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Drug-Induced Liver Injury From Enobosarm (Ostarine), a Selective Androgen Receptor Modulator
Bedi, Harjot MD, MSc, MHSc1; Hammond, Carl MBChB, MRCP(Lond)2; Sanders, David MD2; Yang, Hui-Min MD3; Yoshida, Eric M. MD, MHSc, FRCP(C)2
doi : 10.14309/crj.0000000000000518
January 2021 - Volume 8 - Issue 1 - p e00518
Anabolic steroids are well-known to cause liver injury, which may manifest with jaundice and elevated liver enzymes. Selective androgen receptor modulators (SARMs) have been developed to enhance muscle bulk without the side effects associated with exogenous androgen steroids. We report a case of significant cholestatic liver injury associated with a SARM, ostarine (enobosarm), similar to that associated with anabolic steroids. Liver injury from SARMs has not been reported frequently, and we speculate that this may be seen more often as the consumption of SARMs increases in the athletic market.
Successful Nucleoside Analog and Corticosteroid Therapy for Chronic Inflammatory Demyelinating Polyneuropathy in a Patient With Hepatitis B Virus Liver Cirrhosis
Nugraha, Eka Surya MD1; Huang, Ian MD2; Supriyadi, Rudi MD, MSc, PhD2; Girawan, Dolvy MD1; Bestari, Muhammad Begawan MD, MHS, PhD, FASGE, FACG1
doi : 10.14309/crj.0000000000000519
January 2021 - Volume 8 - Issue 1 - p e00519
Here, we describe the case of a 44-year-old man with chronic hepatitis B virus (HBV) infection, who was admitted with progressive muscle weakness and paresthesia in all extremities. He showed slight icterus. Positive HBV e-antigen test, significant HBV-deoxyribonucleic acid load, hypoalbuminemia, hyperbilirubinemia, mild ascites, and demyelinating peripheral axonal lesions in both sensory and motor nerves led to the diagnosis of Child-Pugh class B HBV cirrhosis with chronic inflammatory demyelinating polyneuropathy. Oral lamivudine, intravenous steroids, calcium, and vitamin D therapy led to a significant recovery of muscle strength within 6 weeks and a gradual return to normal after 24 weeks.
Estrogen-Driven Growth of Focal Nodular Hyperplasia: Truth or Myth?
Ashhab, Ashraf A. MD1; Abu-Sulb, Ahmad MD2; Yang, Ju Dong MD1; Noureddin, Mazen MD1; Sundaram, Vinay MD1; Kuo, Alexander MD1; Ayoub, Walid S. MD1
doi : 10.14309/crj.0000000000000531
January 2021 - Volume 8 - Issue 1 - p e00531
The etiologic association between focal nodular hyperplasia (FNH) and estrogen has been a subject of doubt and controversy. We present a case of a female patient with FNH that had been monitored for several years with noted size stability and later regression, who developed tumor growth during pregnancy. This case suggests that a subset of FNH is indeed hormone sensitive, as opposed to what has been frequently suggested by many other reports that question the association, a finding that may have clinical implications, in terms of monitoring of patients with high estrogen statuses.
Cholestatic Hepatitis in Graves' Disease: A Diagnostic Challenge
Haddaden, Metri MD1; Hanna, Angy MD2; Odish, Fadi MD2; Husami, Samir MBBS3; Imam, Zaid MBBS2; Tahhan, Mamon MD2
doi : 10.14309/crj.0000000000000526
January 2021 - Volume 8 - Issue 1 - p e00526
Cholestatic hepatitis is a rare presentation of thyrotoxicosis potentially confused as an adverse effect of antithyroid therapy. We report a 37-year-old man with cholestatic hepatitis as an initial presentation of Graves' disease. Diagnostic evaluation demonstrated (i) elevated transaminases and alkaline phosphatase (R-factor value: 2.6), and marked cholestasis (total bilirubin: 17.3 mg/dL, direct bilirubin: 9.4 mg/dL); (ii) negative hepatitis, viral, and autoimmune serologies; (iii) normal magnetic resonance cholangiopancreatography; (iv) liver biopsy with marked cholestasis and no fibrosis; (v) thyroid-stimulating hormone <0.01, fT4 (free thyroxine): 1.5, fT4 (free triiodothyronine): 4.3 and positive thyroid-stimulating immunoglobulins. Radioiodine uptake scan confirmed Graves' disease. Clinical resolution was achieved with propranolol, prednisone, methimazole, and thyroidectomy.
