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Three Signs of a Shortcut: Gastrogastric Fistula Permitting Simple Roux-en-Y Endoscopic Retrograde Cholangiopancreatography
Heinrich, Matthew P MD1; Storm, Andrew C MD2
doi : 10.14309/crj.0000000000000694
November 2021 - Volume 8 - Issue 11 - p e00694
An Unusual Gastric Polyp: Brunneroma
Mhanna, Jad MD1; Francis, Fadi F. MD1; Sabatto, Bassel Zein MD2; Tawil, Ayman MD2; Hashash, Jana G. MD MSc1
doi : 10.14309/crj.0000000000000681
November 2021 - Volume 8 - Issue 11 - p e00681
Brunneromas or polypoid hamartomas are benign lesions arising from Brunner glands. They are usually benign lesions with low potential for malignancy. They are usually located in the duodenum and manifest with different unspecific symptoms, such as abdominal pain, nausea, or bloating. Other more serious manifestations are also reported in the literature that are related to the size of the lesion. Usually, they are treated with endoscopic resection, with some lesions requiring surgical intervention. We present a case of a gastric antral polypoid lesion that was consistent with Brunneroma on histology.
A Massive Stone Ingestion
Hans, Amneet K. MD1; Brown, Jason M. MD1; Qayed, Emad MD, MPH1
doi : 10.14309/crj.0000000000000707
November 2021 - Volume 8 - Issue 11 - p e00707
Complete Colonic Diaphragm-Like Stricture After Ileostomy and Sigmoidectomy for Sigmoid Colon Perforation With Diverticulitis
Soga, Koichi MD, PhD1; Mukai, Hiroki MD1; Akamatsu, Naoaki MD1
doi : 10.14309/crj.0000000000000693
November 2021 - Volume 8 - Issue 11 - p e00693
Unusual Location of an Unusual Malignancy
Patel, Jit MD1; Ismail, M. MD2; Fowler, N. MD3; Maronian, N. MD3; Faulx, A. MD2
doi : 10.14309/crj.0000000000000656
November 2021 - Volume 8 - Issue 11 - p e00656
Inflammatory Myoglandular Polyps Presenting With Diarrhea
Fritz, Cassandra D.L. MD1; Navale, Pooja MD2; Mutch, Matthew MD3; Kushnir, Vladimir MD1
doi : 10.14309/crj.0000000000000685
November 2021 - Volume 8 - Issue 11 - p e00685
Case of a Vanishing Colonic Mass
Barrett, Lisa DO1; Goyal, Abhinav MD2; Davis, Nathan DO2; Govil, Yogesh MD2; Zavala, Stacey MD2
doi : 10.14309/crj.0000000000000682
November 2021 - Volume 8 - Issue 11 - p e00682
Colonic ischemia most often presents with abdominal pain and rectal bleeding. Presentation of colonic ischemia as a prominent mass is exceptionally unique and is not often reported. Concern for neoplasm prompted a repeat scope, which revealed the mass had vanished. We present a case of colonic ischemia, which produced a transient colonic mass formed by inflammatory tissue and clots.
A Rare Cause of Massive Hematochezia: Arteriovenous Malformation of the Appendix
Khan, Freeha MD1; Lu, Shengli MD2; Parajuli, Dipendra MD1
doi : 10.14309/crj.0000000000000679
November 2021 - Volume 8 - Issue 11 - p e00679
Peritoneal Loose Body in a Patient With Ampullary Adenocarcinoma
Pradeep, A.V. MD1; Razik, Abdul MD, DNB1; Goyal, Ankur MD, DNB1; Kumar, Atin MD, DNB1; Bansal, Virinder Kumar MS, FACS, FRCS2; Krishna, Asuri MS, FACS, FRCS2
doi : 10.14309/crj.0000000000000680
November 2021 - Volume 8 - Issue 11 - p e00680
Endoscopic Management of A Rare Polypoid Arteriovenous Malformation of the Colon
Jamali, Taher MD1; Ghouri, Yezaz MD2; Qiu, Suimin MD3; Parupudi, Sreeram MD4
doi : 10.14309/crj.0000000000000684
November 2021 - Volume 8 - Issue 11 - p e00684
Endoscopic Removal of a Displaced Tracheoesophageal Voice Prosthesis
Li, Suqing MD1; Enepekides, Danny MD, MPH2; Cohen, Lawrence MD, MSc3
doi : 10.14309/crj.0000000000000708
November 2021 - Volume 8 - Issue 11 - p e00708
Case of Delayed Transhiatal Pancreatic Herniation After Esophagectomy
Martyn, Colin MD1,2; Serrano, Oluwagbenga MD1
doi : 10.14309/crj.0000000000000683
November 2021 - Volume 8 - Issue 11 - p e00683
Hymenolepis nana Infection in an HIV Patient With Diarrhea
Patel, Roohi MD1; Dellatore, Peter MD2; Smith, Colton DO3; Patel, Anish Vinit MD2
doi : 10.14309/crj.0000000000000709
November 2021 - Volume 8 - Issue 11 - p e00709
Calcified Small Bowel Mass
