Introduction: Amoebiasis is a parasitic infection caused by Entamoeba histolytica, which is endemic in many developing countries, but quite uncommon in the developed world. Patients can either be asymptomatic or they can present with symptoms of abdominal pain or bloody diarrhea. We present an unusual case of asymptomatic Amoebiasis in a patient with a positive fecal immunochemical test (FIT). Case Description/Methods: A 58-year-old male with a history of seizures and hypertension underwent a colonoscopy following a positive FIT. The patient denied any symptoms such as abdominal pain, diarrhea, hematochezia, or melena, and lab work did not show any anemia. A previous colonoscopy was done in May of 2019, which only showed a localized area in the cecum of mildly friable mucosa with no bleeding. No biopsies were taken and no follow up was recommended. His most recent colonoscopy showed a 13 mm ulcer and several 2 mm ulcerations of the cecum. The ulcerations were biopsied which showed ulceration, acute inflammation, inflammatory exudate and associated structures consistent with Entamoeba trophozoites. A gastrointestinal stool PCR confirmed the diagnosis, and the patient was immediately started on a course of Flagyl followed by a course of Paromomycin. Discussion: Entamoeba histolytica asymptomatically colonizes the intestines in 90% of infected individuals. However, in 10% of patients, the parasite invades through the colonic mucosa, and patients typically become symptomatic, presenting with symptoms such as abdominal pain or hematochezia, prompting medical investigation, diagnosis, and treatment. Although Entamoeba can potentially affect any segment of intestine, it preferentially colonizes and infects the ascending colon and the cecum. In our patient, the parasite colonized the cecum, and began to invade the mucosa, which would explain the friability of the cecum noticed on colonoscopy back in 2019, though at the time it was largely dismissed as inconsequential. However, over the course of time, the parasite must have invaded more extensively, causing multiple ulcerations, which led to a positive routine FIT. Interestingly, although the patient was affected by invasive Amoebiasis for nearly two years, he was shockingly clinically asymptomatic, and would have had his infection undiagnosed and untreated had he not underwent a routine FIT. This case is unique as it is quite rare to have an invasive Amoebiasis infection to such an extent in a patient who is completely asymptomatic.Figure 1.: Cecal Ulcer.

INTRODUCTION: Clostridium species are anaerobic gram-positive bacilli that can cause a broad range of invasive infections in humans, including bacteremia and intra-abdominal infections. Clostridium glycolicum and Clostridium paraputrificum in particular are infrequent isolates in bacteremia with incidence less than 1%. We describe a rare case of Clostridium paraputrificum and Clostridium glycolicum bacteremia resulting in septic shock secondary to a diverticular abscess. CASE DESCRIPTION/METHODS: A 66-year-old female was admitted with high fevers and seizure like activity. She had a history of Non-Hodgkin’s Lymphoma and breast cancer both of which were confirmed to be in remission. Prior to presentation, her husband had noticed the patient acting unusual and staring to the left with a fixed gaze. On arrival to the ER, she had a rectal temperature of 106.5F and needed vasopressor support. A computer tomography (CT) of the head showed no acute abnormalities and multiple lumbar punctures attempted were unsuccessful. She was empirically treated with levetiracetam/fosphenytoin for possible seizures and vancomycin/meropenem/metronidazole for sepsis. CT of the chest, abdomen and pelvis showed sigmoid diverticulitis with an adjacent small foci of gas which may have been a micro-perforation without fluid collections or pneumoperitoneum. Multiple blood cultures grew Clostridium glycolicum and Clostridium paraputrificum. Subsequent CT of abdomen and pelvis demonstrated a sigmoid diverticulitis with an adjacent abscess measuring 2.4 × 1.3 cm (Figure 1). She was treated with ceftriaxone and metronidazole for 3 weeks given her allergies to penicillin and ciprofloxacin. The patient is planned to have follow up imaging to check for resolution of the abscess. DISCUSSION: Presumably, the source of our patient's Clostridium bacteremia was the complicated diverticulitis given the imaging findings. Most species of Clostridium are considered to be harmless soil saprophytes but there are a few case reports of these strains causing bacteremia. Clostridium bacteremia in humans is usually caused by dissemination of gut colonizing strains due to disturbed host defenses locally or systemically. In our case, sigmoid diverticulitis could be considered a pre-disposing factor but given her past history she will need an outpatient work-up rule out malignancy. This case should heighten the awareness of these particular clostridium species as a clinically important organism and every effort should be made to investigate them further.Figure 1.: Transverse view of a computer tomography of the abdominal/pelvis showing an 2.4 × 1.3 cm abscess (blue arrow) on the anterior wall of the sigmoid colon with reactive thickening of the adjacent urinary bladder wall without evidence of a fistula.

