Introduction:Hepatic encephalopathy after liver surgery is an uncommon but serious complication. Case Presentation:We describe an unusual case of a patient with a history of uretero-sigmoidostomy who developed severe hepatic encephalopathy following hepatectomy for liver metastases of colorectal cancer. Mechanical ventilation, ammonia-lowering drugs and continuous veno-venous hemofiltration were required in order to reverse encephalopathy. As ammonia production is principally governed via hydrolysis of urea in the gut, it is hypothesized that ammonia reabsorption via the uretero-sigmoidostomy played a pivotal role in the clinical course of this patient. Conclusion:This report highlights the need for awareness for reabsorption of ammonia in case of a uretero-sigmoidostomy in order to avoid unnecessary complications.
Introduction: Rupture of nonparasitic hepatic cysts is rare and usually occurs into the peritoneal cavity, whereas intrathoracic rupture has only rarely been described. Case Presentation: We report the case of a 61-year-old woman with polycystic liver disease (PCLD) who presented with right-sided chest pain and dyspnea, suggesting intrathoracic rupture of a hepatic cyst. Computed tomography revealed unilateral pleural effusion and reduction with deformation of a large subdiaphragmatic hepatic cyst compared with prior imaging. Thoracentesis revealed transudative pleural fluid without evidence of infection or malignancy but markedly elevated levels of carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA19-9). Based on these findings, intrathoracic rupture of a nonparasitic hepatic cyst was considered the most likely etiology. The patient subsequently underwent surgical deroofing because of cyst enlargement and symptoms; however, no definitive rupture site was identified intraoperatively, and the diagnosis therefore remained presumptive. To our knowledge, this represents a very rare presentation of intrathoracic rupture of a nonparasitic hepatic cyst in PCLD. Conclusion: This case highlights the importance of comparison with prior imaging and suggests that measurement of pleural CEA and CA19-9 levels may provide limited adjunctive information when intrathoracic rupture of a hepatic cyst is suspected, although these markers are nonspecific.
Introduction: Spontaneously dislodging pancreatic duct stents are generally expected to pass within several days. We report a rare case of markedly prolonged retention of such a stent in a patient with surgically altered anatomy. Case Presentation: A 78-year-old man with a history of distal gastrectomy with Roux-en-Y reconstruction underwent single-balloon enteroscopy-assisted ERCP for choledocholithiasis. After successful biliary cannulation using pancreatic guidewire assistance, stone extraction was performed following a small sphincterotomy and papillary balloon dilation. A 5-Fr × 5-cm spontaneously dislodging pancreatic duct stent without an internal flange was prophylactically placed. The postoperative course was uneventful; however, spontaneous stent dislodgement was not observed on follow-up imaging. Because of the technical burden of repeat endoscopy in surgically altered anatomy, careful observation was initially selected. The stent remained in place for 104 days and was ultimately removed endoscopically using a single-balloon enteroscope without adverse events. Conclusion: This case illustrates that markedly prolonged retention of a spontaneously dislodging pancreatic duct stent may occur in patients with surgically altered anatomy. Careful follow-up, including imaging to confirm spontaneous stent passage, is important, and endoscopic removal should be considered when the stent remains in place, even if repeat endoscopy is technically challenging.
Introduction:Ascites in the absence of liver disease poses a diagnostic challenge. Case Presentation:We report a previously healthy 50-year-old Swiss man with constitutional symptoms and progressive abdominal distension. Extensive workup excluded hepatic and malignant causes. Peritoneal tuberculosis was confirmed by diagnostic laparoscopy with histopathological and molecular analyses. Conclusion:This case highlights the need to consider rare causes of ascites, even in immunocompetent patients without liver disease.
