Sickle cell hepatopathy is an uncommon but severe cause of liver dysfunction after transplantation. We present a case of a 37-year-old man who developed recurrent sickle cell hepatopathy 12 months postliver transplant despite maintaining hemoglobin S (HbS) levels below 30% per American Society of Hematology recommendations. Liver biopsy demonstrated sinusoidal sickling without rejection. Liver tests improved after intensifying red cell exchange to achieve HbS below 20%. This case illustrates that standard posttransplant HbS targets may be insufficient in high-risk patients and highlights the need for individualized HbS goals.
Clinical guidelines recommend the use of histopathology and segment length to risk stratify patients with Barrett's esophagus (BE), the only known precursor of esophageal adenocarcinoma (EAC). However, these clinicopathologic factors have limited ability to accurately identify patients with nondysplastic BE (NDBE) who may be at high risk of progression. The tissue systems pathology-9 (TSP-9) test (TissueCypher) is clinically validated to predict the risk of progression of BE to high-grade dysplasia (HGD) or EAC within 5 years. This case report highlights the clinical utility of TSP-9 test to identify high-risk patients with NDBE and inform shared decision making to prevent progression to HGD/EAC.
Pseudoaneurysm formation is a rare but potentially fatal complication of necrotizing pancreatitis due to the risk of rupture. We report a 28-year-old man with walled-off pancreatic necrosis who developed catastrophic hemorrhage from a ruptured pseudoaneurysm during endoscopic ultrasound-guided necrosectomy, resulting in intraprocedural cardiac arrest. The patient required immediate cardiopulmonary resuscitation and emergent angiography, which identified the bleeding source and achieved hemostasis via coil embolization. He survived following prompt multidisciplinary intervention. This case highlights the unpredictable nature of vascular complications in necrotizing pancreatitis and the critical role of rapid multidisciplinary response in managing life-threatening hemorrhage.
Colonic perineuriomas (PNs), also known as fibroblastic polyps, are rare benign mesenchymal lesions. They are typically found in the distal colon, particularly in the rectosigmoid region. These lesions are usually asymptomatic and incidentally detected during routine screening colonoscopy. We present a 44-year-old woman with long-standing lower abdominal pain and constipation. Colonoscopy revealed a large (5 cm), multilobulated polyp, diagnosed as a colonic PN based on histopathologic and immunohistochemical findings.
Celiac disease is an immune-mediated enteropathy precipitated by gluten in genetically susceptible individuals. Although diarrhea, weight loss, and malabsorption are classical features, extraintestinal presentations are increasingly recognized. Pancytopenia as the initial manifestation of adult celiac disease is rare and often delays diagnosis. We report a 39-year-old woman from Assam, Northeast India, who presented with chronic diarrhea, weight loss, and progressive weakness, and was found to have severe pancytopenia (hemoglobin 3.9 g/dL, leukocytes 1,200/mm3, and platelets 23,000/mm3). Iron studies suggested iron deficiency. Despite a normal serum vitamin B12 level (874 pg/mL), markedly elevated methylmalonic acid (1,600 nmol/L) and homocysteine (56.8 μmol/L) confirmed functional B12 deficiency. Anti-tissue transglutaminase immunoglobulin A was equivocal, but duodenal biopsy demonstrated partial villous atrophy, crypt hyperplasia, and increased intraepithelial lymphocytes (Marsh 3A). Peripheral blood flow cytometry was notable for lymphopenia with elevated T-cell receptor αβ+ double-negative T cells (2.59%), a finding of immunological interest. A gluten-free diet with iron, folate, and parenteral B12 supplementation produced rapid clinical and hematological recovery within 3 weeks. At 3-week follow-up, all 3 lineages had improved (hemoglobin 10.4 g/dL, total leukocyte count 3,800/mm3, and platelets 170,000/mm3 by manual count; the platelet count had normalized while hemoglobin and leukocytes were improving but not yet fully normalized). This case underscores celiac disease as a reversible cause of unexplained pancytopenia, highlights the limitations of serum B12 and serology in equivocal presentations, and adds to the limited literature on celiac disease from Northeast India-a region where the condition remains substantially underdiagnosed.
