ACG Case Reports Journal最新文献

A 54-year-old man with hepatitis C cirrhosis presented with apparent spontaneous bacterial peritonitis, but further work-up confirmed the diagnosis of fluid overload-associated large B-cell lymphoma (FOA-LBCL). FOA-LBCL is a recently recognized entity with limited data on pathogenesis and treatment. Flow cytometry and cytological evaluation of ascitic fluid were key in establishing the diagnosis, whereas peripheral blood flow cytometry and imaging studies helped to exclude alternate infectious causes and secondary involvement by other lymphomas. We report a unique case of FOA-LBCL requiring multidisciplinary diagnosis and management.

Drug-induced liver injury describes the result of toxicity to the liver from offending drugs and/or their metabolites. Most cases are acute and resolve quickly after the medication is discontinued. It is a diagnosis of exclusion after ruling out other causes of liver injury, such as infectious and autoimmune etiologies. When drug-induced liver injury is suspected, the culprit can be determined by establishing a temporal relationship between drug exposure and the development of signs and symptoms of liver injury. In this case presentation, we discuss a patient who developed liver injury from pyridostigmine in the management of acute colonic pseudo-obstruction (Ogilvie syndrome).

Surgical clip migration is a rare but important cause of delayed postcholecystectomy complications. An 83-year-old man presented 8 years after laparoscopic cholecystectomy with abdominal pain and jaundice. Imaging showed biliary dilation with a 20-mm common bile duct stone. Endoscopic retrograde cholangiopancreatography with cholangioscopy identified a migrated surgical clip serving as the nidus. Electrohydraulic lithotripsy achieved fragmentation, followed by balloon extraction and placement of a fully covered metal stent. The patient recovered uneventfully. This case highlights the need to consider clip migration in patients with late-onset biliary obstruction after cholecystectomy and supports cholangioscopy-guided lithotripsy as a definitive therapy.

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.