BACKGROUND:Tracheo and broncho esophageal fistulas and their potential complications in adults are seldom encountered in clinical practice but carries a significant morbidity and mortality.CASE SUMMARY:We present a case of a 39-year-old otherwise healthy man who presented to our hospital after ingestion of drain cleaner substance during a suicidal attempt. He unexpectedly suffered from cardiac arrest during his stay in the intensive care unit. The patient had developed extensive segmental trachea-broncho-esophageal fistulous tracks that led to a sudden and significant aspiration event of gastric and duodenal contents with subsequent cardiopulmonary arrest. Endoscopic evaluation of extension of fistulous track proved a slow and delayed progression of disease despite initial management with esophageal stenting for his caustic injury.CONCLUSION:The aim of this case presentation is to share with the reader the dire natural history of trachea-broncho-esophageal fistulas and its delayed progression. We aim to illustrate pitfalls in the endoscopic examination and provide further awareness on critical care monitoring and management strategies to reduce its morbidity and mortality.

Introduction: Amyloid light-chain (AL) amyloidosis is the most common form of amyloidosis and is the main type to involve the gastrointestinal tract. Monoclonal Gammopathy of Undetermined Significance (MGUS) is a Plasma Cell Dyscrasia (PCD) with potential to precipitate amyloidosis. Our patient presented with a constellation of signs and symptoms that lead to his diagnosis. Case Description/Methods: A 59-year-old man with a history of Hemoglobin S-C presented with recurrent admissions to our hospital for new-onset orthostasis, weight loss, and dyspnea progressing over a 9 month period. Physical exam was unimpressive at the first presentation. Labs were significant for a NT-Pro BNP of 17,100 pg/ml. Echocardiography and cardiac MRI showed a restrictive filling pattern with preserved ejection fraction, however a specific etiology was not identified. Serum immunofixation revealed monoclonal IgA light chain proliferation. Bone marrow biopsy confirmed MGUS. The patient later developed epigastric pain with associated chronic watery diarrhea, peripheral edema, and hypoalbuminemia. A CT demonstrated colonic wall thickening with trace abdominal ascites. Enteroscopy revealed severe inflammation of the duodenum and jejunum characterized by edema, friability, scalloping, and diffuse petechiae. Colonoscopy showed similar but patchy involvement throughout. Histology was initially inconclusive. However, our suspicion remained high so slides were sent to a GI specialty lab. Pathology ultimately demonstrated immunoglobulin light chain lambda amyloidosis. He developed nephrosis as well. A work-up for autoimmune, infectious, and malignant causes was negative. The patient was ultimately transferred to a nearby hospital with specialty care services. (Figure) Discussion: AL amyloidosis develops as a result of monoclonal light chain deposition in various tissues. The cardiac and renal systems are most commonly involved. The main causes include PCDs and autoimmune illnesses. The diagnosis is often delayed. It should be suspected in a patient who presents with restrictive cardiomyopathy or otherwise unexplained heart failure. Our patient’s illness manifested as restrictive cardiomyopathy and likely protein losing enteropathy. MGUS can precede amyloidosis by about 12 years so this was an important finding. Initial GI biopsies were inconclusive but ultimately cinched the diagnosis, highlighting the importance of remaining skeptical. Treatment is aimed at the underlying cause.Figure 1.: Endoscopy Images.

Introduction: Multicentric tumors are more common in genetically-linked cancers. In most instances, tumor occurrence in a different location is due to recurrence of the malignancy. Our case illustrates a rare endoscopic finding of 3 distinct and synchronous adenocarcinomas of the rectum, sigmoid colon, and cecum in an otherwise healthy elderly female at an average risk for colorectal cancer. Case Description/Methods: An 81-year-old female with no medical history presented to the hospital with constipation and diffuse intermittent abdominal pain for 4 months. She had been self-medicating at home with over-the-counter laxatives but recently reported that she was not experiencing relief. She denied any prior endoscopy or family history of colorectal cancer. On admission, her vital signs were normal and her physical exam was significant for diffuse abdominal tenderness to palpation. Digital rectal examination revealed a non-tender, hard mass in the left lateral wall of the rectum. Her complete blood count and comprehensive metabolic panels were normal. Iron studies were also unremarkable. A computed tomography (CT) scan of the abdomen and pelvis showed thickening in the sigmoid colon and the rectum with scattered subcentimeter lymph nodes. On colonoscopy, she was found to have 3 partially-obstructing, malignant-appearing lesions located in the rectum, proximal sigmoid, and cecum. Biopsies of all 3 sites revealed adenocarcinoma. Immunohistochemistry for DNA mismatch repair proteins (MMR) showed intact MLH1, MSH2, MSH6, PMS2 genes. She underwent a laparoscopic total colectomy with end ileostomy, with pathological staging revealing pT3 N0 for the sigmoid tumor and pT4a N2b for the cecal tumor. She was planned for neoadjuvant chemoradiation therapy in anticipation for future robotic proctectomy for treatment of the rectal tumor (Figure 1). Discussion: Synchronous colorectal cancers pose a distinct challenge in terms of management and treatment. The extent of surgical resection and the use of chemoradiation depends on the location, number of lesions, and lymph node involvement. Our patient was an interesting case as she presented later in life and her only symptom was constipation. She was an average risk patient, had otherwise normal labs, and HNPCC/lynch syndrome-related cancers were excluded on the basis of normal immunohistochemistry testing.Figure 1.: Partially-obstructing malignant lesions in the (A) rectum, (B) proximal sigmoid, and (C) cecum.

