Introduction: Sigmoid volvulus is a relatively uncommon cause of intestinal obstruction in children and adolescents. It usually occurs in the elderly with a mean age of 70 years. We present 2 cases: one adolescent and one elderly with challenging presentations of sigmoid volvulus. Case Description/Methods: Case 1: A 16-year-old woman athlete presented with worsening abdominal pain for 2 days. While playing basketball, she suddenly started screaming with pain. She had nausea and non-bloody emesis. She had an episode of loose stools and passed flatus. Negative fever, chills, flank pain, pelvic pain, dysuria and vaginal discharge. Her abdominal pain had also subsided. She has no history of alcohol, tobacco or illicit drug use. Vitals were stable. No pertinent positives on examination. Labs were within normal limits. CT of the abdomen and pelvis with and without contrast demonstrated a narrowing and obstructing process within the mid-level transverse colon, dilatation and distension of the colon proximal to this level without contrast passed through into the proximal colon. Pelvic ultrasound noted pelvic fluid, otherwise negative. She underwent urgent colonoscopy and decompression of sigmoid volvulus. Case 2: A 70-year-old man with a past history of chronic constipation, dyslipidemia, hypertension, CAD s/p CABG presented with abdominal pain and constipation. He had been constipated for the past 1 month with severe lower abdominal pain over the past 3 days. He had nausea and non-bloody emesis. Negative fever or chills. No history of EGD, colonoscopy, abdominal surgery, alcohol, tobacco or illicit drug use. Vitals were stable. He was in moderate distress with a distended, tender abdomen. Labs: WBC 18.0, AST 42, ALT 33. CT abdomen and pelvis with and without contrast demonstrated findings of sigmoid volvulus (Figure 1). It was successfully decompressed via emergent colonoscopy. He continued to have abdominal distension and lower quadrant pain on the next day. Subsequent X-ray abdomen showed findings of sigmoid volvulus. Gastrograffin enema was performed to confirm if this was from the previous volvulus vs recurrence. It demonstrated persistent sigmoid volvulus with distension and obstruction. Subsequently, he underwent an exploratory laparotomy with resection of the sigmoid volvulus with end colostomy, Hartmann’s pouch. Discussion: Early diagnosis and treatment are extremely crucial to avoid complications of sigmoid volvulus. Though uncommon in adolescents, it should be on the differential for intestinal obstruction.Figure 1.: Coronal section of CT abdomen and pelvis showing sigmoid volvulus.

Introduction: Inflammatory bowel disease (IBD) is a complex autoimmune condition characterized by diverse risk factors and pathophysiologies. There is a hypothesized linkage between neurological and gastrointestinal disorders, possibly through the alterations in the "gut-brain axis". Migraines, defined as episodic neuroinflammatory conditions, are believed to have a potential association with systemic inflammation. However, the existing literature lacks comprehensive exploration of IBD as a potential risk factor for migraines. Our aim is to analyze the association between migraines and IBD through a systematic review and meta-analysis. Methods: We conducted an extensive search of PubMed, Scopus, and Google Scholar until May 2023, screening for studies that reported the prevalence of migraines in IBD patients using MeSH and TiAB terms. In addition, we performed a cross-citation search. Our literature search yielded 117 reports. After pre-screening exclusion, 66 reports were eligible for screening. Binary random-effects models were used to perform meta-analysis. The I2 statistics was used to assess heterogeneity, and sensitivity analysis was done using the leave-one-out method. Results: Our meta-analysis analyzed 6 studies- 3 cross-sectional, 2 prospective, and one retrospective, originating from the USA (2), Brazil (1), Israel (1), Switzerland (1), and the UK (1). We evaluated 62,325 IBD patients (46.7% male) and 2,537,535 controls. The pooled prevalence of migraine was higher in IBD compared to controls (7.5% vs. 2.7%). However, our forest plot analysis showed a non-significant increase in migraine risk in IBD, both unadjusted (OR 1.30, 95% CI 0.81-2.07) and adjusted (OR 1.55, 95% CI 0.98-2.44). Heterogeneity was substantial with P< 0.01 for both unadjusted (I2=92.87%) and adjusted (I2=82.03%) analysis. Sensitivity analysis using the leave-one-out analysis confirmed this finding (Figure 1). In the Crohn's disease subgroup, we observed a non-significant association with migraine risk, with heterogeneity ( P< 0.01) remaining substantial (unadjusted OR 1.06, 95% CI 0.17-6.37, I2=92.57%, P=0.95; adjusted OR 0.70, 95% CI 0.26-1.86, I2=87.45%, P=0.48). Conclusion: No significant association between the risk of migraine and IBD was found in our study. The lack of association might be attributable to heterogeneous data sources and inadequate power for this analysis. Further prospective studies are warranted to investigate the risk of IBD in migraine.Figure 1.: Forest plot depicting unadjusted and adjusted odds ratios for risk of migraine in IBD.

