ACG Case Reports Journal

Pancreatic Tuberculosis Abscess Successfully Treated With Serial Endoscopic Ultrasound-Guided Aspirations No abstract available

Endoscopic Diagnosis of Early Acute Appendicitis in an Asymptomatic Patient A 50-year-old woman with a paternal medical history of colon cancer presented for a routine screening colonoscopy. On presentation, she denied symptoms of abdominal pain, nausea, vomiting, fevers, chills, or anorexia. During the procedure, 5 polyps ranging from 2- to 7-mm were excised from the transverse and sigmoid colon. Evaluation of the cecum revealed a normal mucosa surrounding the base of the appendix and a moderate amount of purulent discharge from the appendiceal orifice (Figure 1). Given these endoscopic findings, which were suggestive of acute appendicitis, she was referred to the emergency department for evaluation and surgical consultation. On initial evaluation, her vital signs were within normal limits, and her abdominal examination was soft, nontender, and without signs of peritonitis. A complete blood count and basic metabolic panel were unremarkable. Abdominal computed tomography showed a 6-mm appendix, mild hyperemia of the appendiceal wall, and lack of intraluminal contrast consistent with acute appendicitis (Figure 2). She was taken for a laparoscopic appendectomy where her appendix and adjacent tissues appeared mildly hyperemic. The appendix was evaluated by a board-certified pathologist, and the final diagnosis was acute appendicitis (Figure 3). Figure 1.:  Appendiceal orifice (black arrow) with purulent discharge and no other significant mucosal changes. Figure 2.:  Computed tomography showing hyperemic and dilated appendix (red arrow) with lack of intraluminal contrast consistent with acute appendicitis. Figure 3.:  Hematoxylin and eosin staining of the appendix mucosa with ulceration and fibrinopurulent exudate (20× magnification). Appendicitis is a common diagnosis with a well-established clinical course.1 Despite advances in imaging modalities, we have not seen the expected fall in the rate of negative appendectomies, which highlights the fact that better modalities to aid in the diagnosis of appendicitis may still be needed.2 Endoscopy is not currently in the algorithm for the evaluation or treatment of suspected appendicitis and is unlikely to become an effective modality for this disease in the future. However, endoscopists should be aware of the early mucosal changes seen in appendicitis that should prompt further investigation and surgical consultation. Interestingly, there are only 2 previously reported cases of acute appendicitis diagnosed at the time of colonoscopy in patients who were asymptomatic.3,4 These cases were presented as an account of the earliest mucosal changes seen on endoscopy in appendicitis. In them, mucosal erythema, edema, abscess, and purulent discharge are cited as the earliest findings. This helped the reporting authors corroborate that the pathophysiology of appendicitis begins with luminal obstruction of the appendix and ultimately advances to appendiceal perforation. On the contrary, we argue that the earliest changes in acute appendicitis, even before patients become symptomatic, may not necessarily be luminal obstruction of the appendix. Rather, this obstructive phase of appendicitis may be a secondary change incited by the inflammatory response to an already developing infection.

Duodenal Gangliocytic Paraganglioma: A Unique Cause of Abdominal Pain No abstract available

An Acute Presentation of Chronic Gastric Volvulus A 96-year-old man presented to the hospital with 3 episodes of hematemesis with nausea. He was started on a proton-pump inhibitor and successfully resuscitated. Esophagogastroduodenoscopy demonstrated diffuse gastropathy with heme staining in the gastric body (Figure 1). A large paraesophageal hernia with volvulus of the stomach was also observed. Computed tomography the following day confirmed the presence of a paraesophageal hernia along with a gastric mesenteroaxial volvulus (Figure 2). A chest computed tomography from 2 years ago showed the same paraesophageal hernia and volvulus. The patient had been asymptomatic since that discovery up to his current presentation. The endoscopic reduction was considered but was not attempted because of the chronic nature of the volvulus and concern that fibrotic changes would not make it feasible. The hematemesis was likely from bleeding gastropathy, possibly ischemic from an acute worsening of his chronic volvulus vs bleeding gastropathy exacerbated by clopidogrel. Owing to his age, high surgical risk, and chronic nature of the volvulus, the patient elected for observation rather than surgery. The patient had no further episodes of hematemesis, tolerated a diet, and was discharged to a facility. Large paraesophageal hernias complicated by volvulus should be referred for surgery, but in our patient, who was a poor surgical candidate, he did well over the course of years without surgical intervention. Figure 1.:  Diffuse gastropathy with heme staining in the gastric body. Figure 2.:  Computed tomography showing (A) gastric mesenteroaxial volvulus (sagittal view) and (B) paraesophageal hernia with gastric volvulus (coronal view).

