A 49-year-old man presented with abdominal pain and rectal bleeding for two days associated with a 50-pound unintentional weight loss. History was notable for hypertension, chronic kidney disease, obesity, gout, and acute cholecystitis status post cholecystectomy. Computed tomography (CT) of the abdomen and pelvis showed rectal wall thickening. Colonoscopy showed proctitis with superficial ulcerations. In the setting of renal insufficiency, malabsorption, and low-voltage QRS complexes on electrocardiogram (ECG), amyloidosis was considered in the differential diagnosis. Rectal and renal biopsies with subsequent retrospective staining of gallbladder tissue confirmed amyloid deposition. Gastrointestinal involvement of amyloidosis is relatively uncommon. Particularly, amyloid deposition in the gallbladder and rectum is very rare. The development of AA amyloidosis in our patient may have been related to gout, obesity, and the presence of a heterozygous complex variant for the MEFV (familial Mediterranean fever) gene. Awareness of this atypical presentation of amyloidosis is important, as additional staining of biopsy samples is necessary, and diagnosis allows for directed treatment.
Pancreaticoduodenectomy, or Whipple procedure, is a high-risk surgical procedure commonly performed for tumors of the pancreatic head. The pancreatico-enteric anastomosis is an important component of this procedure. The maturation and adequate healing of this anastomotic site is critical to decrease the risk of postoperative pancreatic fistulas. The use of stents can help in the healing of this anastomotic site. We present a patient with pancreatic adenocarcinoma who underwent pancreaticoduodenectomy, and presented with progressively worsening lumbar pain 7 years later. The patient was found to have osteomyelitis as a complication from an entero-spinal fistula secondary to a migrated pediatric feeding tube that was placed at the pancreaticojejunal anastomosis.
Cholangiocarcinoma is a rare clinical entity representing approximately 2% of all cancers diagnosed. More than 65% of these tumors can present at the bifurcation of the hepatic duct and are known as Klatskin tumors. Pancreatic cancer is among the top 5 leading causes of cancer death, and it usually presents at an advanced stage with metastasis commonly seen in the liver. We report a patient with established pancreatic adenocarcinoma who presented with an obstructing mass at the hepatic duct bifurcation without any prior history of biliary tract disease. This represents a new diagnosis of either intracholedochal metastatic tumor or a new diagnosis of cholangiocarcinoma found at the hepatic duct bifurcation without liver involvement in the setting of pancreatic cancer, suggesting metachronous cholangiocarcinoma with pancreatic adenocarcinoma.
GOO is often the first sign of advanced upper gastrointestinal neoplasms. The most common neoplasms associated with GOO include gastric, pancreatic, and biliary tract cancers. Urinary tract urothelial carcinoma has been a rarely documented cause of GOO.
Gastrointestinal stromal tumors (GIST) are uncommon tumors accounting for 1% of gastrointestinal neoplasms. The most common location of GISTs is in the stomach. Commonly, these tumors present incidentally with an increased presence within older patients. Spontaneous rupture of a GIST is a rare presentation of this uncommon tumor. Our case highlights the diagnostic dilemma and imaging that helped diagnose an abnormal presentation of a ruptured GIST in a young patient.
INTRODUCTION:
Proton Pump Inhibitors (PPIs) are generally considered to be safe. Recently, several observational studies have associated PPI use with potential adverse drug reactions (ADRs) including chronic kidney disease (CKD), dementia, and cardiovascular disease. Other potential ADRs such as osteoporotic fractures and increased risk of community acquired pneumonias and Clostridium difficile infection have been known for a longer period of time. Patient awareness of potential ADRs and its effect on continued use of PPIs have received little attention in the medical literature.
AIM:
To survey patients at a single community-setting outpatient endoscopy center to assess and understand gastrointestinal (GI) patient opinions about ADRs from PPI use.
METHODS:
An anonymous survey with 15 multiple choice questions regarding PPI use (two questions allowing for more than one answer) was distributed to all adult outpatient endoscopy patients at Advocate Lutheran General Hospital from January to March 2019. The survey questioned indication and duration of PPI use, awareness of PPI ADRs, level of concern for ADRs, and drug discontinuation.
RESULTS:
Of 2,288 patients surveyed, 1,689 (74%) returned the survey. Of these, 342 patients (20%) were current PPI users and were the subject of this analysis. The most common indications (multiple could be selected) for PPI usage were heartburn (n = 162), GERD (n = 155), and stomach/abdominal pain (n = 78) (Table 1). The most commonly identified ADRs related to PPI use were osteoporosis (n = 43) and CKD (n = 35) (Figure 1). However, 181 (53%) patients reported that they were not aware of any ADRs from PPIs. Of 218 (64%) patients who expressed concern regarding ADRs, 47 (14%) selected extreme concern, 57 (17%) with moderate concern, 88 (26%) somewhat concerned, and 26 (7%) hardly concerned (Figure 2). No concern was selected by 48 (14%), and 76 (22%) felt there were no ADRs from PPIs. There were 91 (27%) patients who attempted to stop their PPI treatment, but only 17 (5%) stopped because of concerns about ADRs.
CONCLUSION:
The majority of GI patients consuming PPIs are unaware of PPI-associated ADRs. However, when patients are alerted to these side effects, only approximately 60% of these patients express some degree of concern. More importantly, concern and awareness of these side effects does not appear to be a common cause for discontinuation for PPI therapy amongst GI patients.
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