Case Reports in Gastroenterology最新文献

Introduction: Immune-mediated colitis (IMC) is a common immune-related adverse event associated with immune checkpoint inhibitors. Other classes of biological therapy, such as monoclonal antibody with anti-CD20 activity, have also been associated with drug-induced gastrointestinal injuries, although through different immunomechanisms. In the literature, there are some previously described cases reporting on enterocolitis induced by rituximab and ocrelizumab highlighting its potential severity. Consequently, recently, the FDA amended the Prescribing Information of ocrelizumab to include IMC in the Warnings and Precautions section.

Case presentation: We present the case of a patient with chronic diarrhea due to immune-mediated enterocolitis, markedly resembling Crohn's disease with ileocolic and perianal involvement induced by ocrelizumab. Endoscopically, this condition is indistinguishable from inflammatory bowel disease with significant overlap in histology. With discontinuation of ocrelizumab, the lesions and the symptoms disappeared. To our knowledge, this is the first case reporting perianal involvement.

Conclusion: There are no clear recommendations on how to manage these patients. Clinicians must be aware of this entity and report on these unquestionably increasing conditions.

Introduction: Argon plasma coagulation (APC) is a widely used technique for hemostasis and ablation in gastrointestinal tract lesions due to its ease of use and safety. However, gastrointestinal tract muscle injury can occur with high-power settings and prolonged application.

Case presentation: We present a case of an elderly female with angiodysplasia bleeding in the second portion of the duodenum treated with APC, resulting in a complication of bowel wall perforation and peritonitis.

Conclusion: Acute perforation has been rarely reported with APC, either due to direct wall injury or explosion from overinflation. To avoid perforation, careful control of ablation power and duration, especially in regions with a thin gastrointestinal wall such as the gastric fundus and ascending colon, should be maintained.

Introduction: Severe acute pancreatitis (AP) may evolve rapidly into systemic inflammatory response syndrome and multiorgan dysfunction syndrome, posing significant management challenges.

Case presentation: We present a rare and complex case of severe AP complicated by septic shock, bilateral renal cortical necrosis (RCN), and Takotsubo cardiomyopathy (TTC). Septic shock contributed to profound hemodynamic instability, while RCN - a rare and often fatal form of acute kidney injury - added to the severity of renal dysfunction. Concurrent TTC, likely precipitated by catecholamine surges during critical illness, led to transient myocardial dysfunction.

Conclusion: This case highlights the importance of early recognition, a multidisciplinary approach, and advanced critical care strategies, including SLED with hemoadsorptive filters, to improve outcomes in patients with severe AP complicated by rare systemic manifestations.

Introduction: Gastrointestinal tract stenosis is a common pathological condition encountered in clinical practice, caused by various factors such as malignant tumors, postoperative anastomotic strictures, radiation injury, or inflammatory diseases like Crohn's disease. It often leads to serious complications, including dysphagia, obstruction, and malnutrition. Endoscopic metal stent placement has become a key treatment for alleviating both benign and malignant stenosis due to its minimally invasive nature, effectiveness, and repeatability. However, stent displacement is one of the most frequent complications, and its management requires a comprehensive approach based on the type of displacement (partial or complete), clinical symptoms, and anatomical location. Endoscopy is the preferred intervention method, and multidisciplinary collaboration can optimize patient outcomes.

Case presentation: A 22-year-old male patient developed persistent nausea and vomiting 2 months ago after accidentally ingesting toilet cleaner. Gastroscopy revealed pyloric obstruction. After admission, a covered intestinal metal stent was placed. Two days later, the stent had migrated distally beyond the narrowed intestinal lumen. We attempted to directly remove the displaced stent under endoscopic visualization. However, the procedure was unsuccessful. Subsequently, we safely removed recyclable metal stents directly using a simple method: a transparent cap-fitted endoscope inserted through the forceps channel to control the stent's retrieval line.