Perihepatic teratomas are exceedingly rare extragonadal germ cell tumors that may mimic more common hepatic cystic lesions on imaging. We report a 38-year-old woman with several months of abdominal bloating and early satiety. Laboratory studies and tumor markers (α-fetoprotein and carcinoembryonic antigen) were unremarkable. Magnetic resonance imaging demonstrated a 17.7 cm complex cystic lesion adjacent to the left hepatic lobe with fatty components and a mural nodule. Elective laparotomy revealed a well-encapsulated mass arising from the lesser omentum, excised intact. Histopathology confirmed a mature cystic teratoma with elements from all 3 germ layers. The postoperative course was uneventful.
A previously healthy 29-year-old man presented with abdominal pain and was found to have a liver mass with periductal infiltration and a stricture of the common bile duct, concerning for cholangiocarcinoma. Hepatic function panel disclosed alanine transaminase 293 U/L, aspartate aminotransferase 122 U/L, γ-glutamyl transferase 2019 U/L, normal total bilirubin, carcinoembryonic antigen, and carbohydrate antigen 19-9. Biopsy established the diagnosis of diffuse large B-cell lymphoma, with no underlying hepatic disease. He was started on polatuzumab-rituximab-cyclophosphamide-doxorubicin-prednisone chemotherapy and achieved complete tumor response. This case highlights the importance of a thorough evaluation of liver tumors and the critical role of tissue diagnosis.
A woman in her early 40s with MLH1-deficient Lynch syndrome was incidentally found to have a cecal gut-associated lymphoid tissue (GALT)/dome carcinoma during routine surveillance colonoscopy. This case highlights the co-occurrence of 2 rare entities: a germline MLH1 pathogenic variant and a GALT/dome carcinoma, now recognized within the lymphoglandular complex-like carcinoma spectrum, which carries potential for nodal metastasis. The intersection of mismatch repair deficiency and GALT/dome carcinoma raises a management dilemma: prophylactic colectomy vs endoscopic surveillance in the absence of high-risk histologic features. We review the literature to guide management in this rare scenario.
A 31-year-old woman with mullerian agenesis and a neovagina derived from the sigmoid colon presented with bleeding per vaginum along with luminal gastrointestinal symptoms. Diagnostic evaluation revealed ulcerative colitis (UC) involving the native colon and neo vagina. Both her gastrointestinal and vaginal symptoms responded very well to conventional UC treatment. This case highlights a rare complication of UC in patients with Mullerian agenesis who have undergone sigmoid colon vaginoplasty. The association between UC and neovaginal bleeding underscores the need for careful monitoring and early intervention in such complex cases to prevent further morbidity and improve patient outcomes.
Inflammatory bowel disease (IBD) mimics pose a significant diagnostic challenge, particularly in patients with atypical features or refractory disease. Intestinal lymphomas, especially extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (MALT) lymphoma, can closely resemble Crohn's disease clinically, endoscopically, and histologically. We report a 23-year-old woman with a 2-year history of chronic, large-volume diarrhea, weight loss, and malabsorption, initially diagnosed and treated as Crohn's disease. Despite corticosteroids, azathioprine, and biologic therapy, she demonstrated only a partial response. Further evaluation revealed hypoalbuminemia, elevated inflammatory markers, and monoclonal gammopathy on serum protein electrophoresis. Endoscopic and radiological findings showed ileal and jejunal involvement. Histopathological examination demonstrated a dense lymphoplasmacytic infiltrate, and immunohistochemistry revealed CD20 and CD138 positivity with light chain restriction. A final diagnosis of small intestinal extranodal marginal zone lymphoma was established. The patient was treated with combined chemotherapy, with plans to escalate to rituximab-based therapy due to a suboptimal response. This case highlights the importance of reconsidering the diagnosis in patients with presumed IBD who exhibit atypical features, such as severe malabsorption, proximal small bowel involvement, monoclonal gammopathy, or refractory disease. Early recognition of IBD mimics, particularly intestinal lymphomas, is critical to ensure appropriate management and improve outcomes.
Granulomatous cheilitis, a localized subset of orofacial granulomatosis, can rarely be the presenting symptom of Crohn's disease. It can appear before any gastrointestinal (GI) symptoms develop. Orofacial granulomatosis has been associated with more widespread granulomatous Crohn's disease, which tends to be more aggressive. We present a case of isolated granulomatous cheilitis progressing to diffuse granulomatous involvement of multiple portions of the upper and lower GI tract with eventual secondary loss of response to initial anti-tumor necrosis factor-α therapy, underscoring the need for these patients to be monitored very closely even in the absence of GI symptoms.