Introduction: Sump syndrome is a rarely seen complication of choledochoduodenostomy (CDD) in the era of Endoscopic retrograde cholangiopancreatography (ERCP). We present a case of recurrent cholangitis post-CDD. Case Description/Methods: A 78 y/o. female with a PMH of CDD, cholangitis status post-ERCP with CBD stent placement presented to the ER with lethargy, decreased oral intake, and vague non-radiating epigastric pain for 1 week. The patient couldn’t provide past medical and surgical records. She was hypotensive on arrival, with blood pressure at 84/61 mm Hg and a temperature of 101.8F. CT scan of the abdomen and pelvis without contrast showed post-cholecystectomy changes, mild non-specific stranding, and edema in the periportal region. AST, ALT, and ALP are 56, 46, and 362, respectively. The patient was admitted to ICU for septic shock secondary to possible cholangitis and/or choledocholithiasis and started on empiric IV antibiotics. ERCP was performed due to concern for acute cholangitis. Evidence of prior cholecystectomy was seen in the lower third of the main bile duct. The biliary tree was swept with a 12 mm balloon starting at the bifurcation. Pus and debris were swept from the duct appeared to be secondary to sump syndrome. One Fr by 7 cm plastic stent was placed into the common bile duct. The flow of pus through the stent was noted. She was followed up after 6 weeks of outpatient for ERCP and stent removal (Figure 1A, 1B). Discussion: Sump syndrome is a rare long-term complication of CDD, a common surgical procedure before the advent of ERCP. It is caused by the buildup of lithogenic bile, debris, and duodenal contents in the distal common biliary duct (CBD), which causes biliary cholangitis and pancreatic complications. The bile no longer drains through the distal CBD in this setting. As a result, the CBD distal to the anastomosis transforms into a poorly drained reservoir, making this sump prone to debris accumulation. Indigestion, abdominal pain, nausea, vomiting, postprandial discomfort, and jaundice are presenting symptoms. Diagnostic findings on imaging include debris/stones in the CBD, with the possibility of pancreatitis, cholangitis, or a liver abscess. To confirm the diagnosis of sump syndrome, an ERCP or percutaneous transhepatic cholangiography (PTC) is required. Management includes the drainage of debris endoscopically. In refractory cases, surgical treatment includes CDD revision to a Roux-en-Y hepaticojejunostomy. Sump syndrome is less common as ERCP replaces CDD.Figure 1.: A) Endoscopic retrograde cholangiopancreatography and B) Computed tomography abdomen showing dilated biliary tree.

