Introduction: Hepatic artery thrombosis (HAT) is a serious complication after orthotopic liver transplantation (OLT) and is the most common vascular complication. It is often categorized into early HAT which is defined as occurring < 30 days after liver transplantation & late HAT defined as occurring > 30 days post transplantation. The etiology of HAT is often related to surgical factors, such as vessel kinking, anastomotic stenosis, and intimal dissection, but can factors such as hypercoagulability, elderly donors, and rejection episodes can contribute. Symptoms can often be vague with common complaints being abdominal pain, fever, nausea, & emesis. Case Description/Methods: A 68-year-old male with OLT (20 years prior to presentation) for primary sclerosing cholangitis (PSC), ulcerative colitis presented with 1 month history of nausea, emesis, and weakness. He was afebrile & hemodynamically stable. On physical exam, abdomen was soft, nontender, nondistended, and patient was jaundice. Laboratory data was notable for a two-month elevation of alkaline phosphatase, ALT, AST, direct bilirubin. An ultrasound of the liver with doppler evaluation was obtained that demonstrated an absence of flow in the left and right hepatic arteries within the liver. A computed tomography angiography (CTA) of the abdomen was obtained that confirmed these findings (Figure 1). Due to the history of PSC, a magnetic resonance cholangiopancreatography was obtained that showed no biliary dilation or evidence of recurrent PSC. A liver biopsy demonstrated paucicellular ductopenia with cholestasis consistent with chronic arterial insufficiency and no significant fibrosis. Transplant surgery and interventional radiology were consulted for potential recanalization. However, due to prolonged elevations in liver enzymes >4 weeks, both teams determined that recanalization would likely provide no benefit yet held greater risk. Discussion: This case highlights an uncommon, very late presentation of HAT. In the literature, late HAT has been described in the order of months, not years as it was in this case. It is usually associated with a less fulminant presentation and a milder course, in comparison to cases of HAT that present earlier in the post-transplant course. This case highlights the importance of considering HAT as a diagnosis in a patient with history of OLT who presents with abdominal pain, nausea, and emesis.Figure 1.: Focal filling defect in the hepatic artery seen in this venous phase CTA.

Introduction: Double pylorus is a rare condition that consists of a communicating channel between the gastric antrum and the duodenal bulb. Double pylorus can be a congenital condition, or more commonly, acquired as a sequelae of peptic ulcer disease (PUD). Estimates of the prevalence of double pylorus vary, ranging from 0.001-0.04% of upper endoscopies, and is often discovered incidentally on endoscopy performed for other indications. Case Description/Methods: Our patient is a 70-year-old woman with chronic obstructive pulmonary disease who presented to the hospital with epigastric pain. She reported taking ibuprofen over the counter. Abdominal examination was positive for epigastric tenderness. Lab tests showed hemoglobin of 6.3 g/dL with a prior baseline of ∼ 10 g/dL. She underwent esophagogastroduodenoscopy (EGD) showing 20mm gastric ulcer at the antrum with fistula formation into the duodenal bulb (Figure 1A and 1B). Two non-bleeding cratered duodenal ulcers without stigmata of bleeding were found in the duodenal bulb (Figure 1C). Gastric biopsies were taken and returned negative for Helicobacter pylori. The patient was discharged home and advised to avoid tobacco, alcohol, illicit drugs, and NSAIDs. She was also prescribed a proton pump inhibitor to be taken twice daily. She had a follow up EGD three months later showing scarring from healed ulceration in the gastric antrum and pre-pyloric region with closure of the fistula (Figure 1D and 1E). No residual ulcers were present. Discussion: Acquired double pylorus is associated with Helicobacter pylori infection as well as ingestion of NSAIDs. These exposures are known to predispose patients to development of gastric ulcers, which when penetrating, can result in fistula formation. Interestingly, chronic obstructive pulmonary disease (present in our patient) is also a recognized risk factor. Double pylorus does not have specific symptoms and can include epigastric pain, dyspepsia and upper GI bleeding. Many patients are diagnosed incidentally on EGD. Management of acquired double pylorus should focus on protecting the gastric mucosa to promote healing. Noxious stimuli such as NSAIDs should be avoided. Helicobacter pylori should be treated when indicated. In the majority of cases, treatment does not result in closure of the fistula. Most fistulas remain open and in some cases convergence of the fistula with the normal pyloric ring occurs. However, closure of the fistula with treatment is rare.Figure 1.: (A) Pre-pylori stomach with native pylorus denoted by left arrow and new fistula between gastric antrum and duodenal bulb denoted by right arrow. (B) Pre-pyloric stomach with fistula opening to the duodenum. (C) Small duodenal ulcers (yellow arrows) (D) Gastric Antrum (E) Pre-Pyloric stomach.

