Case Reports in Gastroenterology最新文献

Introduction: The exact etiology of acinar cell cystadenoma (ACC) has been debated, primarily whether it originates from or carries the risk of an underlying neoplasia. Pancreatic intraepithelial neoplasia (PanIN) is presumed to be a noninvasive precursor of pancreatic ductal adenocarcinoma. This report presents a rare case of ACC with low-grade PanIN that required surgical resection.

Case presentation: A 60-year-old female with an unremarkable medical history presented with epigastric pain for 2 weeks. Her initial laboratory workup was notable for mild isolated elevation of alkaline phosphatase. Abdominal computed tomography revealed a 5.0 × 4.0 cm cystic lesion in the pancreatic head with thick internal septations. Magnetic resonance cholangiopancreatography showed a 5.2 × 4.5 × 6.8 cm lobulated cystic lesion in the pancreatic head with a microcystic configuration, multiple internal septations, and a hypointense central scar. Endosonographic examination showed a large multicystic lesion in the pancreatic head region. Fine-needle aspiration showed a carcinoembryonic antigen level of 555 ng/mL and an amylase level of 13,593 U/L. No KRAS or GNAS mutations or loss of heterozygosity was detected. Subsequently, the patient underwent a Whipple procedure. Pathologic examination revealed a complex cystic lesion with well-differentiated acinar cells and patches of ductal epithelium compatible with ACC. Histological examination confirmed the presence of low-grade PanIN without invasive carcinoma. The patient recovered well from surgery, and repeat imaging 2 months later was unremarkable.

Conclusion: ACC is a rare benign pancreatic lesion. Low-grade PanIN is typically found in benign pancreatic lesions. Resection is recommended for symptomatic patients.

Introduction: Mixed acinar-neuroendocrine carcinoma (MANEC) is a rare variant of pancreatic carcinoma, the morphology of which shows features of both acinar cell carcinoma and neuroendocrine carcinomas. To date, only approximately 70 cases of MANEC have been reported.

Case presentation: We report a rare case of a 63-year-old male cirrhotic patient who presented with a pancreatic body/tail mass, which was later confirmed to be an MANEC. He was initiated on neoadjuvant chemotherapy with FOLFIRINOX, but unfortunately died before surgery.

Conclusion: MANEC is a rare sporadic tumor of the pancreas. Further studies on the clinicopathological behavior of MANEC are needed to help better understand the disease and establish standardized management.

Introduction: Some of the most common presentations of gastrointestinal diseases are nausea, vomiting, and generalized abdominal pain. These symptoms could also be associated with other diseases and require a structured approach to the specific diagnosis. Eosinophilic granulomatosis with polyangiitis (EGPA), also known as Churg-Strauss syndrome, is a small and medium-sized vessel vasculitis that can affect any body system and present with a wide range of symptoms and atypical presentation. Therefore, diagnosis of this condition may not always be straightforward.

Case presentation: This case report presents a challenging case of a young man presenting with symptoms of abdominal pain, nausea, vomiting and non-specific symptoms of lethargy and fatigue. The case describes overlapping features with granulomatosis with polyangiitis (GPA) and anti-neutrophil cytoplasmic antibodies (ANCA)-positive and -negative vasculitis. The patient needed extensive workup and investigations to be eventually diagnosed with EGPA. In this case, myeloperoxidase (MPO) ANCA was negative, which is positive in the majority of EGPA cases, and this poses an additional diagnostic dilemma.

Conclusion: The case highlights that non-specific complaints of vomiting and abdominal pain should be addressed methodically and not just be treated symptomatically.

Introduction: COVID-19, although primarily a respiratory illness, has been linked to complications in multiple organ systems, including the liver. Proposed mechanisms for liver injury include direct viral cytopathic effects, systemic inflammation, hypoxia, and drug-induced liver injury (DILI). Moreover, post-COVID cholangiopathy is an emerging entity with features that may overlap with autoimmune phenomena.

Case presentation: A 60-year-old male patient with multiple comorbidities presented with fever, chills, and cough for 1 day. In the emergency department, he tested positive for COVID-19 by PCR and his chest X-ray revealed features suggestive of pulmonary edema. The patient was intubated and admitted to the Medical Intensive Care Unit (MICU) for management of COVID-19 pneumonia with pulmonary edema. During hospitalization, he developed cardiac complications that required targeted management. Approximately 1 week after admission, his liver enzymes began to rise. Although drug-DILI was initially suspected and hepatotoxic medications were discontinued with the initiation of ursodeoxycholic acid (UDCA), the liver function tests (LFTs) remained elevated. Subsequent magnetic resonance cholangiopancreatography revealed periportal inflammation with intrahepatic biliary dilatation and stricturing, findings consistent with COVID-19 induced cholangiopathy. The UDCA dosage was doubled, resulting in gradual biochemical improvement; however, the patient ultimately discharged against medical advice.