A 36-year-old woman presented with a 3-month history of recurrent substernal chest pain, which acutely worsened 2 days prior to presentation. Her initial troponin I was mildly elevated and ECG showed subtle changes initially concerning for ischaemia; however, these were present on her prior ECG and were not considered an acute change. Because of her age and lack of significant risk factors, she was considered low risk for cardiac disease and initially treated conservatively for a non-ST elevation myocardial infarction. Due to persistent symptoms and dynamic changes on ECG concerning for ischaemia, she was immediately taken for a cardiac catheterisation and was found to have critical left main coronary artery dissection with a focal stenotic lesion. She had an extensive workup to identify the underlying cause of her coronary artery dissection which was unrevealing. She underwent an uncomplicated coronary artery bypass graft surgery and was discharged home in stable condition.

Butt, Ifrah; Dave, Kairavee; Rindy, Lucas; Concepcion, Livasky; Heller, Daniel; Kaplan, Steven; Kasmin, Franklin; Rivas, John Author Information

Butt, Ifrah; Shaikh, Umair; Fernandez, Marlena; Shaharyar, Sameer; Heller, Daniel Author Information

Liver abscesses have a low incidence and can be caused by multiple etiologies. We present an interesting case of a 74-year-old woman who presented with abdominal pain and leukocytosis. Imaging revealed a foreign body in the antrum of the stomach extending to an area of hypodensity in the liver. She was taken for an exploratory laparotomy and was found to have a gastric perforation due to a sewing needle. The needle had embedded in the liver causing the formation of an abscess. The patient was successfully treated with surgical management and a course of antibiotics.

Gastroesophageal reflux disease (GERD) is a common disorder of the gastrointestinal tract that involves the movement of stomach contents into the esophagus or mouth, causing discomfort or complications. Population-based studies have identified GERD as one of the most common upper gastrointestinal (GI) tract disorders, with a prevalence of about 20% in the United States. Patients may present with typical symptoms, including heartburn or regurgitation, or atypical symptoms such as cough, asthma, hoarseness, chronic laryngitis, throat-clearing, chest pain, dyspepsia, and nausea. Typically, GERD is diagnosed clinically and with the response to a trial of proton-pump inhibitor (PPI) therapy. Relief of heartburn and regurgitation after a 6 to 8 week trial of PPI therapy is a reliable indicator of GERD. This approach has a sensitivity of 78% and a specificity of 54%; hence a negative trial does not rule-out GERD. However, this is a cost-effective approach to diagnosing GERD rather than proceeding directly to endoscopic or alternative diagnostic testing. If patients present with alarm features (i.e., new-onset dyspepsia at age greater than 60, GI bleeding, dysphagia, odynophagia, weight loss, anemia, persistent vomiting), a trial of PPI therapy is not necessary and the work-up should directly proceed to early endoscopy.Ambulatory esophageal pH testing is done with a wireless pH capsule or a traditional pH probe and is the gold standard test for the diagnosis of GERD. There are some patients with typical or atypical GERD symptoms that have a normal upper endoscopy and normal ambulatory esophageal pH testing but are unresponsive to standard PPI therapy. Ambulatory pH testing does not detect all types of reflux, especially when the refluxate contains little or no acid. It relies on the acidification of intraesophageal pH to less than 4 as a marker for the presence of gastric contents in the esophagus to diagnose gastroesophageal reflux (GER) episodes. Hence, it has limited use in detecting episodes where the pH fails to fall below 4.A newer technique combining multichannel intraluminal impedance (MII) testing with pH testing, allows for the detailed characterization of the refluxate, including its physical and chemical properties. The MII detects the intraluminal bolus movement with the esophagus via strategic placement of a catheter, and it can characterize, in combination with pH testing, whether the bolus is composed of liquid, gas, or mixed components as well as its pH.