ABSTRACT We describe a patient who presented with hematemesis and was found to have unusually well-demarcated erythematous mucosa with a 2–3 cm irregular nonbleeding necrotic ulcer in the gastric body on esophagogastroduodenoscopy. Biopsy and pathologic examination of the tissue indicated infection with a rare bacterium, Sarcina ventriculi, prompting treatment with an unproven combination of 4 agents: metronidazole, ciprofloxacin, sucralfate, and pantoprazole. Repeat esophagogastroduodenoscopy 8 weeks later revealed complete resolution of the ulceration and surrounding erythema. These results may contribute toward establishing an appropriate therapeutic regimen for future S. ventriculi infections.

Introduction: Histoplasmosis capsulatum is a dimorphic fungus found throughout the world and in the United States is particularly endemic to the Ohio and Mississippi river valleys. It is often found in soil and associated with bat guano and bird droppings. Disseminated histoplasmosis infection is rare, but commonly associated with immunosuppressed states. However, disseminated histoplasmosis infection is particularly rare in patients who underwent orthotopic liver transplantation (OLT) and most commonly occurs within 1 to 2 years post transplantation. Case Description/Methods: A 63-year-old male with history of OLT (21 years prior to presentation) from hepatitis C virus cirrhosis presents with complaints of fevers, chills, fatigue, & abdominal distention for three months. On presentation he was febrile but hemodynamically stable. Physical exam was notable for abdominal distention and scleral icterus. Laboratory data was notable for elevated alanine aminotransferase (71 U/L), aspartate aminotransaminase (98 U/L), total bilirubin (6.2 mg/dL), and alkaline phosphatase (300 U/L). A magnetic resonance cholangiopancreatography was performed which demonstrated cirrhotic changes in the graft liver and a 4.4 cm right adrenal mass and 3 cm left adrenal mass. A biopsy of the adrenal mass showed fungal forms consistent with histoplasma species, background necrosis, and acute inflammation. A liver biopsy showed granulomatous hepatitis with fungal forms consistent with histoplasma species and advanced bridging fibrosis. Further imaging demonstrated bilateral ground glass opacities in the lungs but no abnormalities elsewhere. The patient was treated with amphotericin B and transitioned to itraconazole with 12 months of therapy planned with surveillance of urine histoplasma antigen levels. Discussion: In this case, we present a unique case of disseminated histoplasmosis with histoplasmosis hepatitis in a patient who underwent OLT greater than 20 years prior. While any immunosuppressed patient is at a higher risk of disseminated histoplasmosis, it remains relatively rare among patients who have undergone solid organ transplantation. This case highlights the need to remain vigilant against all opportunistic infections in the post-transplant patients at any time post transplantation and particularly those that are endemic to the patient’s area of residence.

Introduction: Cytomegalovirus (CMV) is a known cause of severe infection in immunocompromised hosts. When the gastrointestinal tract is involved, colitis and esophagitis are the two most common manifestations. However, any part of the gastrointestinal tract may be involved, including the small intestine. Case Description/Methods: We describe a case of 70-year-old woman who presented to the hospital with diffuse petechial rash and abdominal pain. A skin biopsy showed leukocytoclastic vasculitis requiring treatment with high doses of systemic corticosteroids. A CT showed thickening of the duodenum and jejunum that was treated with antibiotics. On hospital day 12, the patient developed six episodes of melena associated with hemodynamic instability. Her hemoglobin dropped from 10 mg/dL to 5.8 mg/dL. An esophagogastroduodenoscopy (EGD) with push enteroscopy was performed and showed a large circumferential ulcer (Figure 1A) in the proximal jejunum with an active bleeding vessel (Figure 1B). The ulcer was treated with a combination of epinephrine and hemospray. Over the next week, her bleeding had completely stopped and her rash improved as well. Hospital course was complicated by deep vein thrombosis and repeat endoscopic assessment was planned to weigh the risk and benefit of initiating anticoagulation. Repeat EGD with push enteroscopy re-demonstrated the previously identified circumferential jejunal ulcers. No active bleeding was identified and biopsies were taken. The pathology from the jejunum showed CMV enteritis with ulceration. Serologic testing for CMV polymerase chain reaction found a level of 7,033 IU/mL. Thus, the patient was ultimately diagnosed with CMV enteritis and CMV viremia. She was started on valganciclovir and demonstrated no further bleeding. Discussion: In summary, we present a rare case of CMV enteritis manifesting as gastrointestinal bleeding with no involvement of esophagus and colon that are traditionally associated with CMV infection. Diagnosis of CMV enteritis can be challenging, especially for patients in which CMV is not initially suspected.Figure 1.: Large circumferential jejunal ulcer (A) and actively bleeding vessel (B).