Introduction: Small cell carcinoma (SCC) usually occurs in the lungs, where they account for 25% of lung carcinomas. Extrapulmonary small cell carcinomas (EPSCC) are rare aggressive neoplasms, accounting for only 2-4% of SCCs. Almost half of extrapulmonary cases are found in the gastrointestinal tract. Primary SCC in the hepatobiliary system has been reported in only a few reported cases in the literature. Case Description/Methods: A 59-year-old man with hypertension, type 2 diabetes mellitus, presented with gradually progressive abdominal pain for few weeks, associated with increasing difficulty breathing, loss of appetite and occasional night sweats. Imaging with CT abdomen was suggestive of innumerable confluent hepatic masses spanning the right and left lobes measuring 26 x 14 x 20 cm with masslike thickening of the gallbladder fundus, initially thought as part of metastatic foci. However, the search for primary focus was futile as extensive imaging evaluation with Chest CT scan with and without contrast, NM scan lung, MR chest and abdomen were negative for lesion outside hepatobiliary system. MRI abdomen with contrast showed multiple confluent hepatic masses extending into the right and left lobe of the liver with a combined size of approximately 26 x 14 x 20 cm and mass within the gallbladder fundus (3.6 x 3.4 x 3.4 cm) that extends into the adjacent liver, representing gallbladder primary. Image-guided biopsy of liver mass confirmed small cell neuroendocrine carcinoma, positive for CAM 5.2, CK7, synaptophysin, chromogranin, CD56 and TTF-1 and negative for LCA, CK20, CDX2 and CA 19-9. PET-CT of the skull to midthigh showed heterogeneous uptake in the liver with several ill-defined foci of more intense uptake in the anterior right hepatic lobe/hepatic dome with SUV max of 9.2, fundus of the gallbladder with SUV max of 17.3 corresponding to active lesion. Thus, he was treated as primary small cell carcinoma of the gallbladder metastatic to liver with combination chemotherapy cycles of carboplatin, etoposide, and atezolizumab (Figure 1). Discussion: Primary small cell carcinoma of the liver and gallbladder is a very rare and distinct entity requiring careful systemic evaluation, tissue biopsy, and immunohistochemistry. Normal CT scan of the chest, sputum cytology, negative bronchoscopy, or PET scan differentiates EPSCC from metastatic pulmonary SCC. Although no established standard treatment exists, surgical excision is done for resectable cases, and Platinum-based combination chemotherapy for unresectable cases.Figure 1.: MRI abdomen with contrast showing multiple confluent hepatic masses extending into the right and left lobe of the liver with a combined size of approximately 26 x 14 x 20 cm and mass within the gallbladder fundus (3.6 x 3.4 x 3.4 cm) that extends into the adjacent liver, representing gallbladder primary.

Introduction: Parenteral nutrition is required in individuals who are not candidates for enteral feeding. Long term use is in decreased intestinal function, also called as intestinal failure. It is associated with wide variety of complications, which rarely includes liver injury. We describe a case of liver injury caused by prolonged period of total parenteral nutrition in a young adult due to intestinal failure secondary to short bowel syndrome. Parenteral nutrition induced liver disease is a rare but a life threatening condition, early recognition with prompt treatment is required before the development of end stage liver disease. Case Description/Methods: 40-year-old woman with past medical history significant for cervical cancer post chemoradiotherapy followed by radiation colitis status post partial colectomy with ostomy, short-bowel syndrome on Total parenteral nutrition (TPN) for 3 years presented with diarrhea, fatigue, pruritis. Physical examination showed thin body habitus, icterus, mild abdominal tenderness, and bilateral lower limb edema. Labs showed conjugated hyperbilirubinemia, elevated liver enzymes, low albumin, elevated INR, worsening creatinine. Hepatitis panel negative. Iron studies negative for hemochromatosis. Negative for ANA, AMA, P- ANCA, ASMA, CMV. Ultrasound revealed intrahepatic ductal dilatation. MRCP showed abnormal liver signal intensity likely secondary to fibrosis, splenomegaly due to portal hypertension. Transjugular liver biopsy confirmed liver cirrhosis. Liver injury was considered to be secondary to TPN. TPN was initially held for few days, later restarted with low lipid, hypocaloric formulation and given as small boluses spread over time. Her liver enzymes and liver function markers improved. She was discharged with a long-term plan for multivisceral transplant. Discussion: Parental nutrition associated liver disease (PNALD) is a rare complication with long-term use of TPN. Lack of enteral feeding result in decreased production of bile acids, which result in altered expression of transcription factors, resulting in cholestasis, fibrosis. Lipid formulation in the TPN is also associated with liver injury with an unknown mechanism.PNALD is a diagnosis of exclusion. In patients who have developed end-stage liver disease, multivisceral transplant (intestine and liver) should be considered.