A Rare Case of Antemortem Metastatic Gastric and Small Intestine Melanoma No abstract available

Sweet Potato Esophagus An 80-year-old woman with a medical history of solid dysphagia presented to the clinic with regurgitation of solids and liquids after eating sweet potatoes for the past 48 hours. Esophagogastroduodenoscopy (EGD) under moderate sedation was performed and showed complete obstruction of the esophageal lumen by potato debris throughout (Figure 1). Multiple attempts were made to remove the food burden through an overtube with retrieval net and forceps without significant progress. The following day, a repeat EGD was performed under general anesthesia. Initially, a 15-mm biliary extraction balloon was passed through the food bolus, inflated and pulled back, with partial removal of the potato through the overtube (Figure 2). Next, suction tubing was inserted alongside a stricture scope to provide efficient clearance of the debris under direct visualization. Water irrigation with suction was used for residual potato debris without resultant mucosal injury (Figure 3). Several hours after the procedure, the patient demonstrated tolerance of a solid diet and was discharged the same day. A follow-up EGD several weeks later revealed normal esophageal biopsies and evidence of presbyesophagus which was thought to be the likely etiology of the food impaction. This case demonstrates a novel approach to treating esophageal food bolus of an uncommon etiology. The use of suction tubing under direct visualization appears to be safe and effective for the removal of small food debris. Figure 1.:  Esophagogastroduodenoscopy showing complete obstruction of the esophageal lumen by potato debris. Figure 2.:  Biliary extraction balloon was passed through the food bolus, inflated and pulled back, with partial removal of potato through the overtube. Figure 3.:  Water irrigation with suction to remove residual potato debris without resultant mucosal injury.

Metastatic Renal Cell Carcinoma Found in the Stomach and Duodenum No abstract available

Proctocolitis From Coffee Enema Coffee enemas are often used by naturopathic practitioners to treat a number of diseases, including cancer. However, there is no supportive evidence, and its use comes with major risks. We report a case of proctocolitis in a healthy patient after coffee enema treatment. To our knowledge, only 3 other cases of this adverse effect exist in the literature.

Pancreatic Adenocarcinoma With Synchronous Colonic Metastases Metastases from pancreatic malignancy are commonly known to occur in the regional lymph nodes, liver, lung, and peritoneum. Synchronous or metachronous metastasis from the pancreas to the colon is rare, with only 6 cases reported in the literature. We report a man who was found to have adenocarcinoma on biopsies from synchronous lesions in the colon and the pancreas. The immunohistochemistry report revealed the diagnosis of a primary pancreatic malignancy with synchronous colonic metastases.

Endoscopic Ultrasound Guided Drainage of a Post-Surgical Fluid Collection Using a Lumen-Apposing Metal Stent in a Patient With Crohn's Disease Patients with Crohn's disease (CD) are susceptible to postsurgical fluid collections and abscesses. Traditionally, these have been drained either percutaneously or surgically. Endoscopic ultrasound-guided drainage using a lumen apposing metal stent has not been used commonly for drainage of abdominal abscesses in patients with CD, given the concern of fistula formation because of transmural inflammation in patients with CD. We report a case of a large perigastric abscess that was drained through the stomach, using a lumen apposing metal stent with complete resolution of the abscess.