Introduction: Percutaneous endoscopic gastrostomy (PEG) tube placement is a common procedure to provide enteral nutrition to patients who are not candidates for oral intake and those needing gastric decompression. Pneumoperitoneum, the presence of air in the peritoneal cavity, is a well-recognized complication of PEG tube placement. We present a case herein of a patient with persistent and clinically significant pneumoperitoneum managed by paracentesis with air evacuation, a previously unreported intervention in this clinical setting. Case Description/Methods: Our patient is a 72-year-old man with relevant medical history of tongue cancer treated with chemoradiation. He developed dysphagia and progressive weight loss despite nutritional supplements necessitating PEG tube placement. On post-op day one, he developed worsening abdominal pain and distention. A computed tomography (CT) of the abdomen was obtained and showed an appropriately placed PEG tube in the gastric body as well as moderate size pneumoperitoneum (Figure 1). Six days after the PEG tube placement, the patient’s symptoms had still not improved with conservative management. Interventional radiology was consulted, and patient underwent aspiration of air from the peritoneal cavity. Following air evacuation, abdominal pain promptly resolved and tube feeds were advanced to goal rate. The patient was seen two months later in the outpatient clinic and was gaining weight with PEG tube feeding and denied abdominal symptoms. Discussion: Pneumoperitoneum after PEG tube placement is typically considered a benign and self-limited finding. The etiology is likely related to elevated intragastric air pressures from the endoscope and escape of air from the stomach following needle puncture. If patients are asymptomatic without any signs of peritonitis, no further intervention is necessary other than monitoring. In our case, the patient’s symptoms failed to improve with conservative management. Thus, the decision was made to proceed with paracentesis with air evacuation by interventional radiology, resulting in the resolution of both the pneumoperitoneum and the patient’s symptoms. A literature review using Pubmed, Cochrane, and Medline uncovered no other cases of pneumoperitoneum following PEG tube placement that were managed with air evacuation.Figure 1.: 1a.- Histopathology showing lipid laden histiocytes 1b.- Endoscopic image of gastric nodule.

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.

Introduction: Mantle Cell Lymphoma (MCL) is an uncommon form of non-Hodgkin Lymphoma with variable presentations. MCL is due to a translocation (11;14)(q13;q32) that results in an overexpression of cyclin D1, which plays a prominent role in the regulation of the cell cycle. MCL of the gastrointestinal tract typically only occurs with widespread disease. Case Description/Methods: We describe a case of 40-year-old man with no significant past medical history who presented for evaluation of chronic diarrhea for six months duration and a thirty pound weight loss. His physical exam was normal. A serologic and stool work-up showed erythrocyte sedimentation rate of 11 MM/HR (0-15 MM/HR), C-Reactive protein of 1.0 mg/dL ( < /= 0.5 mg/dL), and fecal calprotectin of 575 ug/g ( < /= 49 ug/g). Infectious work up was negative. The patient subsequently underwent a colonoscopy with biopsies. Notable endoscopic findings included: Inflammation, nodularity, and erythema of the distal terminal ileum, pan-colonic moderate colitis with mucosal erythema, cobblestoning, and erosions and ulcerations (Figure 1). These endoscopic findings were concerning for inflammatory bowel disease. However, pathology report surprisingly showed mantle cell lymphoma (Figure 1). He underwent a positron emission tomography scan which showed widespread systemic involvement with the most prominent area of gastrointestinal intensity being the rectosigmoid region of the colon. The patient was ultimately diagnosed with stage IVa MCL. Discussion: The estimated rate of involvement of the gastrointestinal tract in patients with MCL is in the range of 30%. Some presenting symptoms include abdominal pain, gastrointestinal bleeding and diarrhea, with many patients not experiencing any gastrointestinal symptoms. A review in 2010 by Iwamuro et al found that the most common endoscopic manifestation in the colon was multiple lymphomatous polyposis followed by the appearance of protruded tumors or lesions (1). In summary, our case represents a very unusual endoscopic manifestation of MCL that was initially thought to be inflammatory bowel disease.Figure 1.: CT abdomen/pelvis done on presentation demonstrated a large left-sided hernia with sigmoid colon in the hernia without otherwise any evidence of stranding, inflammation or obstruction. The right side was also noted to have a large hernia with what appeared to be the cecum and appendix in the hernia sac with stranding and some pericolonic fluid collection.

