A 63-year-old man presented with fever and generalized weakness for 2 days. Computed tomography scan showed an intramural duodenal abscess and a linear radiolucent foreign body penetrating the duodenal wall. Endoscopic drainage was performed. Endoscopic ultrasound showed fluid collection in the second portion of the duodenum. The duodenal lumen was punctured with the creation of stoma using a lumen-apposing metal stent and electrocautery system. The stent was deployed, and the drainage of purulent fluid followed. The foreign body was suspected to be a wire brush bristle. The patient received intravenous antibiotics for 14 days. Follow-up images showed the resolution of the abscess.

INTRODUCTION: Metastatic melanoma of cutaneous origin is known to affect the GI tract. The jejunum and the ileum are commonly involved sites. Metastatic melanoma of uveal origin affecting the GI tract has been rarely reported. CASE DESCRIPTION/METHODS: A 46 year-old male with a diagnosis of right-sided ophthalmic uveal melanoma (diagnosed in 2007, treated with brachytherapy, with no evidence of recurrent disease) presented to Emergency Department with complaints of abdominal pain, nausea, and vomiting of 2 days. The CT scan of the abdomen showed a small bowel mass, measuring 4.3 × 4.6 × 6 cm causing intussusception. The patient underwent laparoscopic small bowel resection, and was found to have a jejunal mass causing intussusception. The mass was reported as malignant melanoma invading through the muscular wall into subserosal adipose tissue, and two lymph nodes were positive for metastatic melanoma. Next generation sequencing showed GNAQ and SF3B1 mutations, confirming metastatic uveal melanoma. The patient was initially started on a chemotherapy regimen and is now undergoing treatment with immunotherapy. DISCUSSION: Malignant melanoma of cutaneous origin has high metastatic potential. The GI tract is one of the most common sites of metastasis, among which the jejunum and the ileum are the most common sites. Most metastases go unrecognized or do not present clinically with gastrointestinal symptoms. Uveal melanoma does not contain recurrent BRAF or NRAS mutations, which are present in metastatic cutaneous disease. Common sites of metastasis of uveal melanoma include the liver, lung, soft tissue, and bone, whereas cutaneous melanoma metastasizes to the lung, soft tissue, and the GI tract. Cutaneous melanoma metastases to the GI tract have been reported multiple times in the literature, while uveal melanoma metastases to small bowel causing intussusception have rarely been reported. In our case, the patient had no evidence of disease for 11 years before he suddenly presented with GI symptoms. In patients with a history of uveal melanoma, metastatic melanoma should be considered when presenting with unusual GI symptoms.

INTRODUCTION: Rectal melanoma is a very rare, highly aggressive malignancy. Anal melanoma is the 3rd most common melanoma after the cutaneous and ocular varieties. It is the most common site of primary GI melanoma. Cutaneous melanoma metastasizes to the GI tract only 2% of the time, and only 2% of these metastases are to the rectum. CASE DESCRIPTION/METHODS: A 68-year-old male with a past medical history of HTN presented for evaluation of changed bowel movements. His stool diameter had decreased, and he noticed bright red blood mixed with his stool. He sometimes experienced fecal urgency, with no output. Rectal bleeding occurred just before or with bowel movements. He recently changed his diet, because of constipation. He recently lost 10 lbs. unintentionally. He did not use NSAIDs aside from aspirin 81 mg qd. He had a colonoscopy 5 years ago, with a 2 mm polyp removed (no abnormality seen on pathology). He had no family history of colon cancer. He was a retired chiropractor. A colonoscopy was performed, which found a suspicious lesion in the rectum (biopsied). Pathology showed pigmented melanoma. EUS staged the rectal mass as uT2uN1. Immunostains of the biopsy were performed: CK20-, CDX2-, p63-, S100 focally positive, HMB45 diffuse and strongly positive. No evidence of cutaneous melanoma was found. He was referred for surgical and oncology evaluation and treatment. He successfully underwent laparoscopic abdominal perineal resection with end colostomy. 9/10 sampled lymph nodes during surgery were positive for melanoma. He was started on nivolumab/ipilimumab dual therapy. He proceeded to undergo chemotherapy as outpatient (currently on chemotherapy cycle 2). DISCUSSION: Anorectal melanoma is a rare disease, accounting for ∼ 0.05% of all colorectal malignancies, and 1% of all anal cancers. Risk factors for anorectal mucosal melanoma are not currently known, although there is an increased risk associated with HIV infection. Survival is poor, depending on staging (Stage I – 24 month median survival; 5-year survival 26.7%, Stage II – median survival 17 months; 5-year survival 9.8%, Stage III – median survival 8 months; 5-year survival 0%). Adjuvant therapy consists of radiotherapy, however adjuvant immunotherapy with nivolumab has an established role in treating lymph node involvement. Anti-CTLA4 monoclonal antibody ipilimumab has been shown to significantly prolong survival in cutaneous melanoma, however more investigation is necessary to clarify role of ipilimumab in patients with mucosal melanoma.