Joseph, Abel MD1; Mehta, Neal MD2; Zhang, Xuefeng MD3; Siddiki, Hassan MD2; Bhatt, Amit MD2
doi : 10.14309/crj.0000000000000706
November 2021 - Volume 8 - Issue 11 - p e00706
Ischemic Colitis From Idiopathic Myointimal Hyperplasia of the Mesenteric Veins in a Post–Liver Transplant Patient
Wong, Rochelle MD1; Westerveld, Donevan MD1; Yeo, Heather MD2; Jessurun, Jose MD3; Jesudian, Arun MD1
doi : 10.14309/crj.0000000000000692
November 2021 - Volume 8 - Issue 11 - p e00692
Idiopathic myointimal hyperplasia of the mesenteric veins (IMHMV) is a rare cause of nonthrombotic, noninflammatory ischemic colitis. IMHMV classically presents in men with abdominal pain and bloody diarrhea and is frequently misdiagnosed as inflammatory bowel disease. However, IMHMV causes a more protracted, relapsing course of abdominal pain that does not respond to medical therapy. The diagnosis can be secured by colonoscopic biopsy. Surgical resection is curative and should be considered even in high-risk patients. Here, we describe a case of IMHMV diagnosed preoperatively in a post–liver transplant patient with residual portal hypertension who ultimately underwent successful surgical resection.
An Unusual Delayed Complication of Urogynecologic Surgical Mesh: Perirectal Abscess 10 Years After Initial Placement Treated by Endoscopic Removal
West, Sara F.J. DO1; Diehl, David L. MD1
doi : 10.14309/crj.0000000000000703
November 2021 - Volume 8 - Issue 11 - p e00703
Surgical mesh is commonly used for the management of pelvic organ prolapse and stress urinary incontinence with overall beneficial effects. However, the Food and Drug Administration has issued safety notifications about potentially serious complications assisted with the use of synthetic mesh in pelvic organ prolapse procedures. In this report, we describe a perirectal abscess in a patient which developed 10 years after initial mesh placement. Percutaneous management of the abscess was not possible because of the deep pelvic location. The abscess was successfully managed endoscopically, including the removal of a large piece of mesh. Endoscopic management of pelvic abscesses, including an endoscopic ultrasound-guided approach, should be considered early.
Abdominal Actinomycosis Abscess Presenting as an Isolated Gastrointestinal Pseudotumor
Clarrett, Danisa MD1; Ray, Jennifer Michelle MD2; Taylor, Jason R. MD2
doi : 10.14309/crj.0000000000000672
November 2021 - Volume 8 - Issue 11 - p e00672
Actinomyces is a gram-positive anaerobic bacterium that is ubiquitous in nature. It typically presents as respiratory, cervicofacial, or abdominopelvic abscesses. We present a 66-year-old man with a progressive enlarging abdominal wall nodule concerning for malignancy. The patient had a negative workup, including an ultrasound-guided fine-needle aspiration and colonoscopy, with biopsy for a possible extension to the colonic wall. Diagnosis of an Actinomyces abscess was obtained through surgical resection with right hemicolectomy. He was successfully treated with a prolonged course of intravenous antibiotics. This is a rare case of an isolated abdominal wall Actinomyces abscess mimicking a gastrointestinal malignancy.
Tangier Disease: An Unusual Cause of Chronic Diarrhea
Ritaccio, Gabrielle MD1; Asif, Bilal MD2,3; Yfantis, Harris MD4; Wong, Uni MD3
doi : 10.14309/crj.0000000000000659
November 2021 - Volume 8 - Issue 11 - p e00659
Tangier disease is a rare autosomal recessive disease resulting in cholesterol deposition in different organs. We report a case of a 52-year-old white man who presented for chronic diarrhea without significant findings on noninvasive testing. Subsequent colonoscopy revealed endoscopically normal mucosa, with random biopsies remarkable for foamy macrophages in the lamina propria. Genetic testing showed adenosine triphosphate–binding cassette transporter gene mutation with low high-density lipoprotein and low low-density lipoprotein. To the best of our knowledge, this is the first report of chronic diarrhea in a patient with Tangier disease without any other clear etiology.
