Percutaneous Endoscopic Gastrostomy: A Possible Trigger for Dieulafoy's Lesion

Introduction

Upper gastrointestinal (GI) bleeding is a medical condition commonly seen in clinical practice due to variable etiologies and a multitude of presentations. The patients can present with hematemesis, melena, or hematochezia in case of severe bleeding. The initial evaluation should involve assessing the hemodynamic status with adequate resuscitation followed by diagnostic tests to identify the source and potentially treat it. Dieulafoy's lesion, sometimes referred to as Dieulafoy's disease, is a rare cause of upper GI bleeding with no clear risk factors, which makes it a diagnostic conundrum. Here we describe an unusual case of Dieulafoy's lesion developing following percutaneous endoscopic gastrostomy (PEG) placement.

Case Presentation

We describe a case of a 70-year-old female patient with a past medical history of hyperlipidemia, well-controlled hypertension, and an ischemic cerebrovascular accident, which caused neurologic dysphagia and placement of a PEG tube 3 weeks prior. She presented to the emergency department due to melena, with hypotension of 90/50 mmHg, tachycardia of 126 beats/minute, and hemoglobin of 5.6 g/dl. An endoscopy revealed a Dieulafoy's lesion on the lesser curvature of the stomach just across the PEG tube, which was managed with epinephrine and hemoclips.

Conclusion

This is a rare case of Dieulafoy's lesion on the lesser curvature of the stomach, potentially developing due to PEG placement.

Sex and racial disparities in non-alcoholic fatty liver disease-related cardiovascular events: National inpatient sample analysis (2019)

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) increases cardiovascular disease (CVD) risk irrespective of other risk factors. However, large-scale cardiovascular sex and race differences are poorly understood.

AIM

To investigate the relationship between NAFLD and major cardiovascular and cerebrovascular events (MACCE) in subgroups using a nationally representative United States inpatient sample.

METHODS

We examined National Inpatient Sample (2019) to identify adult hospitalizations with NAFLD by age, sex, and race using ICD-10-CM codes. Clinical and demographic characteristics, comorbidities, and MACCE-related mortality, acute myocardial infarction (AMI), cardiac arrest, and stroke were compared in NAFLD cohorts by sex and race. Multivariable regression analyses were adjusted for sociodemographic characteristics, hospitalization features, and comorbidities.

RESULTS

We examined 409130 hospitalizations [median 55 (IQR 43-66) years] with NFALD. NAFLD was more common in females (1.2%), Hispanics (2%), and Native Americans (1.9%) than whites. Females often reported non-elective admissions, Medicare enrolment, the median age of 55 (IQR 42-67), and poor income. Females had higher obesity and uncomplicated diabetes but lower hypertension, hyperlipidemia, and complicated diabetes than males. Hispanics had a median age of 48 (IQR 37-60), were Medicaid enrollees, and had non-elective admissions. Hispanics had greater diabetes and obesity rates than whites but lower hypertension and hyperlipidemia. MACCE, all-cause mortality, AMI, cardiac arrest, and stroke were all greater in elderly individuals (P < 0.001). MACCE, AMI, and cardiac arrest were more common in men (P < 0.001). Native Americans (aOR 1.64) and Asian Pacific Islanders (aOR 1.18) had higher all-cause death risks than whites.

CONCLUSION

Increasing age and male sex link NAFLD with adverse MACCE outcomes; Native Americans and Asian Pacific Islanders face higher mortality, highlighting a need for tailored interventions and care.

Light-Chain (AL) Cardiac Amyloidosis Presenting as Heart Failure With Reduced Ejection Fraction

Systemic amyloidosis is caused by the extracellular deposition of misfolded proteins in various organs and usually leads to organ dysfunction. The two common subtypes include light-chain amyloidosis and transthyretin amyloidosis. Deposition of these proteins in the heart can lead to infiltrative and restrictive cardiomyopathy, commonly manifesting as heart failure with preserved ejection fraction. However, systolic heart failure with reduced ejection fraction is mainly seen in the advanced stages of the disease. Here, we present the case of a 53-year-old female who presented with new-onset heart failure with reduced ejection fraction with no prior symptoms or diagnosis of amyloidosis and diastolic dysfunction.