Wernicke’s Encephalopathy (WE) is a neurological condition characterized by ophthalmoplegia, ataxic gait, and altered mental status. It is an underdiagnosed yet severely limiting disease process precipitated by thiamine deficiency. Often times, it can occur in conjunction with other disease states like refeeding syndrome in which the underlying etiology is prolonged periods of malnutrition. We present a unique case of non-alcoholic WE in a middle-aged male who initially presented with gallstone pancreatitis complicated with severe metabolic derangements. This ultimately resulted in the development of non-alcoholic WE. Prevention of this condition is a clinical challenge for most physicians as the classic features associated with thiamine deficiency lack diagnostic sensitivity and specificity in critically ill patients. As a result, early recognition and prompt management of this can dramatically decrease morbidity and mortality. Our case highlights and emphasizes the importance of maintaining a high index of suspicion for WE and refeeding syndrome in the setting of altered sensorium and metabolic derangements.

We present a case of a 58-year-old man with delayed diagnosed moyamoya disease who underwent encephaloduroarteriosynangiosis (EDAS) procedure. This patient with a history of three strokes presented to our facility with new left facial droop. Neurological examination revealed left facial droop and hemiparesis. Brain magnetic resonance imaging (MRI) described right frontal lobe acute ischemia. Head computed tomography (CT) angiography revealed bilateral supraclinoid internal carotid artery (ICA) occlusions. Cerebral angiography demonstrated diffuse intracranial vascular irregularity with stenosis, more above the bilateral supraclinoid ICAs and the right middle cerebral artery (MCA) suggestive of moyamoya disease. Due to the lack of MCA patency, he underwent EDAS. Superficial temporal artery (STA) was dissected inferiorly and the posterior branch was bipolared, then STA was movable. A bur hole made at the superior and inferior portion along the STA. Dura was opened, and STA was brought on top of the pia. His facial droop gradually improved after that. Nine months later, no new strokes reported. Moyamoya disease is a rare neurovascular disorder characterized by narrowing and occlusion of the ICA branches. Its symptoms include recurrent ischemic/hemorrhagic strokes. Incidence in Hispanics has not been studied. The gap between the first manifestations and disease progression is one to eight years. Its diagnosis is often delayed. Our patient had recurrent strokes for five years. Despite therapy with antiplatelets, new ischemic stroke brought him to our institution. Rate of recurrent strokes despite antiplatelets was reported 10.3% per year. Brain CTs and MRIs had failed to detect strokes’ etiology. Catheter-directed angiography is the gold standard test for diagnosis of moyamoya disease. Antiplatelet alone is ineffective and surgery is the effective method to prevent further strokes, although there are no studies in adults regarding the efficacy of indirect revascularization. In direct revascularization, usually STA anastomoses to MCA. Indirect method works through the development of leptomeningeal collaterals. Postoperative complications are infarction and hyperperfusion syndrome. Seong-eun et al. proposed that modified EDAS is simpler with less complications in comparison with direct revascularization. Some other studies showed higher chance of stroke in indirect method versus direct technique. In conclusion, it is important to consider moyamoya disease as a differential diagnosis in patients with recurrent strokes.

BackgroundEarly detection of lung cancer using low-dose computed tomography (LDCT) can potentially reduce morbidity and mortality. However, LDCT for lung cancer screening, especially in low income countries, has been underutilized. The objective of this study was to evaluate the prevalence and the potential personal, social, and economic barriers of lung cancer screening using LDCT.MethodsA total sample of 156 smokers and 200 general physicians was collected during December 2016-February 2017 from community settings in Karachi, Pakistan. Two separate questionnaires were constructed to characterize participants' knowledge, attitudes, and practices regarding lung cancer screening. Screening-eligible smokers and physicians were asked to identify patient barriers to screening and were asked their opinion regarding most effective approach for increasing awareness of screening guidelines.ResultsThe majority of smokers' (n=91, 58.3%) and physicians' (n=131, 65.7%) beliefs about the US Preventive Services Task Force (USPSTF) eligibility criteria were inconsistent with the actual recommendations. Major barriers to screening included financial cost, lack of patient counseling and health anxiety related to screening. Over two-thirds (n=105, 67.3%) of smokers were receptive to further information about LDCT screening, and half (n=78, 50.0%) favored one-on-one counseling by their physician, compared to other media. Only one-third (n=65, 33.3%) of physicians reported use of LDCT screening, although 54.5% (n=108) felt that screening implementation would be very effective in their practice.ConclusionLDCT screening is currently an uncommon practice in Pakistan. Financial cost, inadequate doctor-patient communication, and lack of awareness of guidelines among both patients and physicians are the major barriers in the utilization of LDCT screening.