A Rare Presentation of Ileocecal Mucormycosis in a Heart Transplant Recipient
Hoang, Sook MD1; Sestito, Michael MD2
doi : 10.14309/crj.0000000000000699
November 2021 - Volume 8 - Issue 11 - p e00699
Mucorales is an order of angioinvasive fungi that classically infects immunocompromised patients. As an aerogenous pathogen, it most frequently causes disease of the lungs and paranasal sinuses. Gastrointestinal mucormycosis represents a particularly rare site of infection. This case report describes the complicated presentation of ileocecal mucormycosis in an immunocompromised orthotopic heart transplant recipient. The diagnosis was made status-post ileocolonic resection, and the patient was promptly started on liposomal amphotericin B and micafungin. Unfortunately, the patient ultimately succumbed to disseminated infection. In this study, we review the epidemiology, the presenting features of gastrointestinal mucormycosis, and emphasize the prompt initiation of therapy on suspected disease.
A Rare Case of Waldenstrom Macroglobulinemia of the Rectosigmoid Colon
Zelman, Sara MD1; Russell, Michael B. MD1; Hojat, Amin MD2; Pilichowska, Monika MD, PhD2; Olans, Lori B. MD, MPH1; Sterling, Mark J. MD1
doi : 10.14309/crj.0000000000000689
November 2021 - Volume 8 - Issue 11 - p e00689
Waldenstrom macroglobulinemia is an uncommon mature B-cell lymphoma characterized by monoclonal immunoglobulin M protein in peripheral blood and lymphoplasmacytic cells in bone marrow and/or extramedullary sites. The gastrointestinal tract is a rare site of involvement. The diagnosis is based on clinicopathologic findings, although somatic mutations, such as MYD88, can aid in the diagnosis. We present a patient with irregular stools diagnosed with Waldenstrom macroglobulinemia involving the rectosigmoid colon by histopathology and immunohistochemistry on colonic biopsies, immunoglobulin M protein in serum, clonal plasma cells in bone marrow, and MYD88 mutation in colonic and bone marrow specimens.
Using Immunohistochemistry to Expand the Spectrum of Lynch Syndrome–Related Tumors
Farha, Natalie MD1; Savage, Erica MD2; Sleiman, Joseph MD1; Burke, Carol A. MD3
doi : 10.14309/crj.0000000000000691
November 2021 - Volume 8 - Issue 11 - p e00691
The most common genetic and molecular process leading to sporadic colorectal cancer is chromosomal instability. By contrast, mismatch repair deficiency, which results in high levels of microsatellite instability or lack of mismatch repair (MMR) protein expression on immunohistochemistry (IHC), is the predominant cancer pathway in patients with Lynch syndrome (LS). Importantly, patients with LS may still develop sporadic tumors through chromosomal instability. Testing tumors with IHC staining helps expand the spectrum of LS-related tumors. In this series, we describe 4 cancers in patients with LS that are not typical of the syndrome. Lack of MMR protein expression on IHC staining confirmed that 2 cancers are related to LS, expanding the spectrum of LS-related tumors, and the presence of MMR protein expression on IHC in the other 2 cases confirmed that they were sporadic and not related to mismatch repair deficiency and, thus, not related to LS.
Primary Effusion Lymphoma: Small Bowel Recurrence After Stem Cell Transplant
Mushtaq, Sarah MD1; Prabakaran, Sabrina MD1; Elharake, Maher MD1; Mirza, Sayeef MD, PhD1; Ravindran, Adharsh MD2; Faramand, Rawan MD3; Sokol, Lubomir MD, PhD4
doi : 10.14309/crj.0000000000000698
November 2021 - Volume 8 - Issue 11 - p e00698
Primary effusion lymphoma (PEL) is a rare AIDS-associated non-Hodgkin lymphoma, growing in the serous body cavities as a lymphomatous effusion. The endoscopic features of PEL can mimic Kaposi sarcoma (KS). We present a case where PEL presented as small intestinal masses which had a similar macroscopic appearance to KS. Endoscopic evaluation was used with biopsies which confirmed the diagnosis of PEL. PEL is a differential of gastrointestinal KS. Accurate diagnosis is crucial for prognostication in these patients. Our case emphasizes that PEL presenting as intestinal tumors can mimic KS macroscopically. Although treatment for PEL and KS includes standard chemotherapy with concurrent antiretroviral therapy, early detection of PEL can improve overall survival in these patients.