INTRODUCTION: Extrapulmonary small cell carcinomas (ESCCs) are considered to be a distinct clinicopathological entity that are extremely rare representing 2.5–4% of all small cell carcinoma (SCC) cases. Given the aggressive nature of the malignancy, patients often present late in the disease course with metastatic disease. We report a case of a young patient found to have ESCC presenting initially with atypical chest and epigastric pain with jaundice. CASE DESCRIPTION/METHODS: A 23-year-old male presented to an outside hospital with a 2-week history of intermittent chest pain radiating to the epigastric region. He also reported generalized pruritus and jaundice for four days. Social history was unremarkable and initial blood work was unremarkable except for hyperbilirubinemia. An ultrasound of the abdomen showed a hypoechoic mass in the porta hepatis measuring 2.0 × 2.5 × 2.4 cm. Contrast enhanced computer tomography (CT) imaging of the abdomen/pelvis confirmed the mass lesion with suggestion of an enlarged lymph node or early onset pancreatic adenocarcinoma. A subsequent endoscopic ultrasound (EUS) showed a poorly circumscribed hypoechoic mass in the porta hepatis (Figure 1) and fine needle biopsy (Figure 2) was performed which showed poorly differentiated small cell carcinoma. Patient had stent placement in common bile duct to relieve obstruction. Patient was then transferred to our intuition for further oncologic work up. At our hospital, the patient had a positron emission tomography with concurrently low dose CT scan which demonstrated multiple focal areas of uptake in lymph nodes with the largest being the porta hepatis node demonstrating a maximum SUV of 10.6 (Figure 3). An MRI of the head with contrast was negative for metastatic disease. The patient is planned to be treated with cisplatin plus etoposide for three to five cycles. DISCUSSION: Our case demonstrates the use of EUS to effectively and safely diagnose ESCC in a young patient with atypical chest pain and jaundice. The histopathology did not reveal the primary source. This case would be classified as SCC of unknown primary which is a type of ESCC. There are no randomized trials or prospective clinical studies on ESCC treatment and approach is based on extrapolation from experience with SCC of lung. As the outcomes have remained poor, further study may be beneficial to adequately define treatment strategies.Figure 1.: Endoscopic ultrasonography showing a 36.92 mm × 27.97 mm poorly circumscribed hypoechoic mass near the porta hepatis.Figure 2.: Endoscopic ultrasonography showing a fine needle biopsy (blue arrow) penetrating into hypoechoic mass.Figure 3.: Transverse view of positron emission tomography showing uptake in lymph node adjacent to the porta hepatis demonstrating a maximum SUV of 10.6.