Gastrointestinal stromal tumors (GISTs) are rare, potentially malignant mesenchymal neoplasms that can arise anywhere within the gastrointestinal tract or abdominal cavity. We present a case of an incidentally discovered duodenal subepithelial lesion that was initially endoscopically sampled using bite-on-bite biopsy technique and misdiagnosed as a benign hemangioma. Following multidisciplinary review, the patient underwent endoscopic ultrasound with fine-needle aspiration and fine-needle biopsy, which ultimately confirmed the diagnosis of GIST. This case highlights the limitations of the bite-on-bite technique for diagnosing subepithelial lesions and underscores the importance of multidisciplinary evaluation when managing potentially high-risk subepithelial lesions.
Social media has rapidly transformed communication, education, and professional networking within graduate medical education. Increasingly, residency and fellowship applicants rely on social media platforms to evaluate training programs, particularly to gain insights into program culture, trainee experiences, and educational environments that may not be easily conveyed through traditional program websites. The COVID-19 pandemic further accelerated the adoption of social media by both applicants and training programs, highlighting its growing role in recruitment and outreach. Gastroenterology fellowship programs are uniquely positioned to leverage these platforms given the visual and procedural nature of the specialty, which lends itself to digital content such as endoscopy demonstrations, educational discussions, and conference highlights. This editorial argues that gastroenterology fellowship programs should move beyond passive or reactive social media use toward a structured, intentional strategy, one built around 4 core pillars: recruitment transparency, educational dissemination, cultural representation, and inclusive outreach. We outline practical considerations including platform selection, content governance, and professionalism standards, while also acknowledging the risks of misrepresentation and inequity that programs must actively work to mitigate.
We describe the case of a 71-year-old man with hepatitis C virus/alcohol-associated cirrhosis and a liver mass consistent with hepatocellular carcinoma (HCC) who experienced tumor regression after the initiation of direct acting antivirals and undergoing an emergent transjugular intrahepatic portosystemic shunt placement for variceal bleeding. Repeat imaging showed nonviable HCC despite no locoregional therapy, and liver explant pathology revealed <5% residual tumor. This is a rare instance of HCC regression potentially linked to viral eradication and portal pressure reduction. Understanding how direct acting antiviral therapy and transjugular intrahepatic portosystemic shunt influence tumor biology may offer insights into HCC management in decompensated cirrhosis.
Evidence for upadacitinib in ulcerative colitis (UC) after tofacitinib failure is limited, with unclear long-term outcomes. A single-centre retrospective case series at a Canadian tertiary hospital included adult UC patients who lost response to tofacitinib and were subsequently treated with upadacitinib (January 2016 to March 2024). Nine patients, who failed a median of four therapies, received upadacitinib. Eight completed induction, and four archived steroid-free clinical remission during maintenance, supported by endoscopic and histologic improvement. Durable remission beyond one year was observed in these four patients, suggesting that upadacitinib may be effective in a subset of patients after tofacitinib failure.
We present a case report of severe gastritis and colitis in the context of recent zolbetuximab administration in a patient receiving combination chemotherapy for metastatic gastric adenocarcinoma. This case highlights the potential gastrointestinal toxicity associated with zolbetuximab, particularly in patients with previous mucosal injury from chemotherapy and tumor involvement.
Acute mesenteric ischemia remains one of the most lethal abdominal emergencies, particularly when bowel necrosis has already occurred at the time of diagnosis. Embolic occlusion of the superior mesenteric artery is most commonly associated with atrial fibrillation. Although hyperthyroidism is a recognized trigger for atrial fibrillation, widespread systemic arterial embolization in this setting is rarely reported. We describe a 77-year-old woman with biochemical thyrotoxicosis and new-onset atrial fibrillation who developed simultaneous superior mesenteric and peripheral arterial occlusions, resulting in near-total small bowel necrosis that was not surgically survivable. Her rapid clinical deterioration underscores the aggressive nature of embolic mesenteric ischemia and the narrow window available for intervention.
Pancreatic involvement in paraesophageal hernias is rare and can precipitate acute pancreatitis through mechanical compression or ischemia. We report an 82-year-old woman who presented with epigastric pain and an elevated lipase level. Imaging demonstrated a large type IV paraesophageal hernia containing the stomach, transverse colon, and pancreatic body and tail, with inflammatory changes localized to the pancreatic tail. Common causes of pancreatitis were excluded. The patient improved with conservative management and was referred for elective hernia repair after resolution of pancreatitis. This case highlights an uncommon mechanical cause of acute pancreatitis and the importance of anatomic evaluation in atypical presentations.
