Patient: Female, 88-year-old Final Diagnosis: Esophageal web • iron deficiency • Plummer-Vinson syndrome Symptoms: Dysphagia Medication:— Clinical Procedure: Esophagogastroduodenoscopy Specialty: Gastroenterology and Hepatology Objective: Rare co-existance of disease or pathology Background: Plummer-Vinson syndrome is a rare disease that presents with iron-deficiency anemia, dysphagia, and esophageal webs. It usually occurs in middle-aged White women, and it increases the risk for esophageal cancer. The prevalence of Plummer-Vinson syndrome has decreased due to early detection of iron deficiency and repletion of iron stores. Although Plummer-Vinson syndrome has also been commonly described in children and adolescents, it is seldom reported in the elderly population. Case Report: An 88-year-old women with a history of mild cognitive impairment, allergic rhinitis, and gastroesophageal re-flux disease presented with difficulty in swallowing solid foods. She had a decreased appetite, along with a 4.5-kg weight loss in the last 1 year. She was also found to have severe iron deficiency and mild anemia. Her dysphagia continued to progress even after starting iron supplementation for her iron deficiency. She eventually had a food bolus trapped in her cervical esophagus that required removal via esophagogastroduodenos-copy. A barium swallow revealed a narrowing in the upper esophagus. A repeat esophagogastroduodenoscopy revealed an esophageal web that was dilated, resulting in relief of symptoms. Conclusions: Dysphagia is reported in up to 10% of the elderly population. It commonly causes malnutrition and is associated with increased mortality. The usual etiologies include cognitive dysfunction, neurological disorders, and/or esophageal dysmotility or narrowing. Although the incidence of Plummer-Vinson syndrome has decreased over time, the possibility of its presence should not be overlooked. To our knowledge, the current case is the third case of dysphagia related to Plummer-Vinson syndrome reported in an octogenarian in the literature so far. Iron replacement can help resolve dysphagia in Plummer-Vinson syndrome but dilation of esophageal webs may sometimes be required.
Introduction:Clostridium difficile (CD) is a serious and increasingly prevalent healthcare-associated infection. The pathogenesis of CD infection (CDI) involves the acquisition of CD with a concurrent disruption of the native gut flora. Antibiotics are a major risk although other contributing factors have also been identified. Clinical management combines discontinuation of the offending antibiotic, initiation of CD-specific antibiotic therapy, probiotic agent use, fecal microbiota transplantation (FMT), and surgery as the “last resort” option. The aim of this study is to review short-term clinical results following the implementation of FMT protocol (FMTP) at our community-based university hospital.Methods:After obtaining Institutional Review Board and Infection Control Committee approvals, we implemented an institution-wide FMTP for patients diagnosed with CDI. Prospective tracking of all patients receiving FMT between July 1, 2015, and February 1, 2017, was conducted using REDCap™ electronic data capture system. According to the FMTP, indications for FMT included (a) three or more CDI recurrences, (b) two or more hospital admissions with severe CDI, or (c) first episode of complicated CDI (CCDI). Risk factors for initial infection and for treatment failure were assessed. Patients were followed for at least 3 months to monitor for cure/failure, relapse, and side effects. Frozen 250 mL FMT samples were acquired from OpenBiome (Somerville, MA, USA). After 4 h of thawing, the liquid suspension was applied using colonoscopy, beginning with terminal ileum and proceeding distally toward mid-transverse colon. Monitored clinical parameters included disease severity (Hines VA CDI Severity Score or HVCSS), concomitant medications, number of FMT treatments, non-FMT therapies, cure rates, and mortality. Descriptive statistics were utilized to outline the study results.Results:A total of 35 patients (mean age 58.5 years, 69% female) were analyzed, with FMT-attributable primary cure achieved in 30/35 (86%) cases. Within this subgroup, 2/30 (6.7%) patients recurred and were subsequently cured with long-term oral vancomycin. Among five primary FMT failures (14% total sample), 3 (60%) achieved medical cure with long-term oral vancomycin therapy and 2 (40%) required colectomy. For the seven patients who either failed FMT or recurred, long-term vancomycin therapy was curative in all but two cases. For patients with severe CDI (HVCSS ≥3), primary and overall cure rates were 6/10 (60%) and 8/10 (80%), respectively. Patients with CCDI (n = 4) had higher HVCSS (4 vs. 3) and a mortality of 25%. Characteristics of patients who failed initial FMT included older age (70 vs. 57 years), female sex (80% vs. 67%), severe CDI (80% vs. 13%), and active opioid use during the initial infection (60% vs. 37%) and at the time of FMT (60% vs. 27%). The most commonly reported side effect of FMT was loose stools.Conclusions:This pilot study supports the efficacy and safety of FMT administration for CDI in the setting of a community-based university ho...
INTRODUCTION: Dieulafoy's lesions account for 1–2% of acute GI bleeding and are characterized by dilated aberrant submucosal vessels that erode the overlying epithelium in the absence of a primary ulcer. While the majority are found in the stomach (71%), they occur along other parts of the GI tract, however rectal sites are rare and only account for 1–2%. We present a case of massive LGIB due to a rectal Dieulafoy's lesion in a patient with intermittent hematochezia. CASE DESCRIPTION/METHODS: A 58-year-old female presenting with DKA had a hospital course complicated by necrotizing pneumonia requiring VATS and trach/PEG placement. Early in her admission she developed hematochezia with Hgb drop of 9.3 to 6.4 (baseline 12–13). EGD was unremarkable. Colonoscopy revealed a 1.5 cm clean based rectal ulcer that did not require intervention. 2 weeks later recurrent hematochezia presumably from rectal tube responded conservatively with TXA soaked Merocel packing. Hematochezia re-occurred 10 days later in the setting of a gradual drop in Hgb over the previous 2 weeks requiring 3u PRBCs(11.7 to 6.7 to 8.5). The following day she had large volume hematochezia with clots and was pale, diaphoretic, and less responsive with BP of 60/45, HR of 122 and Hgb of 5.8. Resuscitative efforts included IVF bolus, 4u PRBCs, 1u platelets, 2u FFP and pressor support. Patient continued to have active passage of multiple blood clots and after bedside evaluation we elected to proceed with emergent bedside EGD/colonoscopy after 1 tap water enema. Initially CTA was considered due to the rapidity of her bleed and significant hemodynamic compromise, however patient developed AKI and was too unstable for transport. EGD was normal and colonoscopy revealed large amounts of blood in rectum, sigmoid and descending colon with brown stool proximal to splenic flexure and normal TI. The colon was irrigated and revealed a large clot in distal rectum which was injected with Epi and then removed, revealing normal mucosa. Continued irrigation revealed blushing and after careful endoscopic inspection an actively spurting small vessel was seen protruding through rectal mucosa without surrounding ulcer suggestive of a Dieulafoy's lesion. Three clips deployed with good hemostasis and site tattooed. Hgb remained stable and no recurrence of bleeding during hospitalization. DISCUSSION: This case highlights the importance of vigilance in the evaluation of recurrent LGIB with timely resuscitative and endoscopic measures in identifying a rare source of massive LGIB.
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