Conclusion: Our method of controlling the retrieval thread of the metal stent through endoscopic forceps to remove the displaced stent is feasible, safe, and effective.

Introduction: Secukinumab is an anti-interleukin (IL)-17 used in the treatment of rheumatological conditions such as ankylosing spondylitis and psoriasis. Despite elevated IL-17A levels in inflammatory bowel disease (IBD) patients, clinical trials suggest IL-17 inhibition may exacerbate disease activity in IBD. Multiple sclerosis (MS) also has a suspected association with IBDs.

Case presentation: A 22-year-old man who has a paternal grandfather with a history of MS was started on secukinumab for suspected ankylosing spondylitis. Three months after secukinumab initiation, he developed new gastrointestinal (GI) symptoms and was diagnosed with ulcerative colitis. He responded to a course of corticosteroids, and his secukinumab was stopped. He remains in clinical and endoscopic remission 5 months after completing his course of steroids.

Conclusions: This case highlights the potential association between IL-17 inhibition and new-onset IBD in a patient with a family history of MS and illustrates a compelling clinical dilemma regarding the initial selection of biologic therapy in a patient with multiple autoimmune risk factors. Before starting an anti-IL-17 agent, physicians should review the patient's personal and family history of IBD, as well as other risk factors, including immune-mediated conditions such as MS that may increase IBD risk. Patients should then be closely monitored for the development of any new GI symptoms.

Introduction: Follicular lymphoma is an indolent B-cell lymphoma that can involve the gastrointestinal tract, most commonly the small intestine. Although rituximab-based therapy is effective, transformation to diffuse large B-cell lymphoma (DLBCL) can occur and becomes difficult to diagnose after CD20 loss.

Case presentation: We report the case of a 64-year-old woman initially diagnosed with primary small intestinal follicular lymphoma who subsequently developed transformation to DLBCL 2 years after rituximab therapy. Double-balloon enteroscopy revealed progression of mucosal lesions, raising suspicion of histologic transformation. However, endoscopic biopsy was inconclusive because of the loss of CD20 expression, likely resulting from prior rituximab therapy. Surgical resection was performed to relieve intestinal obstruction and to establish a definitive diagnosis. Histopathological examination confirmed transformation to CD20-negative DLBCL.

Conclusion: This case highlights the diagnostic limitation of endoscopic biopsy following rituximab therapy. Therefore, clinicians should be cautious in relying solely on endoscopic findings and remain open to surgical intervention to achieve a timely and accurate diagnosis.

Introduction: Achalasia is a primary motility disorder affecting the esophageal body and lower esophageal sphincter. Although the linkage between achalasia and elevated esophageal cancer risk is already known, the precise mechanisms remain poorly elucidated due to the disease's relative scarcity. We aim to summarize the clinical characteristics of esophageal cancer (EC) secondary to achalasia and improve the understanding of achalasia combined with EC and further reduce the risk of ECs.

Case presentations: Retrospective statistics were conducted on patients with ECs secondary to achalasia in our hospital from 2009 to 2023. We categorized all achalasia cases with their initial treatment and recorded subsequent interventions when the symptoms recurred. Additionally, we performed detailed analyses of both EC characteristics and therapeutic regimens. We present a case series comprised of 5 patients with achalasia who presented with EC. Three of the patients diagnosed with achalasia were treated by endoscopy or operation to improve symptoms. One patient was treated by pneumatic dilation. All were histologically diagnosed as squamous cell carcinoma. The validity period of endoscopic treatment has been lost in all patients. The erosions were all distributed over the thoracic esophagus.

Conclusion: The high relative risk of ECs was demonstrated in achalasia patients, even in the treated achalasia patients. Therefore, surveillance endoscopy may be recommended regularly in the treated patients.

Introduction: Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is an essential diagnostic tool for pancreatic tumors, but rare complications such as needle tract seeding (NTS) may cause local recurrence.

