Case Reports in Gastroenterology最新文献

Introduction: Pneumonia is a leading cause of postoperative mortality in elderly patients with ulcerative colitis (UC), and close attention should be paid to the possibility of Pneumocystis jiroveci pneumonia (PJP) in patients with immunosuppression. We present the case of a patient with severe PJP that was challenging to diagnose because of postoperative Candida sepsis complications in an elderly patient with acute severe ulcerative colitis (ASUC) with immunosuppression.

Case presentation: A 70-year-old man was transferred to our hospital and was diagnosed with ASUC. The patient underwent laparoscopic subtotal colectomy for prednisolone and granulocyte and monocyte adsorptive apheresis-resistance UC 22 days after transfer. On postoperative day (POD) 9, the central venous catheter (CVC) was removed because CVC-related blood stream infection (CRBSI) was suspected. On POD 12, fluconazole was administered for Candida parapsilosis sepsis due to CRBSI, and a septic pulmonary embolism was suspected. The patient's hypoxemia worsened; trimethoprim-sulfamethoxazole was administered because PJP was suspected on POD 19; however, ventilatory support was started on POD 21. PJP was diagnosed based on bronchoalveolar lavage on POD 25, and high-dose prednisolone therapy was initiated. The patient was weaned off the ventilator on POD 27 and was discharged home on POD 54. Proctectomy and stapled ileal pouch-anal anastomosis were performed at 10 months postoperatively, and the patient is currently alive at 1 year and 6 months after surgery.

Conclusion: Postoperative hypoxemia in elderly patients with ASUC should be considered in the differential diagnosis of PJP, even during the treatment of Candida sepsis.

Introduction: Patients with longstanding ulcerative colitis (UC) face an increased risk of colorectal cancer, necessitating regular surveillance. Chronic inflammation frequently leads to submucosal fibrosis, making the resection of non-lifting lesions difficult with standard techniques like endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD).

Case presentation: We present a 76-year-old UC patient with a splenic flexure adenoma that was unresectable via EMR/ESD. Given the high surgical risk, the OVESCO system was used, achieving clear margins and avoiding colectomy.

Conclusion: This case highlights full-thickness resection devices as a minimally invasive alternative for challenging polyps in UC, preserving bowel function while avoiding major surgery or stoma formation.

Introduction: Endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy is the standard treatment for common bile duct (CBD) stones. However, in 10-15% of cases involving large or multiple stones, this approach is inadequate. Advanced techniques such as lithotripsy, dilation, balloon extraction, or surgery may be required.

Case presentation: We present 2 post-cholecystectomy patients with large (>1.5 cm), multiple impacted CBD stones. Initial ERCP attempts, including sphincterotomy and 15-mm balloon dilation, failed to clear the stones. As a bridging strategy, two plastic stents (10 Fr and 7 Fr) were placed, and ursodeoxycholic acid therapy was started. On re-evaluation at 50 and 80 days, stone clearance was achieved using simple balloon extraction - without lithotripsy or cholangioscopy - using the same tools as the initial ERCP.

Conclusion: Double plastic stent placement can serve as an effective interim measure for complex CBD stones, facilitating complete clearance in subsequent ERCP with standard equipment.

Introduction: As an osmotic laxative, lactulose offers superior palatability and comparable bowel-cleansing efficacy to PEG, making it suitable for resource-limited settings, but its hypertonicity may potentially increase the risk of intussusception in susceptible individuals (such as children with intestinal polyps).

Case presentation: This first reported case describes a 2-year-old boy with intermittent hematochezia who developed acute descending colonic intussusception confirmed by CT within hours of receiving lactulose (20 mL) for bowel preparation. Laparoscopic reduction and subsequent colonoscopy identified a large pedunculated juvenile polyp (25 × 28 mm) as the pathological lead point, which was endoscopically resected. The temporal link between lactulose administration and symptom onset, combined with its known pharmacological effects, strongly suggests lactulose-induced hyperperistalsis precipitated intussusception by mechanically displacing the occult polyp.

Conclusion: This highlights a novel risk of osmotic laxatives in children with undiagnosed intestinal polyp.

Introduction: Spontaneous fungal peritonitis is a less common yet serious complication of liver cirrhosis with high mortality rates. Awareness of spontaneous fungal peritonitis may improve patient outcomes by increasing early identification and treatment.

Case presentation: We present a case of a 66-year-old female who was admitted to an Australian tertiary hospital with abdominal tenderness and distension on a background of Child-Pugh C liver cirrhosis secondary to increased alcohol intake. Ascitic fluid culture identified the fungus Candida tropicalis as the causative pathogen of spontaneous fungal peritonitis.

Conclusion: We outline appropriate investigations, and management in treating C. tropicalis spontaneous fungal peritonitis, a rare pathogen in spontaneous peritonitis complicating cirrhosis.