Benign Pneumoperitoneum Following Mitral Valve Replacement

The pneumoperitoneum refers to the presence of free air inside the abdominal cavity. This finding is usually a sequela of a gastrointestinal tract perforation. Still, in rare instances, it can present after cardiac surgery due to the proximity of the peritoneal cavity and pericardium, allowing air to enter the peritoneal cavity. Our patient was a 63-year-old female who initially presented for revision of the mitral valve replacement. A chest X-ray on postoperative day 13 revealed a 6.6 cm lucency under the right diaphragm suggestive of pneumoperitoneum. She was discharged after serial chest X-rays revealed a decrease in the size of the pneumoperitoneum. Twelve days later, our patient was readmitted, as another chest X-ray revealed that the size of the pneumoperitoneum was again increasing. An endoscopy was performed, but it did not reveal any lesions or etiology that would lead to a leak from the gastrointestinal tract. Finally, due to the benign nature of the pneumoperitoneum and the decrease in its size over the following days, we opted for conservative management, and she was discharged again. This case emphasizes the rare occurrence of benign pneumoperitoneum post-mitral valve surgery. While surgery may not always be required for asymptomatic cases, careful vigilance post-cardiac surgery remains crucial to detect potential abdominal complications promptly.

A Rare Case of Candida glabrata Cervical Spondylodiscitis

Introduction

Invasive candidiasis can lead to numerous life-threatening sequelae. Candida glabrata is the second-most common causative species of invasive candidiasis. This species possesses a high risk for persistent infection and candidemia. An uncommon complication of invasive candidiasis is spondylodiscitis and can rarely affect the cervical spine.

Case Presentation

The patient is a female in her late 50s with a complex medical history inclusive of chronic obstructive pulmonary disease, chronic pain, multiple abdominal surgeries, prolonged intensive care unit admission, and administration of total parenteral nutrition and broad-spectrum antibiotics who presented with complaints of worsening neck pain. She was last hospitalized 3 months prior and found to have C glabrata fungemia but was nonadherent to antifungal therapy.She was found to have advanced C5-6 spondylodiscitis and an epidural abscess. Her surgical cultures grew C glabrata. Despite surgical intervention and antimicrobial therapy, she clinically deteriorated and acquired septic shock with multiorgan failure.

Conclusion

This is a rare case of cervical spondylodiscitis caused by a deep-seated C glabrata infection.

Primary Dedifferentiated Duodenal Liposarcoma With Gastric Outlet Obstruction: A Rare Small Bowel Tumor

Liposarcoma is the most prevalent malignant soft tissue tumor and is primarily found in extremities and retroperitoneum, but its occurrence within abdominal viscera is rare. Most of these cases have been reported in the esophagus and stomach. Among liposarcomas of the gastrointestinal tract, primary duodenal liposarcomas are exceptionally rare, with only five documented cases in the literature. We describe a case of a 66-year-old female presenting with syncope, melena, and anemia. Computed tomography (CT) showed soft tissue mass involving the superior wall of the duodenum and hypo-enhancing hepatic mass. An endoscopy was performed, which revealed a duodenal mass causing gastric outlet obstruction and significant bleeding. Therefore, laparotomy was performed with extensive lysis of adhesions and gastrojejunostomy.

A Rare Case of Primary Extra-Nodal Marginal Zone Lymphoma of Mucosa-Associated Lymphoid Tissue (MALT) in the Rectum

Mucosa-associated lymphoid tissue (MALT) is a unique clinical condition that can manifest in different anatomic locations. In the gastrointestinal tract, it is typically seen in the stomach but is less commonly found in other sites. There have been a few cases in the literature in which primary MALT lymphoma is found in the rectum. We describe a case of a 63-year-old male who presented with rectal pain and bleeding. Colonoscopy revealed a rectal mass, which was excised with a trans-anal approach. Histopathological examination of the biopsy specimen was significant for MALT lymphoma. Therefore, the patient underwent radiation therapy followed by repeat colonoscopies to monitor disease recurrence.