Introduction: Intestinal spirochetosis, caused by gram-negative, motile spirochetes Brachyspira aalborgi and Brachyspira pilosicoli, is rare in developed countries. Reported cases of spirochetosis are predominantly in children and adults with HIV or men who have sex with men. We present a case of asymptomatic intestinal spirochetosis in an adult with chronic hepatitis C (HCV). Case description/methods: A 66-year-old male with history of hypertension, inflammatory arthritis, compensated cirrhosis secondary to HCV, and colonic polyps presented for surveillance colonoscopy. He denied abdominal pain, diarrhea, or weight loss. He was HIV-negative and sexually active with one female partner. He had just completed a 12-week course treatment for HCV with Sofosbuvir/Velpatasvir and achieved sustained virologic response. Colonoscopy showed three 5-9 mm sessile polyps in cecum, one 4 mm sessile polyp in transverse colon (TC), and also one 2 mm white nodule in ascending colon (AC). The AC nodule and TC polyp biopsies showed a blurred “fuzzy” pale basophilic appearance along the surface epithelium, characteristic for spirochetosis. The same “fuzzy” surface was present on the tubular adenoma in the cecal polyps. Warthin-Starry stain revealed dense dark staining covering the surface epithelium and highlighting the spirochetes, confirming the hematoxylin and eosin (H&E) impression of spirochetosis. Patient was diagnosed with asymptomatic intestinal spirochetosis and referred to infectious diseases. Discussion: This case presents a rare incidental finding of intestinal spirochetosis. Most adults, like our patient, are asymptomatic. Children and severely immunocompromised adults are more likely to have symptoms, which manifest as abdominal pain, diarrhea, and rectal bleeding. Diagnosis is challenging due to the lack of hallmark symptoms and nonspecific labs and endoscopic appearance. Intestinal spirochetosis is a histologic diagnosis, as colonoscopy commonly shows normal mucosa. Histologically, spirochetes coat the surface of colonic epithelium without eliciting mucosal injury or inflammation. Most cases are initially identified by routine H&E stain and confirmed with Warthin-Starry or Steiner silver stain. Our patient was asymptomatic and therefore did not require treatment. Symptomatic or immunocompromised patients may warrant treatment with Metronidazole or Clarithromycin, which in some cases lead to clinical improvement.Figure 1.: Endoscopic appearance of one 2 mm white nodule in the ascending colon.

Menetrier’s disease (MD) is a rare disease characterized macroscopically by gastric rugae thickening and microscopically by foveolar hyperplasia with glandular atrophy, resulting in luminal protein loss. Different treatment strategies, including antibiotics, prednisone, octreotide, and monoclonal antibodies, have yielded varying degrees of success. Here, we present a rare complication of MD with a gastric outlet obstruction from a large adenoma. However, prior to this complication, dramatic clinical and laboratory improvements were observed after 12 months of treatment with subcutaneous octreotide. We also present a review of the literature for the role of octreotide in the treatment of MD.

Background: Unnecessary laboratory tests contribute to the financial burden placed on hospitals, patients, insurers, and taxpayers. In our institution, we noted acute viral hepatitis serologic testing in patients with chronic liver disease, sometimes done repetitively, in the absence of substantially elevated aminotransferase levels. The goal of this study was to determine the frequency of unnecessary testing for acute hepatitis A and B infections and then reduce testing rates by implementing an intervention in the electronic health record. Methods: In a 2-year period, 2 successive interventions questioning the appropriateness of ordering viral hepatitis serology based on transaminase elevation and prior serology results were implemented in the electronic health record system at Saint Louis University Hospital. The first intervention allowed providers to override the warning without providing a reason; the second intervention required justification to proceed with the order. Preintervention and postintervention appropriate and inappropriate testing proportions were compared using Fisher exact test. Results: The electronic reminders resulted in a statistically significant reduction of inappropriate testing rates; however, testing rates remained high whether the provider had to justify overriding the automatic alert or not. Conclusion: Our research demonstrated that the rates of inappropriate testing for acute viral hepatitis at our institution were unnecessarily high and showed that a simple intervention in the medical record system may be useful in reducing inappropriate testing. Our interventions were feasible and implemented at minimal cost. Similar interventions could be used to target other unnecessary tests, but education and additional interventions will likely be required to reduce unnecessary testing further.