Case presentation: A 79-year-old man with a history of right hemicolectomy for colon cancer presented during follow-up in 2020 with a 16-mm pancreatic tail mass. He was asymptomatic, and laboratory findings including carcinoembryonic antigen and carbohydrate antigen 19-9 were normal. EUS-FNA confirmed adenocarcinoma (cT3N0M0, stage IIA), and after neoadjuvant chemotherapy, laparoscopic distal pancreatectomy was performed. No recurrence was observed until 2022, when elevated tumor markers and fluorodeoxyglucose positron emission tomography/computed tomography revealed a lesion near the stomach. Chemotherapy with gemcitabine and nab-paclitaxel was initiated, but the lesion persisted. Repeat EUS-FNA confirmed adenocarcinoma, suggesting NTS from the initial FNA. Subsequently, partial gastrectomy was performed, and pathology confirmed pancreatic adenocarcinoma.

Conclusion: This case illustrates the risk of NTS following EUS-FNA for pancreatic tail cancer, particularly when the puncture route is not resected during pancreatectomy. Despite neoadjuvant chemotherapy, NTS occurred, indicating that this risk cannot be fully prevented. Surgical resection achieved disease control, underscoring the importance of vigilant follow-up and timely intervention in managing this rare but clinically significant complication.

Introduction: Mantle cell lymphoma (MCL) is a distinct subtype of B-cell non-Hodgkin lymphoma. MCL lymphoma can occur in the gastrointestinal tract (GIT) as a primary lymphoma; more commonly, the GIT can be secondarily involved. A colonic polyp simultaneously having MCL with overlying adenomatous changes is highly unusual, and few cases were reported. Herein, we describe a unique instance of a single adenomatous polyp in the left colon overlying a small lymphoid population proven to be MCL in a patient recently diagnosed with MCL. We believe this report will increase the awareness of pathologists and clinicians of such a unique and unusual clinical presentation.

Case presentation: A 53-year-old male patient presented with a history of generalized lymphadenopathy, bilateral pleural deposits, and splenomegaly. Axillary lymph node excisional biopsies were sent for pathology and reported MCL, diffuse pattern, classic variant. Three weeks later, the patient underwent upper and lower endoscopy for mild upper abdominal discomfort. Upper endoscopy showed mild gastropathy, and colonoscopy revealed a small polyp at the descending colon. Pathology of the colonic polyp showed a tubular adenoma with low-grade dysplasia overlying a well-circumscribed mucosal/submucosal nodular lymphoid aggregate. The lymphoid aggregate exhibited histological and immunohistochemical features of MCL. Thus, a diagnosis of tubular adenoma coexisting with MCL in the same polyp was made.

Conclusion: Tubular adenoma with MCL is an exceedingly rare phenomenon with unclear pathogenesis. We report this case to highlight the importance of examining lymphoid tissue in adenomas and to increase the awareness among clinicians and pathologists of such a unique presentation.

Introduction: Toxic megacolon is a serious complication of ulcerative colitis (UC), characterized by marked colonic dilatation, abnormal bowel function, and systemic toxicity. Although toxic megacolon is rare in children and adolescents, it should remain in the differential diagnosis for acute severe UC in this group because delayed diagnosis and treatment can be fatal. The treatment for UC complicated by toxic megacolon is either immediate emergency surgery or short-term intensive drug therapy. If the latter does not result in significant improvement, emergency surgical intervention is necessary. Current treatment guidelines do not establish a standard medical approach for this condition.

Case presentation: In this report, we describe an adolescent case of UC complicated by toxic megacolon. In this patient, the condition was initially controlled with steroid pulse therapy followed by oral tacrolimus. However, due to an inadequate response, treatment was escalated to infliximab (IFX), leading to remission and successful avoidance of surgical intervention.

Conclusion: When opting for conservative treatment of UC complicated by toxic megacolon, intensive steroid pulse, tacrolimus, and IFX therapy should be considered as a potentially effective treatment option.