Introduction: Coronavirus can affect most organ systems in our body, including the lungs, heart, CNS, and GIT. In the gastrointestinal tract, the virus enters the cells through ACE-2 receptors which are present from the esophagus to the colon and can cause inflammation. Secondary infections with Streptococcus pneumoniae, Klebsiella pneumonia, and Hemophilus influenzae are also very common in COVID-19 patients. Most of these secondary bacterial infections are known to cause pneumonia. Here we present a rare case of secondary infection with Streptococcus pneumoniae causing peritonitis in the presence of COVID-19 infection. Case Description/Methods: A 50-year-old woman with no significant medical and surgical history presented to the ER with complaints of abdominal pain, nausea, and diarrhea for 3 days. She describes her pain as diffuse dull pain with 10/10 intensity. She denies fever, shortness of breath, cough, or chest pain. On physical examination, she is afebrile, and the abdomen is diffusely tender and rigid. Labs are significant for elevated WBC of 21.5 and elevated inflammatory markers - CRP, LDH, and Ferritin. She tested positive for COVID-19 PCR. CT scan of the abdomen and pelvis suggested peritonitis, but the primary etiology for peritonitis is unclear on the scan. She was immediately taken to the OR for exploratory laparotomy, which showed significant purulence in the abdomen, but the source of purulence was not identified. She had an inflamed appendix which was removed during the procedure to avoid any confusion in the future. The peritoneal fluid culture grew S. pneumoniae. Appendix pathology was negative for appendicitis. A vaginal speculum examination and cervical swab were done, which ruled out pelvic inflammatory disease (PID) as a cause for the peritonitis. She received IV Zosyn for 7 days, and her symptoms were resolved. She was discharged home on Levaquin (Figure 1). Discussion: This case illustrates the association between S. pneumoniae peritonitis and COVID-19. All other causes for Streptococcus peritonitis were ruled out, including intraabdominal pathologies and PID, thus, peritonitis in this case could most likely be secondary infection due to COVID-19. Studies have shown that coronavirus can cause peritonitis, but pneumococcal peritonitis in the presence of COVID-19 infection was not reported. Among all secondary infections occurring in covid-19, S. pneumoniae was most frequently isolated from the cultures.Figure 1.: Generalized inflammation resembling peritonitis.

Given the global increase in the incidence of head and neck cancers over the last decade, the use of chemoradiation has also increased. It is well known that chemotherapy/radiation are established standard therapies in head and neck cancers, especially in patients who are not candidates for surgery. Despite this increase in chemoradiation therapies in head and neck cancers, there is a lack of established guidelines on the surveillance and screening of these patients for long-term complications. We present an interesting case of acute left eye blindness in a veteran patient with a history of laryngeal cancer status post chemoradiation and in the setting of a left ventricular (LV) thrombus on anticoagulation resulting in a diagnostic challenge determining the etiology. This case emphasizes the need for thorough patient-centered annual evaluation, thus providing an opportunity for early noninvasive or minimally invasive intervention.

Introduction: Heparin-induced thrombocytopenia (HIT) is characterized by thrombocytopenia and a prothrombotic state. It can occur following the use of heparin products of any form or dosage. Various factors predispose cirrhosis patients to thrombocytopenia, such as splenic platelet sequestration, lower levels and activity of thrombopoietin (TPO), bone marrow suppression secondary to chronic viral infections(e.g., Hepatitis C), and use of antiviral therapies such as interferons. As there is a paucity of data on the impact that cirrhosis confers on the outcomes following HIT, we conducted a retrospective nationwide analysis. Methods: A retrospective study of adult patients with HIT was performed using the2016-2019 National Inpatient Sample(NIS), a set of annual hospitalization databases produced by HCUP, AHRQ, and multiple partners. Patients with HIT were identified via the ICD-10 code “D7582”. We studied the differences in patient characteristics and multiple comorbidities among patients with and without cirrhosis, along with the