Introduction:Amebiasis is a disease caused by the protozoan parasite Entamoeba histolytica (Eh) and remains the second leading cause of death due to parasitic infections worldwide. Asymptomatic Eh infections are the most common. Infection with Eh can transition from a harmless colonic colonizer to a pathogenic form, leading to amebic colitis. The clinical presentation of amebic colitis is varied and may include abdominal pain, bloody-mucoid diarrhea, tenesmus, and low-grade fever. These symptoms are often nonspecific and can mimic many other gastrointestinal conditions, both infectious and noninfectious. Case Presentation:We report a case of amebic colitis in a 62-year-old male who underwent routine colonoscopy, which revealed an ulceration in the cecum region. He was asymptomatic at presentation and had normal laboratory findings. The case was provisionally diagnosed as inflammatory bowel disease and received oral metronidazole and probiotics. At follow-up endoscopy, the ulceration had worsened. Biopsy from the margin of the ileocecal ulcer confirmed abundant amebic trophozoites. The patient was treated with metronidazole for 14 days. A follow-up colonoscopy after treatment showed that the lesions were completely healed. Conclusion:This case highlights the challenges of diagnosing amebic colitis. Amoebic colitis shows significant variation in presenting symptoms, and current diagnostic methods have limited sensitivity. The absence of obvious symptoms in this patient further increased the diagnostic difficulty. We recommend that clinicians consider invasive amebiasis in their list of differential diagnosis even in asymptomatic patients presenting with colonic ulceration.
Deglutition syncope is a rare reflex-mediated condition marked by transient bradyarrhythmia or AV block triggered by swallowing. We report a 65-year-old man with a year-long history of meal-related syncope, ultimately diagnosed via Holter monitoring that revealed swallowing-induced sinus pauses. Despite no significant esophageal abnormalities on imaging, a dual-chamber pacemaker was implanted, resulting in full symptom resolution. Our findings indicate the need for careful clinical recognition of deglutition syncope and that permanent pacing can effectively prevent recurrence in selected patients with swallow- induced bradyarrhythmia. KEY CLINICAL MESSAGE: Deglutition syncope is a rare but treatable cause of reflex-mediated bradyarrhythmia triggered by swallowing. Diagnosis requires a high index of suspicion and documentation of cardioinhibitory events during meals. Permanent dual-chamber pacing offers effective symptom resolution in selected patients without reversible esophageal pathology.
We describe a 32-year-old man without gastrointestinal symptoms who presented with chronic fatigue and a two-week history of severe lower back pain. MRI revealed bilateral sacroiliitis, and positive fecal inflammatory markers led to colonoscopy, which showed pancolitis. Further histopathological testing confirmed the diagnosis of ulcerative colitis (UC). He was treated with upadacitinib to address both conditions, resulting in significant improvement in symptoms and inflammatory markers within two months. This case emphasizes the importance of considering inflammatory bowel disease (IBD) in uncommon extraintestinal presentations.
Introduction: Hyperammonemia is a life-threatening condition most associated with liver disease, though non-cirrhotic causes are increasingly recognized. Case Presentation: We report an 18-year-old female presenting with 1 week of progressive confusion, abdominal pain, and nausea. Initial evaluation showed normal routine laboratories but markedly elevated ammonia and respiratory alkalosis. She rapidly deteriorated, requiring intubation and intensive care. Ammonia peaked at 795 µg/dL and improved rapidly after urgent venous hemofiltration and medical therapy, with full neurological recovery by day 3. Further testing revealed late-onset ornithine transcarbamylase deficiency. Conclusion: We present an algorithm for the approach to hyperammonemia and urea cycle disorders through a comprehensive review of current diagnostic and therapeutic strategies pertaining to urea cycle disorders.
Introduction: Biologic and targeted synthetic therapies can obscure underlying immunodeficiency and opportunistic infections, leading to diagnostic challenges in patients with presumed autoimmune disease. Case Presentation: A 51-year-old man with ankylosing spondylitis and presumed ulcerative colitis experienced progressive systemic decline, including 40 lb. weight loss and encephalopathy, while receiving etanercept and upadacitinib. Clinical deterioration prompted reassessment, revealing advanced HIV/AIDS (CD4 count 21 cells/µL) and biopsy-confirmed cytomegalovirus esophagitis. Discontinuation of Janus kinase inhibition and initiation of antiretroviral therapy resulted in clinical stabilization. Conclusion: This case highlights the dangers of diagnostic momentum and demonstrates how opportunistic infections can mimic autoimmune pathology, emphasizing the need for diagnostic reassessment and objectivity in patients receiving potent immunomodulatory therapies.