INTRODUCTION: Single operator cholangioscopy (SOC) and SpyGlass Digital System ‘‘DS” (Boston Scientific Corp, MA, USA) have allowed for visualization of the biliary tract and enabled optically guided biopsies to be performed. Our study evaluated the experience of a high-volume tertiary care center in the management of PB disorders and assess success rates and patient outcomes using SOC and the latest version of SpyGlass DS. METHODS: A retrospective analysis from Nov. 2015 and Sept. 2019 was performed on patients referred for SOC with SpyGlass DS guided intervention for pancreaticobiliary disorders at a single tertiary care center. For stones case, TS was defined as ability to visualize the PB system and perform stone fragmentation/removal. CS was defined as the ability to achieve complete ductal stone clearance after a single procedure. For cases evaluating strictures, TS was defined as the ability to visualize the target lesions. The diagnosis made from the most concerning impression (Spyglass visual +/- Spybite tissue) was compared to the final clinical/surgical pathology diagnosis. Sensitivity (Sn), specificity (Sp), positive predictive value (PPV), and diagnostic accuracy (DA) were taken as markers for CS. RESULTS: 1,542 patients were referred for an ERCP procedure. The SpyGlass DS was used in 151 of those cases for the management of PB disorders. 59 (39.1%) required SOC with stones as their preprocedural indication and 92 (60.9%) patients required SOC with stricture as a preprocedural indication. CS rate after a single procedure was 83.1% (49/59). Only 3.4% (2/59 patients) experienced adverse events which included periampullary edema and post procedure bleeding. 69.6% (64/92) of the cases had SpyBite directed biopsy samples taken and 96.9% (62/64) of those samples were deemed adequate for analysis. Out of the 92 patients, 40 of them were diagnosed benign strictures, 37 with malignant strictures, and 15 with indeterminate strictures. The SOC DS diagnosis Sn was 86.7%, Sp was 76.6%, PPV was 70.3%, and DA was 80.5% when differentiating between benign or malignant strictures. CONCLUSION: Our institution’s experience with SOC using SpyGlass and SpyBite technologies offered a practical, efficient, and safe tool for visual/histologic diagnosis of biliary and treatment of difficult bile duct stones. These favorable outcomes provide evidence for diagnostic and therapeutic utility of these cholangioscopic advancements in managing PB disorders.Table 1.: Pancreaticobiliary Stone Patients ParametersTable 2.: Stricture Patient ParametersTable 3.: SpyGlass DS +/- Spybite tissue impression vs final diagnosis

INTRODUCTION: We describe the use of electrohydraulic lithotripsy(EHL) in conjunction with digital cholangioscopy which was used effectively to treat a retained intraoperative biliary stent in a liver transplant patient due to biliary cast which spared the patient from surgery. CASE DESCRIPTION/METHODS: A 72-year-old male who received an orthotopic liver transplant for end stage liver failure secondary to cirrhosis due to nonalcoholic steatohepatitis and hepatocellular carcinoma which was complicated by hepatic artery thrombus that ultimately required a second liver transplant with a pediatric feeding tube placed intraoperatively as an internal stent to prevent anastomotic stricture of the bile duct. Approximately eight years later, the patient presented to an ER with altered mental status and elevated liver enzymes. A computed tomography of abdomen and later a magnetic resonance cholangiopancreatography was done which showed an intra and extrahepatic biliary ductal dilation of the common hepatic and duct debris indicative of obstruction (Figure 1a,b). Endoscopy showed an enlarged prominent major duodenal papilla with a biliary stent which was visibly occluded (Figure 2). Attempted removal of stent was unsuccessful and a new plastic biliary stent was placed beside the impacted stent to relieve the obstruction. One month later, the new plastic biliary stent was removed and digital cholangioscopy was used to visualize the the bile duct which showed the endobiliary stent was embedded in stony material that was adherent the duct walls. Cholangioscope was slowly advanced from distally to proximally along the encased stent with the use of EHL which sequentially broke up the surrounding stony material. One half of the stent was stripped and the process was repeated on the other side until the stent was free floating. The stent was then successfully removed using rat-toothed forceps (Figure 3). DISCUSSION: This case demonstrated that cholangioscopy with lithotripsy can be used to treat an impacted stent in a liver transplant patient due to biliary cast. This is an unusual case as the intraoperative stent was found to be retained and the timeline of 8 years since liver transplant till presentation of biliary cast syndrome is one of the longest reported in the literature. We demonstrated a novel technique by fragmenting the cast of the encased stent from distally to proximally in order to disimpact the stent and this technique used may be applied to other challenging cases where standard methods have failed. Watch the video: http://bit.ly/32zEMOY.

Waldenstrom macroglobulinemia (WM) is a neoplastic disorder of the B-cell lymphoid system. A 69-year-old man with WM presented with diarrhea for 6 months. Magnetic resonance enterography showed thickening of the terminal ileum (TI). Colonosocopy with TI intubation showed a single TI ulcer, and small bowel enteroscopy revealed multiple ulcers in the TI. Biopsies from both were negative on hematoxylin and eosin staining. Immunoglobulin M immunofluorescence staining of the ulcers was positive for IgM deposits consistent with WM. After 6 cycles of chemotherapy with bendamustine and rituximab, symptoms resolved.