INTRODUCTION: With bariatric procedures becoming more prevalent, performing an ERCP becomes a challenge with patients who have had bariatric surgeries. CASE DESCRIPTION/METHODS: A 60 year old male with a past medical history of hypertension, diabetes mellitus type 2, and Roux-en-Y gastric bypass surgery developed abdominal pain 3 days prior to admission and was admitted for a laparoscopic cholecystectomy. Pre-operative MRCP did not show any significant common bile duct obstruction (a small non-obstructing stone was noted). Intraoperatively, the stone was found to be obstructing the common bile duct after a cholangiogram was performed. A laparoscopic trans-gastric ERCP was scheduled. The ERCP was scheduled for the next day. After a laparoscopic gastrostomy, the ERCP scope was advanced through the gastrostomy and the stone was removed with standard biliary sphincterotomy and balloon extraction without complications. The gastrostomy site was closed, and the procedure finished without complications. The patient was discharged in good condition 2 days after the procedure. DISCUSSION: An ERCP in a Roux-en-Y gastric bypass patient requires careful planning with surgery. Nonetheless, the time of the procedure is shortened considerably compared to the older double-balloon approach and shorter anesthesia overall is associated with better outcomes for the patient. One surgical approach to these patients is a transgastric approach through gastrostomy (either laparoscopic or open surgical approach). The open approach is achieved by creating an opening in the abdominal wall, and attaching the gastric wall to the opening, then opening it for the ERCP scope to be advanced through. In this particular case, a laparoscopic gastrostomy was performed in the distal area of the stomach, and cannulated with a 15 mm cannula through an umbilical port. An 11 mm ERCP scope was then inserted through the trocar directly into the stomach, and advanced to the pylorus where the gastroenterologist was able to cannulate the common bile duct. A stent was not placed in this particular case, as it would require repeat surgery to remove it. The gastrostomy was then closed by a mini laparotomy. Alternative approaches to GI procedures will become more common with the growing prevalence of bariatric procedures.

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Babesiosis is a parasitic infection of the Babesia protozoa, which has been increasing in incidence in endemic areas of the United States. Symptoms of babesiosis can occur on a wide spectrum, from a mild flu-like illness to a fulminant disease course. Known complications of severe cases include intravascular hemolytic anemia and may involve the coagulation system, heart, spleen, kidneys, and in some cases, the lungs. This case report describes an 81-year-old, asplenic female in northern Wisconsin who presented to a hospital with shortness of breath and a non-productive cough. Definitive diagnosis of babesiosis, which was made through both a nucleic acid panel and blood smear, was initially delayed given the rare pulmonary manifestation of babesiosis. When the lungs are involved in the disease course, non-cardiogenic pulmonary edema leading to acute respiratory distress syndrome is among the most commonly seen complications. The pathophysiology of pulmonary involvement has not been made entirely clear but is most likely multifactorial, including the sequelae of changes to both the patient's red blood cells and pulmonary vasculature. This report highlights that atypical tick-borne illnesses like babesiosis should be considered as a cause of acute respiratory failure, particularly in the setting of sepsis and fever. The threshold for parasitic testing should be low in patients in endemic regions with risk factors, including increased age and history of asplenia, as babesiosis frequently has no localizing symptoms to suggest a protozoan infection. As babesiosis incidence continues to rise, prompt diagnosis and proper treatment can prevent severe complications and death in patients.