impact on outcomes. Results: Our study included a total of 60800 cases of HIT, which included 3020(5.0%) cases with a diagnosis of cirrhosis (Table 1). The majority of cases involved patients classified as White, were Medicare-insured and underwent treatment in Urban-teaching centers. While patients with cirrhosis were younger (mean age 61.71 years vs. 64.39 years, p<0.01), they also reported disparities in patient characteristics and comorbidities. Cirrhosis cohort had fewer females (43.9% vs. 46.9%, p<0.01), lower prevalence of hypertension (22.2% vs. 29.4%, p<0.01), peripheral vascular disease (7.0% vs. 10.6%, p<0.01), lipid disorders (24.2% vs. 42.1%, p<0.01), and were overall younger (mean age 61.71 vs. 64.39 years, p<0.01). However, cirrhosis patients showed a higher prevalence of smoking (39.4% vs. 35.1%, p<0.01), chronic kidney disease (39.4% vs. 36.4%, p<0.01), and alcohol abuse ( 24.2% vs. 4.8%, p<0.01). Moreover, 4.1% of cirrhosis patients had a diagnosis of hepatocellular carcinoma (vs. 0.4% of non-cirrhosis patients, p<0.01). No differences in the two groups were observed for diabetes and obesity. Overall, cirrhosis patients reported a higher mean Charlson Comorbidity Index (CCI) score (6.21 vs. 4.58, p<0.01) but had a shorter stay (13.84 days vs. 14.64 days, p<0.01), with a lower mean hospital charge ($167196 vs. $225959, p<0.01). After careful adjustment of confounders, lower odds of Major adverse cardiovascular events (MACEs) were seen among cirrhosis patients (14.2% vs. 19.3%,aOR 0.531, 95% CI 0.474-0.595, p<0.01). Moreover, cirrhosis patients also had lower odds of in-hospital death following events of HIT (11.4% vs. 10.9%, aOR 0.875, 95% CI 0.770-0.994, p=0.040). Conclusion: Our study found lower odds of MACEs and mortality among cirrhosis patients in cases of HIT. However, as the NIS has multiple limitations, such as the unavailability of medication codes and the inability to evaluate post-discharge outcomes, we highly encourage more in-depth studies to improve our understanding of the impact of cirrhosis in patients with HIT.

Introduction: A Clostridioides difficile infection (CDI) can be self-limiting or develop into fulminant colitis, ileus, or toxic megacolon, which are serious and potentially fatal conditions. Patients taking cancer chemotherapy without previous antibiotic medication have been observed to develop colitis and infections caused by C. difficile. Chemotherapeutic drugs can modify the natural bowel flora and lead to significant intestinal inflammation, which promotes C. difficile growth and toxin generation. Our case identified C. difficile colitis in ovarian cancer patients following each infusion of cisplatin-based combination chemotherapy. Case Description/Methods: 71-year-old woman, prior medical history of hypertension, hypothyroidism, ovarian cancer. Patient presented to ED with Grade 1 diarrhea for 4 days following 2 weeks of chemotherapy, associated lethargy and abdominal cramps. Diarrheal episodes are watery, 3-4 bowel movements per day, no melena or hematochezia. Review of systems positive for dizziness, anxiety, subjective shortness of breath. Patient denied any fever, chills, hematemesis, hemoptysis, cough, chest pain. Vitals stable, abdominal examination is soft and non-tender. Labs: Bicarb 8, Hemoglobin 5.8 gm/dl, Positive for C. difficile GDH Antigen and Toxin A along with B, Negative for other GI infectious organisms. CT abdomen: minimal ascites, diffuse colitis. Treated with 2 Units of PRBC’s transfusion. For C. difficile after first 2 chemotherapy cycles, treated with vancomycin for the initial 2 episodes. Treated with fidaxomicin following the 3 consecutive chemotherapy cycles. Discussion: Adults with cancer had a 7%-14% higher incidence of C. difficile infection (CDI) than the overall hospitalized population (1%-2%). Although there is a dearth of data, it appears that the varied symptoms, treatment, and outcome are identical to those for instances associated with antibiotics. Chemotherapy related diarrhea due to inflammation unlike C. difficile infection is known to us in literature. It's possible that C. difficile infections linked to chemotherapy go unreported because they are not suspected or because their true prevalence is hidden by frequent concurrent antibiotic use. Every time a patient receiving antineoplastic treatment experiences diarrhea, C. difficile infection should be considered. Early therapy and prompt, appropriate diagnostic testing may prevent morbidity and death.