Conclusion: COVID-19-induced cholangiopathy is a rare but serious liver complication. Effective management requires a multidisciplinary team. Ongoing research is needed to better understand long-term liver effects and improve care strategies.

Introduction: A 19-year-old male presented with a 6-month history of recurrent ascites and lower limb edema, prompting a detailed diagnostic evaluation at our hospital.

Case presentation: The patient displayed a ruddy complexion, deepening pigmentation in the limbs and abdomen, visible reticular skin pattern changes, and pronounced abdominal striae. Diagnostic investigations included a renal biopsy, which confirmed focal segmental glomerulosclerosis, and an abdominal enhanced CT scan, suggesting hepatic sinusoidal obstruction syndrome. Hematological tests revealed elevated white blood cell count (19.73 × 10⁹/L), hemoglobin level (183 g/L), and platelet count (395 × 10⁹/L). Bone marrow morphology indicated proliferation of red blood cells, white blood cells, and platelets, suspicious for myeloproliferative neoplasm. PCR testing confirmed the presence of the JAK2 V617F mutation, leading to a diagnosis of polycythemia vera. The patient was administered a comprehensive treatment regimen consisting of methylprednisolone, telmisartan, rivaroxaban, furosemide, and spironolactone. This therapeutic approach led to a decrease in the patient's weight and 24-h urinary protein, along with a significant reduction in pleural and abdominal effusions.

Conclusion: This case underscores the significance of a meticulous diagnostic process in uncovering multiple concurrent severe pathologies presenting with nonspecific symptoms. It also highlights the importance of a targeted treatment strategy to achieve clinical improvement. The successful management of this patient's complex case illustrates the value of a multidisciplinary approach in addressing polycythemia vera, hepatic sinusoidal obstruction syndrome, and focal segmental glomerulosclerosis.

Introduction: Portal vein thrombosis (PVT) is a critical factor in portal hypertension, often linked to liver disease but also occurring independently. Superior mesenteric vein thrombosis and PVT can lead to mesenteric ischemia, even without predisposing hepatic or abdominal conditions. While acute or chronic PVT may present with variable occlusion, the development of intestinal strictures is rare. Persistent symptoms necessitate close follow-up for early detection and timely intervention.

Case presentation: A male patient in his early 40s presented with 15 days of progressive upper abdominal pain and one day of vomiting. He had a history of diabetes and hypertension. Examination revealed tachycardia and epigastric tenderness. Laboratory tests showed neutrophilic leukocytosis and positive occult blood in the stool. Contrast-enhanced CT (CECT) revealed PVT extending into its right branch, jejunal wall thickening, and mesenteric engorgement suggestive of ischemia. Upper GI endoscopy showed esophageal varices and portal hypertensive gastropathy. He was managed conservatively with anticoagulation and discharged. One month later, he returned with recurrent vomiting, worsened by solid food. Repeat CECT showed jejunal obstruction with a 3-cm stricture. Exploratory laparotomy revealed dense adhesions; adhesiolysis, bowel resection, anastomosis, and feeding jejunostomy were performed. Histopathological examination showed a sealed-off perforation with acute suppurative inflammation and fibrotic changes consistent with ischemic stricture.

Conclusion: While mesenteric venous thrombosis is primarily managed with anticoagulation, progressive bowel strictures may develop over time, necessitating surgical intervention. Long-term follow-up is crucial, as delayed complications can arise despite initial success in preventing infarction.

Introduction: It is common for advanced pancreatic adenocarcinoma to infiltrate the gastric wall, and the tumor cells invading the gastric wall are usually consistent with pancreatic adenocarcinoma. However, it is very rare for the tumor cells infiltrating the gastric wall to be squamous cell carcinoma.

Case presentation: In this case, we report a 57-year-old man who presented with weight loss for 2 months. CT revealed a pancreatic mass. Endoscopic ultrasound biopsy of the pancreatic mass confirmed pancreatic adenocarcinoma. He refused treatment. Eight months later, he developed melena. CT revealed that the pancreatic mass had invaded the gastric wall. Gastric squamous cell carcinoma was confirmed by biopsy of gastric tissue under gastroscopy.