Introduction:Celiac disease (CD), if left untreated, can predispose a wide range of intestinal malignancies including enteric lymphoma and adenocarcinoma. On rare occasions, intestinal neuroendocrine tumors (NETs) were reported. We present a case of metastatic NET that led to the diagnosis of CD. Case Presentation:A 58-year-old woman presented with a lump in the left axilla without fever or weight loss. Physical examination showed a single tender and rubbery lymph node (LN) of 2.5 cm in size in the left axilla. Laboratories showed mild iron-deficiency anemia. An excisional LN biopsy showed well-differentiated NET, grade 3. A gallium Ga-68 DOTATATE-integrated positron emission tomography (PET)-computed tomography scan showed nonspecific homogenous duodenal and small bowel uptake without apparent signs of fluorodeoxyglucose (FDG)-avid malignancy. Upper endoscopy with push enteroscopy with small bowel biopsies were consistent with CD. The serum tissue transglutaminase-immunoglobulin test was positive. The patient was started on a gluten-free diet and managed with clinical observation. A follow-up FDG-PET scan after 6 months showed no abnormal uptake, and the patient continued to be asymptomatic beyond 1 year of follow-up. Conclusion:This case highlights the possible rare coexistence of CD with an atypical neoplastic process, particularly in patients presenting with unexplained iron-deficiency anemia. While CD is associated with an increased risk of certain rare gastrointestinal malignancies, its relationship with NETs remains poorly defined. Larger studies are needed to further explore any potential association between CD and NETs.
Introduction: Metastatic spread of breast cancer to the gastrointestinal (GI) tract is very uncommon (<1% of all metastases), but it is disproportionately higher in invasive lobular carcinoma (ILC) compared to invasive ductal carcinoma. Its presentation can mimic primary rectal malignancy, often leading to delayed diagnosis. Case Presentation: We describe a 40-year-old woman with metastatic, hormone receptor-positive classic ILC who developed rectal obstruction 2 years after her breast cancer diagnosis. Initial colonoscopy with superficial biopsies was negative. One year later, pelvic magnetic resonance imaging (MRI) demonstrated smooth, concentric thickening of the rectal wall; repeat biopsies confirmed metastatic lobular carcinoma. Conclusion: This case illustrates the diagnostic challenges posed by rectal metastasis from ILC, especially negative superficial rectal biopsies. Endoscopic and radiologic features often mimic primary rectal pathology, underscoring the importance of deep biopsy and imaging in establishing the diagnosis. New lower-GI symptoms in any breast-cancer survivor, especially one with ILC, should prompt pelvic MRI and deep tissue sampling to exclude metastatic disease if superficial biopsies are negative.
Introduction:Revascularization for chronic mesenteric ischemia is generally well tolerated, yet some patients experience acute multisystem deterioration afterward. The term reperfusion syndrome, commonly used in the context of acute ischemia, is often incorrectly applied to chronic disease. Case Presentation:We present a case of hyperperfusion syndrome following successful two-vessel stenting in a patient with chronic mesenteric ischemia, complicated by ascites and supported by imaging and laboratory findings. Our report also highlights new-onset thrombocytopenia as part of the clinical picture. The syndrome resolved spontaneously with supportive care. Conclusion:Clinicians should remain alert to hyperperfusion phenomena in chronic cases, particularly after simultaneous two-vessel revascularization.