Introduction: Glucagon-like peptide-1 receptor agonists such as liraglutide have revolutionized the management of type 2 diabetes and obesity.

Case presentation: We present a case of a 30-year-old woman who developed drug-induced liver injury (DILI) to liraglutide, confirmed on histology, with resolution on cessation of liraglutide over 6 months.

Conclusion: DILI secondary to liraglutide appears to be a rare but an important adverse effect.

Introduction: Paraganglioma is an extra-adrenal pheochromocytoma that requires surgical resection with strict perioperative management because of its catecholamine-producing nature. We report a case of successful laparoscopic resection of a large retroperitoneal paraganglioma in an older patient.

Case presentation: An 80-year-old man was diagnosed with hypertension during a routine health checkup. Elevated plasma metanephrine and normetanephrine levels, along with radiological findings of a 6.5-cm tumor with ¹²³I-metaiodobenzylguanidine accumulation anterior to the aorta, confirmed the diagnosis of retroperitoneal paraganglioma. Surgical resection was planned accordingly. Preoperative optimization with a selective α1 blocker was conducted over 2 months, and intravenous saline infusion was administered the day before surgery. Laparoscopic exploration revealed a tumor on the dorsal side of the small bowel mesentery, extending dorsally and caudally to the third portion of the duodenum. En bloc resection was performed using a six-port approach. Intraoperatively, systolic blood pressure transiently spiked to 170 mm Hg during tumor manipulation but was controlled with an intravenous bolus of phentolamine mesylate. Post-resection hypotension was effectively prevented by the continuous infusion of low-dose noradrenaline. Postoperatively, the blood pressure remained well controlled without medication, and no surgical complications occurred. Histopathological examination confirmed the diagnosis of a paraganglioma.

Conclusion: This case highlights the importance of precise diagnosis, meticulous perioperative planning and management, and minimally invasive surgery in the successful treatment of large retroperitoneal paragangliomas in older patients.

Introduction: Secukinumab is an interleukin (IL)-17A inhibitor approved for psoriatic arthritis (PsA) and ankylosing spondylitis (AS). Its use has been reported to be associated with inflammatory bowel disease (IBD) flare and new onset.

Case presentation: We report a case of a 56-year-old woman with longstanding ulcerative colitis (UC) in remission, who developed a severe UC flare after initiating secukinumab for refractory PsA. She presented with extensive ulcerations, systemic inflammation needing hospitalization, and change of treatment to risankizumab.

Conclusion: This case highlights the emerging evidence of IL-17A blockade in IBD, potentially leading to adverse events, and adds to the growing body of evidence regarding the management of such complications with novel therapeutic approaches in severe cases. Physicians should be aware of this possibility when using IL-17A blockade in patients with pre-existing IBD.

Introduction: Immune-mediated colitis (IMC) is a common and potentially severe immune-related adverse event of immune checkpoint inhibitors (ICIs). Although corticosteroids and biologics are standard treatments, some cases remain refractory. Tofacitinib, a Janus kinase inhibitor, has shown promise in refractory IMC; however, evidence regarding its treatment effects remains limited.

Case presentation: Here, we present a case of pembrolizumab-induced IMC and duodenitis refractory to corticosteroids, infliximab, and vedolizumab. The patient was successfully treated after receiving a 30-day course of tofacitinib, which resulted in rapid symptom resolution and mucosal healing. No recurrence of colitis was observed 3 months after treatment cessation.

Conclusion: As ICIs are increasingly used, the incidence of refractory IMC and other immune-related toxicities is expected to rise. This case highlights the need for further studies to establish the optimal use of tofacitinib in refractory IMC and duodenitis.

Introduction: Biliary tract stones are a common clinical condition. The primary clinical symptoms include intermittent pain in the right upper quadrant and upper abdomen. During acute episodes, the pain may become persistent. A small number of patients may also present with jaundice.

Case presentation: An 80-year-old male was admitted to the hospital due to right upper quadrant pain persisting for over 12 h. Examination revealed that the patient had common bile duct stones with cholangitis, as well as gallbladder stones with cholecystitis. The patient's biliary anatomy showed the cystic duct opening into an accessory right hepatic duct, which formed a low confluence with the common hepatic duct to become the common bile duct. Surgical intervention was therefore performed. We managed the stones in this anatomically complex biliary configuration by placing a C-tube through the cystic duct, performing primary closure of the accessory right hepatic duct, and placing a T-tube in the common hepatic duct.

Conclusion: The patient recovered well postoperatively. By placing the C-tube and performing primary closure of the accessory right hepatic duct, we reduced the incidence of bile leakage and concurrently lowered the risk of soft tissue infection at the incision site and intra-abdominal infection. Furthermore, the placement of a C-tube offers an alternative approach for managing accidental bile duct injury during biliary surgery.