Introduction: Total annual incidence of ischemic colitis [IC] 15.6 - 17.7 per 100,000. IC untreated can lead to bowel perforation, peritonitis, persistent bleeding, protein-losing Colopathy and symptomatic intestinal strictures. predisposition to progress, IC mortality is high. Majority of cases are treated conservatively, with needed 20% surgical intervention. Sumatriptan is a 5-HT1B/1D agonist, from Triptans first of its class, well known for treating, migraine attacks. Case Description/Methods: A 42-year-old woman with prior medical history of Migraine presented with complaint of bright red blood per rectum (BRBPR),cramps in her lower abdomen, vomiting and nausea for 3 days. Abdominal pain crampy, lower abdominal quadrants, with severity of 7/10, 3 days in duration, aggravated with food intake and relieved by bowel rest,associated with diarrhea. Hemoglobin was at her baseline. EGD: No upper gastrointestinal bleeding. Five years ago, colonoscopy shown hyperplastic colonic polyps. Having a history of chronic constipation, predisposed her for Ischemic colitis. She has been using inhalational sumatriptan every 2 hours during migraine episodes, since last 7 years. On admission, her vitals were stable. Colonoscopy showed congested (odematous) and ulcerated mucosa in the descending colon (Figure 1). GI recommended the patient to avoid sumatriptan, and 1 week later patient acknowledged, that her symptoms including nausea, vomiting, abdominal pain, BRBPR resolved and advised to follow up patient, in the GI office as an outpatient for repeat colonoscopy upon clinical assessment. Discussion: Sumatriptan, first in its class, known for its extensive use for migraines since 1990’s, by causing vasoconstriction of cerebral blood vessels and by decreasing the neurogenic inflammation. Sumatriptan action on its receptors 5HTB1/D1 receptors, is not limited to CNS, acts on other vascular bed coronary, mesenteric blood vessels by vasoconstriction and on peripheral vasoconstriction, leading to hypertension. The FDA adverse event reporting system (FAERS) data of 5-year period, March 2008-March 2013, shown 19 “IC” as the main adverse event out of 10,252 sumatriptan-associated events, representing all organ systems which includes ischemic colitis. For any individual on medication for migraine experiencing abdominal symptoms, a high index of suspicion needed for sumatriptan related ischemic colitis.Figure 1.: Sumatriptan induced ischemic colitis - Gross, Microscopic and Imaging pictures.

Introduction: Colorectal cancer often metastasizes to the liver, lungs, and lymph nodes. Orbital metastasis from colorectal cancer is extremely rare, with only 10 cases reported in the literature across the globe. Here, we report a young patient with metastasis to the eye as an initial presentation for metastatic rectal cancer. Case Description/Methods: A 42-year-old man with HTN & treated Hepatitis C presented to PCP with right eye pain. Initially treated with antibiotics for suspected sinusitis but with no improvement he was referred to ENT, where he had a CT scan of the sinuses that showed right eye muscle thickening. He was then treated with steroids which did not help the right eye pain. MRI of the orbits was done, which showed a 1.8 cm mass in his medial rectus muscle of the right eye (Figure 1). Biopsy by Ophthalmology showed pathology consistent with adenocarcinoma of the colon with immunohistochemical stains (CK 7 -, CK 20 +, TTF1 -, P40 -, CDX-2 +, & SATB-2 focal scattered + cells) confirming colonic primary. He was referred to medical oncology for further evaluation, where a PET scan showed an FDG avid mass in the rectum consistent with primary rectal cancer. In addition, a few other metastases were seen, including a nodule in right lung, hypodense lesion in the liver, left perirectal lymph node, and paraspinal muscle to the left of L2. He was started on chemotherapy using a FOLFOXIRI regimen and had a resection of his right eye medial rectus mass to prevent vision loss. Germline genetic testing showed a variant of unknown significance in the ATM gene, and his father had a history of liver cancer. He completed 12 cycles of FOLFOXIRI, followed by a restaging scan that showed a mild increase in disease activity; he was then followed by maintenance therapy with Capecitabine and radiation therapy to the rectal lesion. The patient was enrolled in phase 1 clinical trial and received 1 dose after which he presented with a new complaint of left eye pain. Imaging confirmed disease progression with new diffuse multiorgan metastatic involvement. More recently, the patient was started on FOLFOX therapy and is under oncology care. Discussion: This case presents a rare instance of rectal cancer metastasizing to the rectus muscle of the eye. It is imperative that physicians do consider a broad range of differentials when approaching unusual presentations of common medical conditions. In such cases, an accurate early diagnosis is pivotal to optimize management and improve outcomes to prevent future complications.Figure 1.: MRI of the Orbit showing intramuscular lesion involving the right medial rectus muscle 1.8 x 1.5 x 1.6 cm; enhanced peripherally with some internal nodularity and a cystic center.