Conclusion: By observing the evolution process of this case, we found that the occurrence of gastric squamous cell carcinoma in this case was consistent with one of its pathogenesis: the theory of adenocarcinoma differentiating into squamous cell carcinoma. It provides certain clinical significance for the study of the mechanism of gastric squamous cell carcinoma.

Introduction: Angiosarcomas, constituting less than 1% of all sarcomas, are rare soft tissue tumors originating from the endothelial cells. Hepatic angiosarcoma (HAS) is a rare and aggressive primary hepatic malignancy accounting for only 0.5%-2% of all liver tumors. The patients often endorse nonspecific symptoms like vague abdominal pain, nausea, vomiting, and jaundice making the diagnosis challenging. Most patients succumb to death within 6 months of diagnosis due to liver failure or hemorrhage from spontaneous rupture of HAS. Therapeutic guidelines remain undefined, and management often involves a multidisciplinary approach. Surgical resection is the only potentially curative option, which has been shown to be most beneficial when HAS is limited to one lobe. Hepatic artery embolization is used in the case of rupture of HAS. Chemotherapy can be used for palliative care in cases of advanced tumors. We present a fatal case of metastatic HAS to underscore diagnostic pitfalls and therapeutic challenges.

Case description: A 56-year-old male presented with 2 months of abdominal pain, distension, fatigue, and weight loss. Imaging revealed multifocal hypodense liver and splenic lesions. Laboratory findings included severe anemia (Hb 6.1 g/dL), thrombocytopenia (63 × 10³/mm³), and elevated liver enzymes. Ascitic fluid analysis demonstrated exudative, bloody ascites (SAAG <1.1) without malignant cytology. Liver biopsy confirmed HAS, showing atypical spindle cells infiltrating vascular channels, positive for CD34 and factor VIII. Despite transfusions, paracentesis, and palliative care, the patient developed disseminated intravascular coagulation and died 2 weeks post-diagnosis.

Conclusion: HAS is a rapidly fatal malignancy often diagnosed at advanced stages due to nonspecific symptoms and lack of definitive risk factors in most cases. Multidisciplinary collaboration is essential for symptom management, though treatment options remain limited, and prognosis is poor. Therefore, it becomes imperative for clinicians to keep in mind the common presentation of a rare but lethal disease.

Introduction: Trichobezoar is an aggregation of swallowed hair strands that entangle in the stomach. It presents with abdominal pain, vomiting, and diarrhea. Diagnosis is usually made by imaging and endoscopy. Surgical removal is typically required, but endoscopic retrieval has been successful. Fecal calprotectin is a biomarker of inflammation that is typically elevated in inflammatory bowel disease (IBD) but is also elevated in other gastrointestinal (GI) disorders such as infections. Trichobezoar is not known to precipitate GI inflammation and has never been reported among the etiologies of elevated fecal calprotectin. Herein is a case presenting with vague abdominal pain and elevated fecal calprotectin that was attributed solely to a trichobezoar.

Case presentation: A 7-year-old girl presented with abdominal pain for 6 months associated with occasional vomiting and diarrhea. Family history was positive for ulcerative colitis. Physical examination was unremarkable including normal growth. Diagnostic workup revealed elevated fecal calprotectin at 433.9 mg/kg. Upper and lower endoscopies were performed. A trichobezoar with Rapunzel syndrome was incidentally found in the stomach extending into the duodenum without frank obstruction. Histology showed reactive gastropathy in a few areas of mechanical rubbing by hair strands; otherwise, it was completely unremarkable in both upper and lower GI biopsies. Endoscopic retrieval of piecemeal hair locks was done. Surgical removal was subsequently done due to the generous size of the mass.

Conclusion: Fecal calprotectin is an important biomarker for IBD, as well as other unusual GI pathologies, and clinical context is crucial when interpreting its value.

Introduction: The Strongyloidae family includes at least fifty species of intestinal nematode worms, and Strongyloides stercoralis is the most prevalent one among humans. As a result of this parasite's complex lifecycle, it can either remain localized in the intestines or disseminate to different organs throughout the body, culminating in hyperinfection in case of immunosuppression. Strongyloidiasis is rarely encountered in the USA, and an associated gastric involvement is uncommon.

Case presentation: In this case report, we describe the case of an asymptomatic and immunocompetent Liberian patient with gastroduodenal strongyloidiasis whose diagnosis was based on histologic findings during endoscopic evaluation for iron deficiency anemia.

Conclusion: This case sheds light on the importance of suspecting the diagnosis of disseminated strongyloidiasis in high-risk individuals with iron deficiency anemia in combination with peripheral eosinophilia.