Combined Endoscopic Stent-In-Stent Placement by Lumen-Apposing Metal Stents Through Self-Expanding Metal Stents for Simultaneous Malignant Biliary and Duodenal Obstruction
Metelli, Flavio MD1; Pezzoli, Alessandro MD1; Fabbri, Carlo MD2; Pizzo, Elena PhD3; Arena, Rosario MD1; Cifalà, Viviana MD1; Simone, Loredana MD1; Solimando, Riccardo MD1; Merighi, Alberto MD1
doi : 10.14309/crj.0000000000000704
November 2021 - Volume 8 - Issue 11 - p e00704
The palliation of simultaneous biliary and duodenal obstruction in patients with advanced pancreatic cancer is a clinically and technically challenging scenario. Endoscopic procedures are a valid alternative to surgical or percutaneous transhepatic biliary drainage. The availability of self-expanding metal stents (SEMSs) and lumen-apposing metal stents (LAMS) have expanded therapeutic options. We describe a case in which biliary and duodenal obstructions were treated successfully with the combined use of SEMS and LAMS devices. Endoscopic ultrasound-guided biliary drainage with the use of new LAMS and a duodenal SEMS can be a valid option in expert hands as a palliative and minimally invasive treatment for gastric outlet and biliary obstruction.
A Case of Hepatitis E Persistence in a Patient With Myelofibrosis Under Ruxolitinib
Ribeiro da Cunha, Maria MD1; Marques, Tiago MD1
doi : 10.14309/crj.0000000000000674
November 2021 - Volume 8 - Issue 11 - p e00674
Hepatitis E virus (HEV) is a mostly enterically transmitted agent of viral, usually acute hepatitis. In recent years, however, it has been proven to establish chronicity in immunosuppressed patients. We report the first case of HEV infection in a patient with myelofibrosis under ruxolitinib, a tyrosine kinase inhibitor. Although this patient was able to mount a humoral response with specific immunoglobulin G, viral replication could not be controlled until ruxolitinib suspension. After normalization of liver enzymes and clearance of HEV, ruxolitinib was reintroduced with no disease relapse, suggesting spontaneous eradication of the virus.
Acute Hepatitis A and Hepatitis B Coinfection
Hiramoto, Brent MD1; Liu, Yao MD1; Dara, Lily MD2,3; Zhou, Kali MD2,3
doi : 10.14309/crj.0000000000000702
November 2021 - Volume 8 - Issue 11 - p e00702
Hepatitis A (HAV) has emerged in outbreaks across the United States particularly in at-risk populations such as men who have sex with men, as well as patients with a history of drug use, homelessness, and incarceration. Immunization among these high-risk populations remains underused. In this study, we describe a case of acute HAV and hepatitis B (HBV) coinfection in an MSM patient occurring in the period of these outbreaks. Clinical resolution of acute HAV and HBV coinfection was attained by 5 months from the time of initial hospitalization without viral hepatitis treatment. This case highlights the need for increased awareness of at-risk populations for HAV and HBV infection in promoting guideline-based vaccination efforts.
Symptomatic Pneumoperitoneum After Gastrostomy Tube Placement Managed by Pneumocentesis
Brotherton, Tim MD1; Chhaparia, Anuj MD2; Presti, Michael MD2,3; Sayuk, Gregory MD3; Elwing, Jill MD3
doi : 10.14309/crj.0000000000000700
November 2021 - Volume 8 - Issue 11 - p e00700
Pneumoperitoneum is a known complication of percutaneous endoscopic gastrostomy tube placement that typically resolves spontaneously with conservative management. We describe the case of a 72-year-old man who developed abdominal pain and distention after percutaneous endoscopic gastrostomy tube placement who was subsequently found to have a moderate-sized pneumoperitoneum. Despite supportive care, his abdominal pain failed to improve. We report paracentesis with air aspiration as an intervention for benign pneumoperitoneum resulting in rapid and durable resolution of abdominal complaints.
Multiple Myeloma Presenting as Chronic Diarrhea
Bajwa, Arouj MD1; Trieu, Judy MD, MPH2; Mirza, Kamran MD, PhD3; Ding, Xianzhong MD3; Liem, Brian DO2
doi : 10.14309/crj.0000000000000677
November 2021 - Volume 8 - Issue 11 - p e00677
Extramedullary gastrointestinal tract involvement in plasma cell dyscrasias is rare and represents a diagnostic challenge. We present a 66-year-old man with an unusual presentation of multiple myeloma. He presented with chronic diarrhea, and extensive biopsies in the jejunum allowed for the presumptive diagnosis of multiple myeloma to be made and the weighted decision to treat without a definitive diagnosis. Plasma cell dyscrasias can have highly varied presentations, unclear differentiation, and require a multidisciplinary approach for diagnosis and management. Adequate tissue sampling of the small bowel is critical in assessing patients with chronic diarrhea.