Introduction:Lumen-apposing metal stents (LAMSs) have emerged as a versatile tool for managing various gastrointestinal conditions, including postsurgical complications. This case report describes the successful use of endoscopic ultrasound-guided gastrojejunostomy (EUS-GJ) with LAMS placement to treat efferent limb syndrome (ELS) causing gastric outlet obstruction (GOO) in a patient with altered anatomy after a Whipple procedure. Case Presentation:An 83-year-old female with a history of pancreatic adenocarcinoma status post-Whipple procedure presented with symptoms of GOO 1 year after surgery. Imaging and endoscopy revealed acute angulation at the efferent limb takeoff resulting in mechanical obstruction of the gastrojejunal anastomosis (GJ) without evidence of malignancy. The patient was also found to have ascites concerning for a recurrent pancreatic malignancy. Due to the patient's age and poor surgical candidacy, an EUS-GJ was successfully performed using a 20 × 10 mm cautery-enhanced LAMS bypassing the obstruction in the efferent limb and resulting in immediate symptom relief. The patient gained weight after 1 month of follow-up and remained clinically well with no procedural related complications after a 30-day follow-up. Conclusion:This case highlights the potential of EUS-GJ as an effective, minimally invasive technique for managing complex postsurgical complications in patients with altered anatomy. The technique provided symptom relief while minimizing morbidity and recovery time. In patients with disease progression, EUS-GJ should be considered for the palliation of GOO caused by ELS on a case-by-case basis after discussion between the endoscopists and surgeons.
Introduction: Upper gastrointestinal bleeding (UGIB) is an uncommon complication of pancreatitis and may be challenging to diagnose when bleeding is intermittent and routine investigations are inconclusive. We report a case of intermittent UGIB associated with a hemorrhagic pancreatic pseudocyst and transient cystoduodenal fistula. Case Presentation: A 29-year-old woman with biliary pancreatitis complicated by necrotizing pancreatitis and recurrent pancreatic collections presented with recurrent pancreatitis and intermittent UGIB. Imaging revealed a hemorrhagic pancreatic pseudocyst. During hospitalization, she experienced three discrete bleeding episodes over 10 days, including hematemesis, coffee ground emesis, and maroon-colored stools, with a hemoglobin nadir of 7.5 g/dL, requiring transfusion. Esophagogastroduodenoscopy revealed a duodenal bulb mucosal defect consistent with a cyst-duodenal fistula, which healed spontaneously. Repeated computed tomography angiography revealed no active bleeding or evidence of a pseudoaneurysm. Subsequent evaluation revealed pancreatic duct disruption with contrast leakage into a persistent pancreatic collection. Pancreatic duct stenting was performed, after which no further bleeding occurred. Conclusion: This case highlights transient cyst-duodenal fistulization as an underrecognized mechanism of intermittent UGIB in complicated pancreatitis and emphasizes that negative angiography does not exclude the pancreatic source of bleeding.
Introduction: Clasp-retained dentures are high-risk esophageal foreign bodies that carry a substantial risk of severe esophageal injury. Reliable protection strategies are therefore critical for safe endoscopic extraction. We present a case of successful endoscopic removal of a clasp-retained denture impacted at the aortic arch level using a retrievable silicone-covered esophageal stent as a protection device. Case Presentation: A 50-year-old man with hypertension and coronary stent implantation was admitted with retrosternal pain and dysphagia for 4 h after accidental ingestion of a broken denture. Computed tomography confirmed a 1.3 × 2.0 × 4.7 cm foreign body impacted at the aortic arch level. The foreign body was successfully removed under general anesthesia with tracheal intubation, and no intraoperative complications occurred. Postoperative recovery was uneventful. Telephone follow-up at 1 week, 1 month, and 3 months showed that the patient had a normal diet with no discomfort, and the patient declined endoscopic reexamination. Conclusion: This case confirms that a retrievable silicone-covered esophageal stent is a safe and feasible protection device for endoscopic extraction of high-risk dentures at the aortic arch level, with favorable short- and medium-term outcomes. It provides a valuable clinical reference for managing such life-threatening foreign bodies.
Introduction: A 68-year-old man with branch-duct intraductal papillary mucinous neoplasm (IPMN) in the pancreatic head presented with pancreatic ascites due to main duct rupture in the pancreatic body without typical pancreatitis symptoms. Case Presentation: Although the serum amylase level was elevated, the amylase level in the ascitic fluid was markedly higher. We hypothesize that mucin-induced downstream obstruction may have contributed to elevated intraductal pressure and upstream rupture. After conservative management, the patient developed delayed hemorrhage of approximately 4 months from the same site. Conclusion: Based on a PubMed literature search, this appears to be the first reported case of pancreatic ascites followed by delayed hemorrhage from the same site associated with branch-duct IPMN.