Background While the available literature recommends placement of two large-bore intravenous (2LBIV) lines in every patient presenting with acute GIB, the adherence and impact of this recommendation have never before been reported. Aims We designed a quality improvement project to assess whether the patients presenting to our institution with acute GIB have appropriate intravenous (IV) access or not. Methods We conducted a prospective, observational study, of all patients presenting to our emergency department with overt GIB over a 2-month period. Data analysis was performed, and based on the results, an intervention plan was developed and executed. Post-intervention data collection was done over a 3-month period. Our interventions included physician and nursing education, placing posters in the emergency department, and creation of an order set in the electronic medical record system. Results A total of 46 patients were in the pre-intervention group, and 71 patients were in the post-intervention group. The presence of 2LBIV lines in the pre-intervention group was only 19.5%, which improved to 36.6% in the post-intervention group ( p = 0.049). Factors associated with placement of 2LBIV lines were being in the post-intervention group and admission to the intensive care unit. Conclusion The relatively simple and cost-effective intervention of placing 2LBIV lines is not often executed. We suggest that specific mention of 2LBIV placement in guidelines from national gastroenterology societies might improve compliance in this aspect.

INTRODUCTION: Endoscopic ultrasonography(EUS) of the mediastinum with the use of fine needle aspiration(FNA) or biopsy can be used to characterize lesions that are within or adjacent to the esophageal wall, posterior and inferior mediastinum with minimal risk to the patient. EUS is an underutilized tool for identifying mediastinal masses and can help guide clinical decision making in patients with concerning lesions found on non-invasive imaging modalities. CASE DESCRIPTION/METHODS: A 71-year-old male with history of adenocarcinoma of the rectum with metastases to the liver and lung was treated with surgical resection and adjuvant chemotherapy. Patient responded well and was under regular surveillance when a new irregularly shaped abnormal soft tissue density measuring approximately 5.4 × 3.0 cm adjacent to the aorta and esophagus appearing to invade into the left atrium (Figure 1a) was found on a CT scan and confirmed on PET imaging. These findings favored rectal metastatic disease over thrombus but could not definitively rule out a new carcinoma. For that reason, an endoscopic ultrasonography was performed to determine the nature of the mass. A curvilinear array echoendoscope was used to visualize a 36 × 30 mm exophytic lesion within the left atrium which extended into the posterior mediastinum (Figure 2). Using Doppler to identify a vessel-free path, a 25-gauge needle was passed under ultrasound guidance through the esophagus and directly into the mass with the use of an endoscopic fine needle biopsy (FNB) device for three passes. Histopathological examination confirmed adenocarcinoma (Figure 3) and immunophenotype was compatible with colorectal primary which ruled out a pulmonary adenocarcinoma. DISCUSSION: The patient was determined to not be a surgical candidate due to the location of the mass and high risk nature of the surgery. The multidisciplinary team’s consensus was to repeat chemo-adjuvant therapy since he had responded so well previously. He received treatment and had follow up imaging six months after EUS diagnosis which showed decrease in size (Figure 1b) and activity of the mass. He is planned to have have stereotactic body radiation therapy to further decrease the size of the atrial mass. This case demonstrated how EUS with the use of FNA is a helpful tool in the prompt evaluation and confirmation of a mediastinal mass which allowed all physician’s involved in the care of the patient to develop and implement a treatment plan quickly. Watch the video: http://bit.ly/2Giu99S.