Intragastric Balloon Improves Steatohepatitis and Fibrosis
Lin, Elissa MD1; Huang, Xiaoyan MD2; Pei, Zhiheng MD, PhD2; Gross, Jonathan MD3; Popov, Violeta MD, PhD4
doi : 10.14309/crj.0000000000000534
January 2021 - Volume 8 - Issue 1 - p e00534
Obesity is a major risk factor for nonalcoholic steatohepatitis (NASH). Although weight loss has been shown to reverse histologic features of NASH, lifestyle intervention alone is often challenging and unfeasible. In this case report, we discuss the effects of intragastric balloon (IGB) therapy on steatosis, fibrosis, and portal pressures. We also demonstrate that improvement in histologic features persist at least 6 months after IGB removal. Although there are little data thus far to support IGB therapy in the treatment of NASH, our case provides evidence of the potential benefit of IGB on improving metabolic parameters and markers of liver fibrosis.
Severe Erosive Esophagitis Secondary to Gastric Outlet Obstruction Related to Pseudomyxoma Peritonei
Braun, David S. MD1; Bushe, Bryce MD2; Lytvak, Irina MD3; Kedia, Prashant MD2
doi : 10.14309/crj.0000000000000505
January 2021 - Volume 8 - Issue 1 - p e00505
Pseudomyxoma peritonei (PMP) is a rare clinical condition characterized by a mucin-producing tumor. PMP tumor cells migrate to abdominal and pelvic sites, eventually enveloping intra-abdominal organs and compressing the gastrointestinal tract. Patients with PMP are often asymptomatic in early stages of the disease, but in later stages develop symptoms including abdominal pain, acute abdomen, increased abdominal girth, vomiting, and bowel obstruction. Nonspecific symptoms combined with a relatively modest accuracy of imaging modalities frequently lead to delay in PMP diagnosis and treatment, thereby increasing morbidity. We present a case demonstrating severe erosive esophagitis as a result of PMP-associated gastric antrum compression.
Colonic Intussusception Secondary to Hereditary Angioedema
Roy, Justin MD1; Vunnam, Rama MD2; Gorrepati, Venkata Subhash MD3; Bethards, Deborah MD3; McGarrity, Thomas MD3
doi : 10.14309/crj.0000000000000498
January 2021 - Volume 8 - Issue 1 - p e00498
Hereditary angioedema (HAE) is a rare genetic disease with numerous gastrointestinal manifestations. Intussusception, although rare, has been a reported complication with documentation of bowel wall edema on endoscopy during an acute flare. With the advent of synthetic C1 esterase inhibitors, this disease has become more effectively treatable. This case report shows a HAE flare complicated by colonic intussusception, treated with C1 esterase inhibitor, with complete endoscopic resolution seen on hospital day 5. This case provides evidence that with proper medical treatment, an HAE flare with intussusception has the potential to resolve without any further need for surgical or endoscopic intervention.