Introduction:Primary sclerosing cholangitis (PSC) is a progressive cholestatic liver disease that is often complicated by severe pruritus, which can profoundly impair quality of life. In select cases, intractable pruritus is an independent indication for liver transplantation (LT) even in the absence of advanced liver disease, recurrent cholangitis, or malignancy. Conventional pharmacological and endoscopic therapies frequently provide only partial or transient relief, highlighting the need for mechanism-based treatments. Case Presentation:We report the case of a 32-year-old man with long-standing PSC and Crohn's disease (CD) who developed severe treatment-refractory pruritus despite multiple conventional pharmacologic therapies and endoscopic biliary interventions. In the absence of advanced liver disease or malignancy, he underwent LT evaluation primarily due to debilitating pruritus significantly impairing quality of life, with secondary consideration given to medically and endoscopically challenging but manageable recurrent dominant common bile duct stricture and episodes of acute cholangitis. Upadacitinib, a selective Janus kinase 1 (JAK1) inhibitor, was initiated for a CD flare, after which pruritus completely resolved within 48-72 h. Maintenance therapy with upadacitinib 30 mg daily has sustained symptom-free status for over 27 months, markedly improving quality of life and allowing the patient to remain inactive on the liver transplant waitlist. Conclusion:This case demonstrates the rapid and durable resolution of PSC-associated pruritus with JAK1 inhibition. Effective symptom control allowed deferral of LT driven primarily by quality-of-life impairment, with the patient remaining inactive on the waitlist. To our knowledge, this is the first reported case of successful treatment of PSC-associated pruritus with upadacitinib, supporting further investigation of JAK1 inhibition as a potential therapeutic strategy for cholestatic pruritus.
Introduction: The seemingly harmless side effects of semaglutide, such as vomiting, may rarely lead to serious complications. This case is unique in highlighting spontaneous pneumomediastinum (SPM) as a potential consequence of unsupervised semaglutide use, adding new insight to the literature on the safety profile of weight-loss medications. Case Presentation: We report the case of a 26-year-old woman who developed SPM shortly after the self-administered use of semaglutide purchased online for weight loss. The patient presented with vomiting, chest and neck pain, and progressive facial swelling. Imaging revealed extensive pneumomediastinum and cervicothoracic emphysema. Oesophago-gastro-duodenoscopy was performed to rule out oesophageal perforation and showed no abnormalities. The patient was managed conservatively with spontaneous recovery. Conclusion: This case highlights the importance of distinguishing SPM from life-threatening conditions such as Boerhaave’s syndrome and raises concerns regarding the unsupervised use of injectable weight-loss medications, emphasizing the need for patient education and careful monitoring.
Introduction: Antiphospholipid syndrome (APS) is an acquired thrombophilia. Triple-positive APS, defined by lupus anticoagulant, anticardiolipin, and anti-β2-glycoprotein I antibody positivity, usually requires long-term vitamin K antagonist therapy; direct oral anticoagulants are discouraged, and low-molecular-weight heparin is reserved for selected situations. Case Presentation: A 52-year-old female with systemic lupus erythematosus and triple-positive APS on warfarin (International Normalized Ratio [INR] 2.9) presented with massive hematemesis requiring intubation. Serial esophagogastroduodenoscopy showed extensive esophageal clot burden followed by circumferential friability, sloughing, and necrotic/exudative esophagitis without varices or gastric/duodenal bleeding. Hemostatic powder was applied, fresh frozen plasma partially corrected the INR to 1.8, and anticoagulation was held. Therapeutic heparin bridging on hospital day 8 was followed by recurrent melena, hemoglobin decline from 8.3 to 5.5 g/dL, and gross hematuria; INR at rebleeding was 2.2. Hematology evaluation showed factor VIII activity 87% and negative Bethesda assay, arguing against acquired hemophilia A. Repeat endoscopy showed Los Angeles grade C esophagitis with clean-based linear ulcers and a 7-cm sliding hiatal hernia. Conclusion: Severe diffuse esophageal mucosal injury can cause recurrent major bleeding when anticoagulation is resumed before mucosal recovery. In high-risk APS, anticoagulation resumption should be individualized with hematology and gastroenterology input, and repeat endoscopy may help guide timing.