BACKGROUND:Immunosuppressed women with inflammatory bowel disease (IBD) are at elevated risk of cervical cancer yet have lower screening rates. The objective of this study was to assess the familiarity with cervical cancer screening recommendations, and the perceived responsibility for implementing screening among three physician groups involved in the clinical care of women with IBD: primary care physicians (PCP), gastroenterologists (GI) and gynecologists (GYN).METHODS:We anonymously surveyed a sample of 117 PCP, 52 GYN and 35 GI physicians affiliated with Saint Louis University, Saint Louis, MO, USA, from April 2018 to January 2019. The physicians completed a questionnaire adressing essential aspects of cervical cancer screening such as screening age, screening frequency, human papillomavirus (HPV) vaccination, comfort level in performing Papanicolaou (Pap) smears, perception of physician responsibility in terms of which physicians should perform Pap smears.RESULTS:A total of 2.6% of PCPs, 37% of GIs and 29% of GYNs reported familiarity with cervical cancer screening recommendations. In addition, PCP and GI had no definite opinions regarding which physicians should be in charge of cervical cancer screening and performing Pap smears. However, 94% of GYNs felt that they should be in charge of cervical cancer screening and performing Pap smears.CONCLUSIONS:An apparent lack of familiarity exists among all three physician groups regarding cervical cancer screening recommendations in immunosuppressed patients with IBD. Similarly, there is no consensus regarding which specialty should be responsible for cervical cancer screening in this patient population.

INTRODUCTION: Intrahepatic cholangiocarcinoma is an uncommon hepatic malignancy and accounts for 3% of all gastrointestinal malignancies. Patients with this disease have a poor prognosis, with an average 5-year survival rate of 5 to 10%. Herein we describe a case of BRAF-related cholangiocarcinoma. CASE DESCRIPTION/METHODS: A 26 year-old female presented with right-upper quadrant pain and worsening nausea, vomiting for four months. On exam the abdomen was soft, non-tender and non-distended. A right upper quadrant ultra sound revealed a 7 cm mass in the inferior right hepatic lobe and ensuing magnetic resonance imaging of the liver should an 8 cm lesion with numerous satellite lesions. She underwent laparoscopic wedge excision of the liver mass which revealed poorly differentiated adenocarcinoma with features concerning for cholangiocarcinoma (See Images). PET revealed also portal hepatic lymph node metastasis, and metastatic lytic lesions at the clavicle and scapula. CEA and AFP were elevated. Comprehensive genetic analysis with next generation sequencing genomic panel was performed on her initial biopsy and confirmed BRAF V600E mutation. She was initiated on a phase II trial with trametinib and dabrafenib at a referral center. Despite this, repeat CT imaging revealed she had progression of metastatic cholangiocarcinoma. She was switched to FOLFIRI and vemurafineb. However, the patient developed worsening abdominal distension, hyperbilirubinemia and pancytopenia. At that point, the family elected for hospice care whereupon after a few weeks, the patient expired at home. DISCUSSION: Currently the only curative therapy is surgical resection or transplant. However there has been research in molecular targeted therapies to treat BRAF cholangiocarcinoma with optimal response. BRAF V600 mutation results in activation of down-stream signaling though MAPK pathway and can contribute to malignancies such as melanoma, hairy cell leukemia, or non-small cell lung cancer. The frequency of BRAF V600E mutation has been reported to be 0-22% in intrahepatic cholangiocarcinoma. Inhibitors of BRAF V600 kinase such as vemurafenib and dabrafenib can be used to target these aberrations. Although this patient failed treatment with molecular targeting, precision medicine may change the trajectory in management of intrahepatic cholangiocarcinoma. The implementation of these therapies will require multi-team and institutional collaborations and will positively impact these patients.