A Rare Case of Metastatic Colon Cancer in a Patient With Squamous Cell Carcinoma of the Tongue
Khan, Sikandar MD1; Ur Rahman, Asad MD2; Castillo, Michael MD1; Riaz, Amir MD1; Miret, Rafael DO1; Bejarano, Pablo MD3; Castro-Pavia, Fernando MD2
doi : 10.14309/crj.0000000000000529
January 2021 - Volume 8 - Issue 1 - p e00529
Squamous cell carcinoma (SCC) of the colon, both primary and metastatic, are extremely rare malignancies. We present a case of a 60-year-old man with metastatic SCC of the tongue status after radiation and chemotherapy who presented with fatigue and melena. Colonoscopy revealed a 5 cm mass in the transverse colon. Pathology established the diagnosis of poorly differentiated SCC with p16 immunostaining, similar to biopsies from his initially diagnosed lingual cancer. To the best of our knowledge, there are no previously reported cases of primary SCC of the tongue metastasizing to the colon.
Delayed Removal of Entrapped Snare in Colonoscopic Polypectomy
Phatharacharukul, Parkpoom MD1; Wajid, Maryiam MBBS1; Fatima, Hala MD1
doi : 10.14309/crj.0000000000000535
January 2021 - Volume 8 - Issue 1 - p e00535
Snare entrapment is a rare complication of hot snare polypectomy of large colon polyps. We report a case of snare entrapment in our unit and its management. This report highlights the method of delayed removal of snare followed by repeat colonoscopy.
The Emerging Battle: Lysosomal Acid Lipase Deficiency vs Familial Hypercholesterolemia in Children
Saad, Michelle MD1; Syed, Sabeen MD1
doi : 10.14309/crj.0000000000000516
January 2021 - Volume 8 - Issue 1 - p e00516
Lysosomal acid lipase is an under-recognized enzyme involved in the modulation and expression of genes that part-take in the synthesis and uptake of cholesterol. We describe the unusual course of a 2-year-old patient who presented with hypercholesterolemia and elevated liver enzymes, initially misdiagnosed with familial hypercholesterolemia. The absence of a suggestive family history triggered further testing that revealed complete lysosomal acid lipase deficiency that typically presents in infancy as Wolman disease with failure to thrive, malabsorption, and liver failure. Interestingly, the patient's clinical picture suggested cholesteryl ester storage disease instead, a milder phenotype in older patients.
Successful Treatment of Refractory Autoimmune Enteropathy With Ustekinumab
Scheid, Johannes F. MD, PhD1; Misdraji, Joseph MD2; Nath, Barbara J. MD1; Yarze, Joseph C. MD1
doi : 10.14309/crj.0000000000000520
January 2021 - Volume 8 - Issue 1 - p e00520
Autoimmune enteropathy (AIE) is a rare autoimmune disorder that has been described both in pediatric and adult patients and usually causes intractable watery diarrhea. The management of AIE is not standardized because the disease shows variable response to different immunosuppressive regimens including corticosteroids, azathioprine, cyclophosphamide, 6-mercaptopurine, tacrolimus, cyclosporine-A, infliximab, vedolizumab, and abatacept. We present a patient with adult-onset AIE and intractable high-volume diarrhea resulting in numerous hospitalizations and temporary parenteral nutrition, who is now successfully maintained on ustekinumab. Therefore, ustekinumab should be considered for further evaluation as a therapeutic option in cases of refractory AIE.
Unique Case of a Hamartomatous Duodenal Polyp Associated With Intestinal Schistosomiasis
Gonzalez, Adalberto MD1; Gupta, Kapil MD2; Rodriguez, Sandra MD3; Wadhwa, Vaibhav MD1; Bejarano, Pablo MD4; Charles, Roger MD1
doi : 10.14309/crj.0000000000000485
January 2021 - Volume 8 - Issue 1 - p e00485
Schistosomiasis is a trematode infection rarely diagnosed in the United States. Intestinal involvement is common with chronic infection and causes abdominal pain, changes in bowel habits, hematochezia, and polyp formation. Chronic, disseminated infection can affect the intestines causing the aforementioned symptoms, but reports of intestinal polyps are rare. Most cases are inflammatory fibrous polyps in the colon. There are very few cases reported in the literature of hamartomatous polyps arising in the small intestine. We present the rare case of a U.S.-born, 35-year-old woman diagnosed with a large duodenal hamartomatous polyp in the setting of intestinal schistosomiasis.
