Microscopic colitis is a common cause of chronic diarrhea, particularly in patients with autoimmune disorders. Colonic mucosa appears normal and only shows inflammation on histological examination. There are two histological variations of microscopic colitis. It has been associated with several drug classes, and certain drugs are associated with one variation or another. In this case report, we discuss the case of a patient who is on a drug not previously associated with her variation of microscopic colitis and who has an autoimmune condition whose relationship to microscopic colitis is not well studied. We aim to outline the potential triggers for the disease and to call for further studies regarding how certain drugs and/or autoimmune disorders trigger it in order to further our understanding and improve management.
A 64-year-old woman with traumatic brain injury and chronic percutaneous endoscopic gastrostomy (PEG) tube presented to the emergency room with nonradiating acute epigastric abdominal pain for 3 days. The external PEG bumper measured 8 cm. Lipase was 550 U/L (ref: 0-160 U/L), and abdominal computed tomography revealed migrated inflated PEG balloon into the duodenal bulb resulting in extrinsic mass effect on the pancreatic segment of the common bile duct with notable dilation of the common bile duct (Figures 1 and 2). The PEG tube was repositioned, and the bumper was adjusted to 4 cm. Abdominal X-ray showed the PEG balloon within the midgastric body (Figure 3). Her pancreatitis improved, and she was ultimately discharged. PEG tubes are commonly used for enteral nutrition in patients incapable of maintaining adequate oral intake and are generally safe and effective. 1,2 Complications of PEG include hemorrhage, infection, intestinal perforation, and peritonitis, whereas pancreatitis is rare and has only been reported sparingly. 3 The external bumper may dislodge, leading to tube migration, and therefore warrants frequent checks to ensure the bumper is firmly in place. 3,4 Resolution of symptoms in other cases occurred with tube repositioning, as seen in our patient. [3][4][5]
Neoplasms arising from the ampulla of Vater are exceedingly rare, and there is a paucity of literature regarding their diagnosis and management. Ampullary cancer typically presents with jaundice and signs of biliary obstruction. We present a case of ampullary adenocarcinoma with concomitant choledocholithiasis that proved complex and diagnostically challenging.
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