Percutaneous endoscopic gastrostomy (PEG) tubes have emerged as the standard of care for long-term enteral feeding. This procedure is relatively safe; however, complications do occur, and one of the most dreaded complications is trauma to the surrounding organs. Hepatic injury during PEG placement is an extremely rare complication of the PEG procedure, with a handful of cases described in the medical literature. We describe the case of an accidental trans-hepatic placement of a PEG tube in a 78-year-old morbidly obese female, even with excellent trans-illumination and manual external pressure achieved during endoscopic placement. Post-procedure, cross-sectional imaging of the abdomen showed a gastrostomy tube traversing the lateral margin of the liver with adjacent small hematoma. Physical exam was unremarkable for abdominal tenderness or guarding/rigidity, and no blood or drainage was noted at the site of PEG insertion. Enteral nutrition was started after 24 h of PEG tube insertion and patient tolerated well with no complications. The patient was discharged to a nursing home but unfortunately died the following week to an unknown cause.

Despite being the largest part of the human gastrointestinal (GI) tract, the small intestine accounts for only 1–1.4% of all GI malignancies. Adenocarcinoma is the most common primary small bowel malignancy, with the most common site being the duodenum. On the other hand, squamous cell carcinoma (SCC) of the duodenum is extremely uncommon. We report the first case of mixed adenocarcinoma and SCC occurring in the third part of duodenum (D3). Our patient, a 64-year-old female with history of GERD, hypertension, and IDDM presented with 4 weeks of nausea, vomiting, and abdominal pain. Tomographic imaging of her abdomen demonstrated a distended stomach and a proximal duodenum with narrow caliber changes at the level of D3. An EGD revealed a tight stricture at D3 that could not be traversed. Stricture biopsies revealed duodenal mucosa with two small foci of SCC (positive for p63 and CK5/6) and adenocarcinoma (positive for CK7 and Moc31). Peritoneal metastases were detected on exploratory laparotomy, making the tumor surgically incurable. As she progressively declined and with worsening liver enzymes and general debility, she was not a candidate for chemotherapy and was eventually discharged on home hospice. Small bowel SCC/adenocarcinoma is an exceedingly uncommon cancer, making further case reports such as ours important to understand the nature of this entity and establish management guidelines.

With the alarming rise in prevalence of nonalcoholic fatty liver disease (NAFLD) in the world, there is an increasing need to recognize the strong association between NAFLD and cardiovascular disease (CVD).NAFLD is dynamically involved in the pathogenesis of CVD through the processes that include increased oxidative stress, endothelial dysfunction, accelerated progression of atherosclerosis, and irregular fatty acid, glucose, and lipoprotein metabolism.By reviewing and understanding the mechanisms, the aim of this review is to introduce the association between NAFLD and CVD to health care providers and the importance of statin therapy and mortality benefits.More importantly, we discuss the role of statins as a treatment strategy and possible future directions.

Pyogenic liver abscesses (PLA) develop from the spread of infection through the portal circulation, biliary infections or arterial hematogenous seeding in the setting of systemic infections. PLA are often poly-microbial and are uncommonly reported to be due to anaerobic species. We report the case of a previously healthy, immunocompetent 63-year-old man with hepatic abscesses as a result of Fusobacterium nucleatum periodontal disease. In addition, a systemic review of the literature is performed. Fusobacterium is a very rare cause of PLA in immunocompetent hosts with only a handful of cases reported in the literature. Although anaerobic infections such as Fusobacterium most often occur in immunocompromised individuals, clinicians should have a high index of suspicion in immunocompetent patients with periodontal disease or chronic stomatitis.

Eluxadoline has emerged as an effective treatment option for patients with diarrhea- predominant irritable bowel syndrome (IBS-D). It was approved by the Food and Drug Administration (FDA) in May 2015 for treatment of IBS-D. It is a p-opioid receptor agonist and 6-receptor antagonist that acts locally in the gastrointestinal (GI) tract. In recently published phase IlIl IBS-3001 and IBS- 3002 trials, eight patients experienced abdominal pain due to sphincter of Oddi dysfunction (SOD), and one patient had acute pancreatitis, thought to be related to eluxadoline. Here, we describe a patient with eluxadoline- induced pancreatitis, the first case we know of to be reported outside of phase Ill clinical trials. Interestingly, only patients with prior cholecystectomy developed SOD and acute pancreatitis in the IBS 3001/3002 trials which also stands true with our patient. The enthusiasm with the efficacy of this drug should not have clinicians disregard the potential adverse effects, particularly serious ones, such as acute pancreatitis. We expect more cases of eluxadoline-induced pancreatitis and SOD to be reported, and future studies should focus on better understanding this association so as to guide treatment recommendations.