A Puzzling Case of Pouch Pathology
Rahal, Harman MD1; Ehrlich, Dean MD2; Paredes, Harold MD2,3; Conlon, Wendy MS4; Sedarat, Alireza MD2,3
doi : 10.14309/crj.0000000000000669
November 2021 - Volume 8 - Issue 11 - p e00669
A 36-year-old man with familial adenomatous polyposis secondary to an adenomatous polyposis coli mutation status post proctocolectomy with ileal pouch-anal anastomosis presented with hematochezia. Pouchoscopy revealed a 4-cm indurated mass in the distal ileal pouch just 17 months after a normal pouchoscopy. Histopathology was diagnostic for Burkitt lymphoma, and the patient achieved complete remission with subsequent chemotherapy. Although there are reports of Burkitt lymphoma in patients with ileal pouch-anal anastomosis, to date, this is the first report in a patient with familial adenomatous polyposis. This case highlights the presentation of a rapidly enlarging tumor not commonly seen in the adult gastroenterology population.
Umbralisib-Induced Immune-Mediated Colitis: A Concerning Adverse Effect of the Novel PI3K?/CK1? Inhibitor
Bajaj, Suryansh MBBS1; Barrett, Stevi M. PA-C1; Nakhleh, Raouf E. MD2; Brahmbhatt, Bhaumik MBBS1; Bi, Yan MD, PhD1
doi : 10.14309/crj.0000000000000701
November 2021 - Volume 8 - Issue 11 - p e00701
Novel chemotherapeutic agents are developed to treat recurrent/relapsed lymphoid malignancies. Umbralisib, a novel phosphatidylinositol 3-kinase inhibitor with a selective isoform binding, has shown an improved efficacy and safety profile in clinical trials. Immune-mediated colitis, a frequently observed dose-limiting adverse event of phosphatidylinositol 3-kinase inhibitors, has been mostly observed at supratherapeutic doses in the trials, with grade 1 or 2 diarrhea being the most common adverse event at the therapeutic dose (800 mg PO QD). We present a grade-3 colitis that can be attributed to umbralisib-mediated immune toxicity in a patient with chronic lymphocytic leukemia at the therapeutic dose.
Tofacitinib-Associated Iatrogenic Kaposi Sarcoma in a Patient With Ulcerative Colitis
Wetwittayakhlang, Panu MD1,2; Golovics, Petra A. MD1,3; Afif, Waqqas MD1; Bessissow, Talat MD1; Lakatos, Peter L. MD1,4
doi : 10.14309/crj.0000000000000678
November 2021 - Volume 8 - Issue 11 - p e00678
Tofacitinib is an oral Janus kinase inhibitor. Although it contributes to the induction and maintenance of clinical remission of patients with moderate-to-severe ulcerative colitis, various malignancies have been reported after the use of this small molecule. We report a rare case of biopsy-proven Kaposi sarcoma in a patient with complex biological-resistant ulcerative colitis after 2 years of treatment with tofacitinib. Kaposi sarcoma lesions spontaneously regressed after tofacitinib was discontinued. Given the concern of potential risk of malignancy associated with this agent, we believe that specialists should be aware of this rare but serious possible adverse event.
Treatment of Crohn's Disease and Concomitant Alopecia Areata With Tofacitinib
Akiyama, Shintaro MD, PhD1; Lin, Austin MD1; Traboulsi, Cindy MD1; Rubin, David T. MD1
doi : 10.14309/crj.0000000000000690
November 2021 - Volume 8 - Issue 11 - p e00690
Alopecia areata (AA) is a type of immune-mediated hair loss and is reported in patients with inflammatory bowel disease. This suggests that there might be a shared molecular pathway in the pathogenesis of AA and inflammatory bowel disease. In addition, tumor necrosis factor-alpha antagonists are also rarely associated with new-onset AA. We present a patient with Crohn's disease treated with adalimumab who developed AA that rapidly progressed to alopecia totalis and universalis. We describe the use of tofacitinib, a Janus kinase 1/3 inhibitor, to not only successfully treat the AA but also maintain her Crohn's disease.