Introduction: First generation single operator cholangiopancreatoscopy (SOC), SpyGlass (Boston Scientific Natick, MA, USA) introduced in 2007 helped advance ductal imaging, but fiberoptics made image interpretation challenging. In 2015, the digital version, SpyGlass DS (SOC DS) was introduced for better visualization with higher resolution and wider field of view. Also, the flexibility was improved to facilitate cannulation and inspection. However, there is limited data on the performance of SOC DS. We seek to evaluate the outcomes of patients, specifically the rate of definitive clinical diagnostics and ductal clearance in patients that underwent cholangiopancreatoscopy using SOC DS. Methods: A retrospective analysis was performed in patients who underwent SOC DS intervention for pancreatobiliary (PB) stone therapy and evaluation of indeterminate biliary lesions between Nov 2015 and March 2017. Outcome measures were defined as 1) Procedure Success (PS): for stone cases, ability to visualize the PB system and/or initiate stone fragmentation and removal; for non-stone cases, ability to visualize the target lesions. 2) Clinical success (CS): for stone cases, ability to achieve complete ductal stone clearance either on first or subsequent procedures; for non-stone cases, the SOC DS diagnosis made from the most concerning impression (visual +/- tissue) was compared to a final diagnosis, which was made based on clinical, laboratory, imaging or pathological findings with a minimum of 6 months follow-up. Results: A total of 67 procedures were performed for management of PB disorders with a PS of 100%. CS for stone management was 93.9% (31/33) with complete duct clearance accomplished in a single procedure in 81.8% (27/33), two procedures in 12.1% (4/33). Only 2 (6.1%) patients with pancreatic duct stones had incomplete or partial duct clearance (Table 1). CS was 91.1% in determining benign or malignant stricture. The ability of SOC DS to provide a definitive ductal diagnosis with a single procedure was 85.3% (29/34) (Table 2). Overall CS rate for all SOC DS procedures was 92.5% (62/67). There was an adverse event rate of 6% (4/67), two patients developed abdominal pain and two patients developed pancreatitis.Table: Table. Stone casesTable: Table. Stricture casesConclusion: SOC DS demonstrated a high rate of ductal stone clearance and definitive ductal diagnosis with an acceptable adverse event rate. The favorable outcomes may be due to the technological advancement with better visualization. Further, multicenter prospective studies are needed.

Introduction: Gastrointestinal bleeding (GIB) is a common clinical presentation and carries substantial morbidity and mortality. While the available literature recommends placement of 2 large bore intravenous lines (2LBIV) in every patient presenting with GIB, the adherence and impact of this recommendation has never before been reported. We designed a quality improvement project to assess whether the patients presenting to our hospital with symptoms consistent with acute GIB have appropriate intravenous (IV) access or not. Our goal was to improve adherence to 2LBIV lines in patients with acute GIB. We hypothesized that appropriate IV access in acute GIB patients will result in reduction in length of stay, transfers to higher levels of care, mortality, and number of blood transfusions received.Table: Comparison of Outcomes in Pre and Post Intervention Group.Methods: We conducted a prospective, observational study, of all patients presenting to our emergency department with overt GIB over a 2 month period. Data analysis was performed and based on results, an intervention plan was developed, and executed. Post-intervention data collection was done over a three month period. Our interventions included physician and nursing education, placing posters in the emergency department, and creation of an order set in the electronic medical record system. Results: A total of 46 patients were in the pre-intervention group and 71 patients were in the postintervention group. The presence of 2LBIV lines in the pre-intervention group was only 19.5%, which improved to 36.6% in the post-intervention group (p=0.049). Outcomes between pre and post-intervention group are compared in table 1. Conclusion: The relatively simple and cost-effective intervention of placing 2LBIV lines is not often executed. Our investigation suggests that patients with GIB who are more critical are likely to get 2LBIV lines, i.e. patients admitted to the ICU, patients with acute kidney injury and those with lower blood pressures on presentation. A systematic multi-directional intervention strategy can improve compliance with 2LBIV lines, which is the basic first step in management of acute GIB patients. We suggest that specific mention of 2LBIV placement in guidelines from national societies like the American College of Gastroenterology (ACG) might improve compliance in this aspect.

Extraintestinal Clostridium difficile is rare. A 74-year-old man with a history of ulcerative colitis presented after a fall. Trauma work-up showed liver cirrhosis. Two days later he developed abdominal pain, distension, diarrhoea and leucocytosis. Stool tested positive for C. difficile CT abdomen showed pancolitis with toxic megacolon. Total abdominal colectomy and ileostomy with a rectal stump was performed. He was discharged, but was readmitted with sepsis. CT abdomen showed a 10.4×7.2 cm fluid collection in the pelvis. C. difficile stool was negative. CT-guided abscess drainage grew C. difficile Barium enema was negative for communication from the rectal stump to the abscess. The patient was treated with metronidazole for 2 weeks. In summary, extraintestinal C. difficile can develop from recent antibiotics use, gastrointestinal surgery and microperforations from toxic megacolon. We recommend abscess drainage, concomitant treatment with metronidazole and or vancomycin, and reimaging of abscess location 2-4 weeks after cessation of antibiotics.

