 μg/d), and paracentesis led to clinical improvement. This case underscores the rarity of chylous ascites and the efficacy of multimodal conservative management.