Introduction: Hymenoptera insect sting bite was known to cause toxic reactions leading to hemolysis, serum sickness, rhabdomyolysis, vasculitis, renal failure, myocarditis, and neuritis. It is extremely rare to present with pancreatic involvement, as noticed in our case. Here we report an 82-year-old with severe necrotizing pancreatitis and multi-organ failure secondary to a bee sting. Case Description/Methods: An 82-year-old male presented with complaints of nausea, non-bilious, non-bloody vomiting, and abdominal pain within an hour following a bee sting. He has a past medical history of colon cancer s/P cecal resection with side-to-side anastomosis, hypertension, and hyperlipidemia. His Initial blood workup was significant for elevated BUN/Creatinine- 60/3.1 mg/dl, elevated lipase –6800 u/l, elevated AST/ALT- 161/116 u/l, with normal ALP and T Bil-1.4 mg/dl. CT abdomen with IV contrast showed peripancreatic inflammatory changes with fluid extending into the perirenal and paracolic gutters, hypoenhancement of the pancreatic body and tail concerning pancreatic necrosis. He was started on intravenous fluids and a broad-spectrum antibiotic, Meropenem. During the hospital course, his clinical condition deteriorated with the development of sepsis, and he had an episode of PEA arrest, which he got through with resuscitation in 4 minutes. After 9 days in the hospital with continuous pressor requirements and worsening mental status, the family decided to make him comfortable care. Discussion: Pancreatic necrosis is associated with substantial morbidity and mortality. Optimal management requires a multidisciplinary approach, IV antibiotics penetrating the pancreas, drainage, or debridement in persistent cases. Given the rarity of the bee sting-associated pancreatitis without a specific anti-toxin, it would be clinically challenging to manage. We noticed that this could also progress rapidly and require immediate transfer to a tertiary care center, which was unsuccessful in our case due to an unstable clinical condition.

Introduction: Hepatic angiosarcoma (HA) is uncommon yet notoriously deadly, accounting for 0.1- 2% of total primary liver malignancies. It is clinically challenging to diagnose due to its nonspecific presentation and absence of tumor markers. Case Description/Methods: A 75 y/o male with a history of COPD and GERD presented with complaints of chronic fatigue. A routine CT chest identified an incidental liver mass 11 x 8 mm along with lower esophageal thickening and pulmonary nodules. Initial lab work-up showed AST/ALT-44/45 u/l, ALP-94 u/l, T Bil- 0.6 mg/dl, and acute hepatitis panel was negative. The patient was discharged for outpatient follow-up. Due to persistent symptoms, two months later, he was then referred to gastroenterology. He denied exposure to vinyl chloride, arsenic, thorium dioxide, and anabolic steroids. Tumor markers came back normal, CA 19-9 -8 u/ml, & AFP- 1.82 ng/ml. An MRI showed benign venous malformation, but a liver biopsy confirmed HA. Eventually, the patient started chemotherapy with a suspicion of metastasis based on prior CT imaging. He could not tolerate the side effects of Paclitaxel after two doses, so he opted for hospice care and was discharged. Discussion: Hepatic angiosarcoma rapidly progresses with a potential for metastases increasing mortality. Often, radiological findings can be misleading in the initial stages, warranting an invasive approach, liver biopsy, to confirm the diagnosis. Due to its rare occurrence and absence of specific symptoms, we encourage a multi-disciplinary approach, particularly involving gastroenterology during the initial stages, to decrease the mortality in these cases. Also, additional research is required to improve diagnostic accuracy, establish treatment guidelines, and guide our future therapies.