The First Case of Daratumumab-Induced Fulminant Hepatic Failure

Drug-induced liver failure is a relatively uncommon condition with a vast spectrum of clinical manifestations, and it is a leading cause of acute hepatic failure in the United States. We describe the first case of fulminant hepatic failure induced by chemotherapeutic drug daratumumab, a common FDA-approved agent. A 77-year-old male, with a history of multiple myeloma, was admitted for left lower extremity cellulitis, two weeks after receiving his first intravenous infusion of daratumumab. He developed fulminant hepatic failure in the hospital a few days later. Despite multiple doses of N-acetylcysteine, his liver function continued to decline, and he expired shortly after.

Acute Pancreatitis-Induced Thrombosis of Celiac Artery: An Unusual Complication of Acute Pancreatitis

Acute pancreatitis can lead to both local and systemic complications, including pseudocysts, biliary obstruction, duodenal obstruction, sepsis, necrosis, vascular complications, and multiorgan failure. Vascular complications following acute pancreatitis are associated with a high risk of morbidity and mortality due to their thrombotic and hemorrhagic effects. When thrombosis is present, it usually involves the splanchnic venous system, but it is rarely seen in the arterial system. Celiac artery thrombosis is rare with only a few cases reported in the literature. In this case, we present a 65-year-old Hispanic female who presented to the emergency department with abdominal pain and nausea, with computed tomography angiography (CTA) of the abdomen revealing acute pancreatitis with thrombosis of the celiac artery, which was managed with anticoagulation.

Acute Fulminant Cerebral Edema Caused by Influenza Type B in an 18-Year-Old Female: A Rare Case

Most influenza B infections are self-limited, but in some instances, they can cause substantial morbidity and mortality due to complications. Acute fulminant cerebral edema (AFCE) is one of the rare complications. AFCE, a consequence of acute encephalitis, presents as acute onset of alteration in mental status, seizure, and/or headache followed by rapidly progressive encephalopathy, often leading to death. The exact pathophysiology of AFCE is unknown, but many pathomechanisms have been proposed. We present a case of an 18-year-old female in excellent physical condition who presented with respiratory insufficiency after being recently diagnosed with influenza B infection. Three days later, she developed acute encephalopathy, leading to brain death. To our knowledge, this rare case of AFCE developing following influenza B infection is the first reported case outside the pediatric population.

Ileocecal Mesentery Arteriovenous Malformation as a Rare Cause of Ectopic Variceal Bleeding in a 58-Year-Old Male With Cirrhosis

Ectopic varices can be defined as dilated portosystemic venous collaterals that are located at a site other than the esophagus or stomach. These varices can be seen in patients with underlying portal hypertension, but bleeding from them is quite rare. The bleeding usually occurs in patients with a history of intra-abdominal surgery and adhesions. These varices are commonly found in the duodenum or rectum, but they can be present anywhere along the gastrointestinal tract. Currently, there are no well-established guidelines regarding the diagnosis and management of these variceal bleeds, and further investigations with randomized controlled or large-scale trials are required. Here, we report an unusual case of ectopic variceal bleeding from an ileal arteriovenous malformation (AVM), which presented as syncope associated with an acute abdomen in a patient with no prior history of intra-abdominal surgery.

Fulminant Hepatic Failure With Minimal Alcohol Consumption in a 25-Year-Old Female With Hereditary Hemochromatosis: A Rare Case

Hereditary hemochromatosis (HH) is an inherited disorder in which organ damage and other clinical manifestations are commonly seen in patients with a homozygous mutation involving C282Y of the HFE gene, causing increased iron absorption in the intestine. The liver is the primary site of iron deposition, and excessive iron overload can eventually lead to hepatic cirrhosis. Patients who drink significant amounts of alcohol are more likely to develop cirrhosis, and in females, it is commonly seen after menopause. We describe a young female with hereditary hemochromatosis who developed fulminant hepatic failure with minimal alcohol consumption at age 25.