Endoscopic Management as a Viable Therapy for Pancreaticopleural and Pancreaticopericardial Fistulas
Chan, Sandy MD1; Petersile, Matthew MD2; Churrango, Gustavo MD2; Zivny, Jaroslav MD2
doi : 10.14309/crj.0000000000000533
January 2021 - Volume 8 - Issue 1 - p e00533
Pancreatic fistulas are rare complications of chronic pancreatitis, typically caused when disruption of the pancreatic duct causes leakage of pancreatic fluid that erodes through neighboring organs and structures. Pancreatic fistulas to the pericardium and pleural spaces are extremely rare, and cases of multiple fistulas tracking from the pancreas have not been reported before. Management of these fluid collections is challenging with no consensus described in the current literature. We report a case of a patient with concurrent pancreaticopericardial and pancreaticopleural fistulas who improved with endoscopic management.
Metastatic Pancreatic Neuroendocrine Tumor With Primary Presentation as Orbital Cellulitis
Mehtani, Rohit MD1; Venkitaraman, Aswath MD1; Roy, Aakash MD1; Premkumar, Madhumita MD, DM1
doi : 10.14309/crj.0000000000000524
January 2021 - Volume 8 - Issue 1 - p e00524
Neuroendocrine tumors (NET) are rare malignancies of the gastrointestinal tract or lung with the most common metastases being the liver. Surgery remains the mainstay of treatment. We describe a 53-year-old woman with pancreatic NET metastatic to the liver, spleen, and orbital fossae. She presented with orbital cellulitis and was managed as a case of ocular tuberculosis after a preliminary ultrasound of the eye which showed soft-tissue edema of the orbit, and aspiration cytology showed ill-formed lymphocyte clusters. Eight weeks later, she developed antitubercular therapy-induced hepatitis. Further investigations revealed the real diagnosis of metastatic NET with orbital deposits. She received somatostatin analogue therapy, everolimus, and peptide receptor radionuclide therapy with significant reduction in size of lesions and resolution of symptoms.
Empagliflozin-Associated Pancreatitis: A Consideration for SGLT2 Inhibitors
Dziadkowiec, Karolina N. MD1; Stawinski, Peter M. MD1; Proenza, Jose MD2
doi : 10.14309/crj.0000000000000530
January 2021 - Volume 8 - Issue 1 - p e00530
Empagliflozin belongs to a class of sodium-glucose cotransporter-2 inhibitors, a medication approved by the US Food and Drug Administration in 2014 for the treatment of type 2 diabetes mellitus. Well-known side effects of this medication include symptomatic hypotension, hypoglycemia, and urinary tract infections among others. We present a case of severe epigastric abdominal pain consistent with acute pancreatitis in the setting of empagliflozin use, suggesting a possible drug-induced acute pancreatitis.
Propofol-Induced Severe Necrotizing Pancreatitis
Parekh, Akarsh MD1,2; Zhang, Howard MD3
doi : 10.14309/crj.0000000000000528
January 2021 - Volume 8 - Issue 1 - p e00528
Propofol is a widely used sedative for gastrointestinal endoscopic procedures. Drug-induced pancreatitis is a relatively rare disease possibly because of poor recognition. Propofol-induced pancreatitis is an extremely rare phenomenon. We present a 22-year-old healthy man who underwent esophagogastroduodenoscopy with propofol as a sedative. Soon after, he developed acute upper gastrointestinal symptoms and was diagnosed with pancreatitis. His prolonged hospital course was complicated with necrotizing pancreatitis, acute respiratory distress syndrome, septic shock, and other end-organ damages. We hope to increase awareness of a life-threatening adverse event of a commonly used anesthetic such as propofol.