Introduction: Amyloidosis is a condition in which abnormal amyloid proteins deposit into various tissues of the body resulting in organ dysfunction. Immunoglobulin light chain amyloidosis (AL amyloid) is the most prevalent type. The clinical features of AL amyloid vary greatly. Gastrointestinal (GI) symptoms typically include constipation and dysmotility. Hemorrhage is an uncommon feature. Case Description/Methods: An 84-year-old woman presented to the emergency department April 2019 with complaints of nausea and intermittent hematemesis. EGD on the day of admission was notable for a Mallory-Weiss tear, severe erythematous gastritis and necrotic-appearing changes of the gastric body, and adherent clot in the stomach. The areas were treated with epinephrine injections and clip placement. Gastric mucosa was biopsied and showed mild to moderately active chronic gastritis, positive congo red staining, and involvement of lambda light and heavy chains. Further biopsies of the GI tract included duodenum and colon and were negative for amyloid. Workup did not reveal any additional underlying malignancy or other systemic involvement. The decision was made to closely observe her clinical course. She had additional hematemesis in June 2021. EGD redemonstrated friable gastric mucosa. A daratumumab-based regimen was proposed for treatment of the amyloidosis, but the patient ultimately opted for observation. Discussion: AL amyloidosis uncommonly presents as an isolated gastric disease which causes hematemesis. Of those with an affected GI tract, 25-45% of patients present with GI bleeding . GI manifestations typically include abdominal discomfort, malabsorption, and dysmotility. Hemorrhage may occur if the disease causes ischemia, mucosal friability, or ulcerations. In patients with localized amyloidosis, treatment is not needed unless the symptoms are severely symptomatic or if amyloidosis extended to the regions outside of stomach. If systemic treatment is needed, then it is aimed at treating the underlying plasma cell dyscrasia with monoclonal antibodies or chemotherapy.

Introduction: Solitary rectal ulcer syndrome (SRUS) is a rare colorectal disorder that presents as bright red blood per rectum (BRBPR), rectal pain, straining, incomplete evacuation, and rectal prolapse. The incidence of SRUS is 1: 100,000 individuals per year. SRUS is a misnomer as it can present as multiple ulcers and polypoid lesions. Differential diagnoses include inflammatory bowel disease (IBD), ischemic colitis, pseudomembranous colitis, and malignancy. Ergo, histopathological evaluation is necessary for differentiation. Typically, these lesions occur on the anterior surface of the rectum given the movement of the muscles in the rectum. In our case, we present a patient who has a posterior SRUS which was misdiagnosed as Crohn’s disease. Case Description/Methods: 45-y.o. heterosexual male with PMH of presumed Crohn’s and diverticulosis presented to ED multiple times with recurrent complaints of BRBPR & abdominal pain intermittently over 18 years. Imaging showed rectal wall thickening & inflammation (Figure 1). Patient underwent multiple sigmoidoscopies and colonoscopies showing a single ulcer in the posterior with stigmata of bleeding. Multiple clips and hemostatic therapies were applied. Repeat biopsy results showed chronic ulceration with reactive rectal epithelium; all negative for dysplasia/malignancy and no evidence of IBD. Patient was treated conservatively with mesalamine enemas, steroids, & laxatives. Defacogram was normal. Given repeated episodes of bleeding despite this, colorectal surgery performed a laparoscopic low anterior resection of the ulcer. Discussion: The pathogenesis behind SRUS is poorly understood but thought to be a result of rectal prolapse and rectal trauma by 2 different mechanisms. (1) Prolapsed rectal mucosa forced downward due to the pressures generated by the rectum during defecation, while opposing forces of the paradoxical contraction of the puborectalis muscle tendon cause high pressures within the rectum, leading to mucosal ischemia, and predisposing to ulceration. (2) Contraction of the puborectalis muscle result in shear forces on the rectal mucosa. Treatment is biofeedback therapy and topical therapies. Surgery is a last resort. A postero-lateral rectal ulcer is atypical unlike the usual anterior ulcers. Our patient was noted to have an exaggerated cul-de-sac along with a partially prolapsed anterior wall of rectum. Post op, he is doing well without any clinical symptoms.Figure 1.: Posterior SRUS.