Lyme disease (LD) is a tick-borne illness caused by Borrelia burgdorferi sensu stricto. An 80-year-old female from Pennsylvania, USA, presented to an outside hospital with fever, confusion, lower extremity weakness, and stool incontinence. CT head and MRI spine were unremarkable. An infectious work-up including lumbar puncture was negative. She was transferred to our tertiary care hospital. Patient was noted to have mild unilateral right-sided facial droop and a diffuse macular rash throughout the body. She denied any outdoor activities, tick bites, or previous rash. Intravenous ceftriaxone was started for suspected LD. The patient's symptoms including facial droop resolved within 24 hours of antibiotic therapy. Polymerase chain reaction of the blood, IgMELISA, and IgMWestern blot testing for LD came back positive a few days after initiation of therapy. She was treated for a total of 21 days for neurological LD with complete symptom resolution. Not all patients have the classic "targetoid" EM rash on initial presentation, rash could develop after neurological manifestations, and prompt initiation of antibiotics without awaiting serology is paramount to making a quick and a full recovery. There should be a high index of suspicion for early disseminated LD, as presentations can be atypical.

Introduction: Endoscopic ultrasound (EUS) requires a high level of physician alertness in the evaluation of pancreatic lesions. Colonoscopy studies that demonstrated decreased polyp detection in the afternoon as compared to morning schedules have postulated physician fatigue as contributory factor. It is possible that timing of EUS-guided FNA of solid pancreatic lesions may impact its quality. We aimed to compare the diagnostic yield of morning versus afternoon EUS-FNA procedures of solid pancreatic lesions.Table 1: Baseline Patient Demographics and CharacteristicsTable 2: EUS-FNA Performance CharacteristicsFigure 1Methods: This was a retrospective study performed at two academic tertiary care hospitals from July 2014 to December 2015. Patients who underwent EUS-guided FNA of a pancreatic lesion were included. Outcome variables, including diagnostic accuracy, number of FNA passes, procedure length, FNA cytology results, and complication rates between morning and afternoon procedures were compared. Results: A total of 167 procedures were included (62 [37.1%] in morning and 105 [62.9 %] in the afternoon). There were no significant differences in diagnostic accuracy, sensitivity or specificity between morning and afternoon groups (85.5% vs 91.4%, 87.7% vs 92.7%, 75% vs 100%, respectively). Overall mean number of pass counts required to obtain an adequate sample was similar between the two groups. Procedures performed in the morning took longer compared to afternoon cases (43.6 min vs 37.2 min, p=0.02). Cumulative dose of propofol and overall procedure-related complications were not significantly different between the two groups. Conclusion: Timing of EUS-FNA of solid pancreatic lesions does not affect diagnostic accuracy, adequacy of sampling, cumulative dose of anesthetic, and procedure-related complications.

FigureSurgical therapy is the gold standard for any sub-epithelial lesions. Endoscopic therapy including endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are routinely being utilized but these have an inherent risk of perforation.When surgical or endoscopic therapy cannot be used the “Loop and Let Go” technique can be utilized for auto amputation of the sub-epithelial lesions. A 93-year-old white female with multiple comorbidities including coronary disease status post CABG with repeat cardiac stent on aspirin and plavix presented to outside hospital for weakness. She was subsequently found to have melena with hypotension and drop in hemoglobin and transferred to our institute. Upper endoscopy demonstrated a 2cm subepithelial lesion in the duodenal apex. An endoscopic ultrasound demonstrated a 2cm hypoechoic lesion arising from the 3rd layer likely a gastrointestinal stromal tumor (GIST). With significant comorbidities a “Loop and Leg Go” technique was approved by the patient and family. An upper endoscopy was performed. A double channel therapeutic scope was used for this procedure. Through one channel, an endoloop was advanced, and was placed around the lesion. To get a better approximation and take the loop down to the the pedicle, a rat-tooth forceps was placed through the other working channel. It was used to grasp the lesion and pull it towards the scope. After further manipulation endoloop was taken down to the base of the lesion, tightened and deployed. Three weeks later we repeated an endoscopy and demonstrated no GIST tumor. The duodenal mucosa was normal. There was no ulceration or necrotic tissue at the site of the prior loop placement. This demonstrates the safety of utilizing the “Loop and Let Go” technique as a noninvasive management of large GI tract subepithelial lesions in patients with multiple co-morbidities who are not good surgical candidates.