A Rare Case of Metastatic Merkel Cell Carcinoma to the Stomach and Pancreas Presenting With Upper Gastrointestinal Bleeding and Obstructive Jaundice
Elkafrawy, Ahmed MD1; Numan, Laith MD2; Albawaliz, Anas MD2; Liu, Cynthia MD3; Bahaj, Waled MD2; Tawfik, Ossama MD, PhD4; Hamid, Fadi MD5
doi : 10.14309/crj.0000000000000523
January 2021 - Volume 8 - Issue 1 - p e00523
Merkel cell carcinoma (MCC) is a rare and aggressive primary neuroendocrine tumor of the skin. Gastrointestinal (GI) metastasis in MCC is uncommon. We present a case of MCC with metastasis to the stomach, duodenum, and pancreas presenting with melena and obstructive jaundice. A large, bleeding metastatic mass was identified in the duodenum. Hemostasis was achieved with coil embolization. Endoscopic retrograde cholangiopancreatography with stenting of the common bile duct was performed to relieve the obstruction. Close surveillance with positron emission tomography/computed tomography scan and possible GI endoscopy should be performed in cases with distant metastasis to identify and treat early GI tract lesions.
Posterior Reversible Encephalopathy Syndrome After Azathioprine Administration in Severe Ulcerative Colitis
Vernia, Filippo MD1; Di Ruscio, Mirko MD2; Massella, Arianna MD2; Variola, Angela MD2; Montanari, Renzo MD2; Bocus, Paolo MD2
doi : 10.14309/crj.0000000000000521
January 2021 - Volume 8 - Issue 1 - p e00521
Posterior reversible encephalopathy syndrome is a rare syndrome characterized by brain edema and neurological symptoms, often resulting from several drugs. Treatment is based on discontinuation, and diagnosis is thus essential. Only 13 cases of posterior reversible encephalopathy syndrome have been reported in inflammatory bowel diseases, and we present the first after azathioprine in adults. A 56-year-old patient with active ulcerative colitis was found unconscious 5 days after the institution of azathioprine. Right-sided hemiplegia was found after the patient regained consciousness. Magnetic resonance imaging showed altered signal associated with diffusion restriction in the occipital lobe and cerebral vasogenic edema. Complete regression of neurological signs occurred after azathioprine discontinuation.
Spontaneous Rupture of Gallbladder Hemangioma Presenting as Hemoperitoneum
Ray Choudhury, Satyaprakash Mch1; Mohanty, Sumit Subhadarshi MS1; Pattanaik, Premananda Mch1; Lenka, Anasuya MD2; Panda, Bhagaban MS1
doi : 10.14309/crj.0000000000000522
January 2021 - Volume 8 - Issue 1 - p e00522
Hemangioma of the gallbladder is rare, with less than 10 cases reported in the literature. It may represent a hamartomatous proliferation of connective tissue in the gallbladder or may be congenital in origin. Although liver hemangiomas rarely present with spontaneous rupture, it has not been documented in gallbladder hemangiomas. This report presents a case of gallbladder hemangioma that ruptured spontaneously and presented with hemoperitoneum.
The Next Endoscopic Frontier: Considering a Career in Resection Endoscopy
Mehta, Neal A. MD1
doi : 10.14309/crj.0000000000000515
January 2021 - Volume 8 - Issue 1 - p e00515
Getting Started in Global Health: A Practical Guide for Gastroenterology Fellows
Chudy-Onwugaje, Kenechukwu MBBS, MPH, MS1,2
doi : 10.14309/crj.0000000000000514
January 2021 - Volume 8 - Issue 1 - p e00514
Correction to: Navigating Through Right Career Choice After Gastroenterology and Hepatology Fellowship
Devani, Kalpit MD
doi : 10.14309/crj.0000000000000536
January 2021 - Volume 8 - Issue 1 - p e00536