Clostridium difficile infection (CDI) occurs due to disruption of the normal colonic flora and overgrowth of toxigenic clostridium difficile (CD) causes a spectrum of manifestations, ranging from an asymptomatic carrier state to fulminant disease with toxic megacolon. CDI very rarely presents outside the colon. A 70 year old male with history of ulcerative colitis (UC), previously on sulfasalazine and antibiotics presented to the hospital with hip fracture after sustaining a fall. Trauma work up included a computed tomography (CT) of the abdomen, which showed an incidental finding of liver cirrhosis. Over the next 2 days, the patient developed severe abdominal pain, distension, diarrhea and leukocytosis. He tested positive for CDI, confirmed by PCR from the stool sample. A repeat CT abdomen showed pancolitis with dilated colon, suggestive of toxic megacolon. For the severe, complicated CDI a total abdominal colectomy and ileostomy with a rectal stump was done. He was discharged to a rehabilitation facility 10 days later. A week after discharge the patient represented to the hospital with chills, nausea, vomiting, mucus like discharge from the rectum. CT scan of the abdomen without contrast showed ileal loops with severe inflammatory changes and a 10.4 x 7.6 cm fluid collection in the pelvis above the urinary bladder. Repeat testing for CD was negative. A CT guided drainage of the abscess with catheter placement was done by Interventional radiology. The fluid aspirate culture grew CD. A barium enema performed did not reveal any leakage or communication from the rectal stump to the abscess. He was treated with intravenous metronidazole for 1 week with resolution of symptoms and was eventually discharged on oral metronidazole. The development of extra-intestinal CD abscess is very rare. Although no absolute causal link can be established in our case, it is likely due to a combination of factors such as gastrointestinal surgery causing possible leakage, severe and complicated CDI with toxic megacolon which might have led to microperforations, helping in setting up an extra-intestinal focus of infection. Immunosuppressed states such as UC and liver cirrhosis might have had a role in the development of this abscess as reported in the literature. In such cases, we recommend drainage of the abscess along with concomitant treatment with metronidazole and or vancomycin. We also recommend reimaging the abscess prior to cessation of antibiotics.

Mirizzi syndrome (MS) is characterized by extrinsic compression of the common bile duct (CBD) by an impacted stone in the cystic duct or Hartmann's pouch. An 80 year old female with history of questionable ulcerative colitis (UC) presented to the hospital after sustaining a fall with complaints of abdominal pain and diarrhea. Physical exam was negative for organomegaly or tenderness. Labs showed a WBC of 14,000/μL with normal LFTs. Computed tomography (CT) of the abdomen showed transverse and descending colon thickening consistent with colitis, intra and extra-hepatic dilation and choledocholithiasis. Endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and stone removal was done. No extravasation of dye or air was noted. Colonoscopy was performed which showed diffuse mucosal erythema of the entire colon, multiple pseudo-polyps and a 10 mm polyp at approximately 70 cms proximal to the anus with 1 mm mucosal defect (? fistula vs microperforation) in the region of the flat polyp. Biopsies were not performed for concerns of perforation. Pathology with random biopsies of the colon revealed features suggestive of UC without dysplasia. She was taken up for laparoscopic total abdominal colectomy for refractory colitis and concern for DALM. The diagnosis of MS was made intra operatively. A thick, hard mass of gallbladder (GB) containing a stone with chronic inflammatory changes involving the duodenum and colon was found along with a cholecysto-colonic fistula (CCCF), correlating with the indentation noted endoscopically. CCCF take down and stone removal was done. A cholangiogram showed a normal anatomy to the intrahepatic ducts and duodenum. A partial cholecystectomy with a T tube placement in the CBD for MS type II was done. Pathology of the resected specimen was negative for malignancy of the GB and colon. MS is seen in 1% of gall stone disease. It is associated with GB cancer in 2% of the cases. Incidence of CCCF has decreased over the past two decades due to increased frequency of cholecystectomy at a younger age, reducing cholecystectomy in the elderly, when a long lasting GS disease is more likely to cause it. Etiology of CCCF is likely due to chronic inflammatory process of the GB. Preoperative diagnostic tools often fail to demonstrate it, with low sensitivity (50%). Diagnosis is often achieved intraoperatively. In those circumstances intraoperative hepatobiliary exams should be performed to look for other possible anomalies.