Figure 1. Liver biopsy shows portal inflammation with marked increase in plasma cells. Marked interface activity is seen with areas of necrosis.
Introduction: Colorectal cancer (CRC) is the third most common cancer in men and women in the United States. Studies suggest that 20% of patients present with metastasis, most commonly to liver and lungs. Few cases have been reported with metastasis to the skull. Statistical data suggest a steady increase in CRC in patients under fifty years of age. We present an atypical presentation of metastatic adenocarcinoma of colon to the base of the skull in a young female patient. Case Description/Methods: Case of a 36-year-old female patient without medical history who presented with one month history of posterior neck pain radiating to her right ear with associated recurrent otitis refractory to oral antibiotics. There was no family history of CRC and no history of toxic habits. Physical exam with benign abdomen. Digital rectal exam with no abnormalities. Laboratories remarkable for leukocytosis with neutrophilia, thrombocytosis, hypochromic microcytic anemia; elevated alkaline phosphatase, hypoalbuminemia and normal liver function tests. Negative HIV and hepatitis profile. Head and Neck CT scan with asymmetrical nodular fullness in the posterior nasopharynx with extension and invasion of clivus consistent with osteomyelitis of skull base for which patient was started on broad spectrum IV antibiotic therapy. However, patient deteriorated with aphasia, right cranial nerve abducens paresis. Head and neck CT angiography with right cavernous sinus thrombosis requiring full dose anticoagulation. After developing acute right upper quadrant abdominal pain with decreased levels of hemoglobin without any visible bleeding source, abdominopelvic CT was performed and showed a large distal sigmoid peri colonic mass measuring 11cm x 9.4cm (Figure ) with disseminated metastatic disease. Brain MRI confirmed clivus metastatic lesion. Liver biopsy confirmed adenocarcinoma of colon. Serologic markers with elevated carcinoembryonic antigen; negative cancer antigen (CA) 19-9 and CA 125. Hospitalization was complicated due to rapidly progressive multiorgan failure for which neither colonoscopy nor chemotherapy were feasible. Supportive comfort care and hospice management were provided. Discussion: United States statistical data reports an incidence of 12% of CRC among people under 50 years old. In younger population, CRC presents in a clinically advanced and biologically more aggressive disease. Therefore, close attention to alarming and atypical symptoms in this population should warrant low threshold for early colonoscopy screening.[2253] Figure 1. Necrotic heterogenous pericolonic mass in the distal sigmoid measuring 11.0 cm x 9.4 cm.
Introduction: Colorectal Cancer (CRC) is the 3rd most diagnosed cancer worldwide with a high incidence in the USA. Most common sites of involvement with metastatic colorectal cancer (mCRC) are liver and lungs. Brain metastasis (BM) and osseous metastasis (OM) are rarely seen, let alone as the initial presentation of CRC. BM confers poor prognosis among patients with CRC. Diagnosing BM remains critical, as early surgical intervention improves outcome. This is an unusual case of mCRC presenting with neurological deficits as a feature of atypical metastatic sites -brain and bone, with concurrent lung metastasis. Case Description/Methods: A 62-year-old healthy female presented with 3 days of right upper extremity weakness. She denied any other neurological or GI complaints. Her mentation was intact but motor deficit of 2/5 in the right upper extremity was present. Labs were consistent with microcytic anemia (Hg 7.6 g/dL, MCV 71.5 fL), and elevated CEA level (36 ng/mL); transaminases were normal. CT head showed left frontal and right temporoparietal masses with vasogenic edema and mass effect upon left lateral ventricle. MRI brain was deferred due to claustrophobia. CTA chest revealed multiple nodules in bilateral lung fields and NM bone scan showed increased tracer uptake in bilateral ribs concerning for metastatic disease in lungs and bones, respectively. Concurrently, irregular wall thickening of the rectosigmoid colon suspicious for neoplasm was noted on CT abdomen. Dexamethasone was initiated and patient underwent right craniotomy with tumor resection. Pathology was positive for APC, tp53 and kras mutations, consistent with metastatic adenocarcinoma of colorectal origin. Patient was ultimately discharged home with hospice care and colonoscopy was deemed futile. Discussion: Most common sites of mCRC are liver (50%) and lungs (36%), whereas metastasis to brain and bone is very rare and is often a late presentation. Increased risk of BM and OM is associated with known lung metastasis and KRAS mutation in a patient with primary CRC. The average time between detection of OM and diagnosing CRC is reported to be 21 months. We did not find any case describing simultaneous metastasis to lung, brain and bones from primary CRC at the time of diagnosis especially in the absence of hepatic lesions. Lastly, neurological deficit, as seen in our patient, is an uncommon presentation for CRC. Increased awareness of BM and OM in mCRC is crucial for early diagnosis and intervention.
Introduction: Gastroesophageal reflux disease (GERD) is a very common disease that often presents with symptoms such as heartburn, dysphagia, odynophagia, chronic cough, asthma, belching and regurgitation. Common etiologies of GERD are-Transient lower esophageal sphincter(LES) relaxation, motility disorder, lower esophageal sphincter (LES) incompetence, short lower esophageal sphincter (, 2 to 5 cm) and increased intra-abdominal pressure due to obesity or pregnancy for example. Dolichocolon is an uncommon disease in which patients have redundant colon. It commonly presents with constipation, lower abdominal pain and in severe cases, volvulus. Dolichocolon is an unusual cause of GERD. We present an unusual presentation of an uncommon pathology. Case Description/Methods: Our patient is 56-year-old woman presented with chronic cough and chronic abdominal pain. Initially patient was diagnosed with GERD. Fundoplication was planned since patient failed medical management. During workup, dolichocolon was discovered and after subtotal colectomy, the patient's symptoms of GERD resolved (Figure ). Discussion: Dolichocolon is defined as redundant colon. We can use the following criteria to diagnose it. • Sigmoid colon above the line between iliac crests.• Transverse colon below the aforementioned line.• Extra loops at the hepatic and splenic flexure. If all of the aforementioned redundancies are present at the same time a fully developed Dolichocolon is diagnosed. The reason for the redundant sigmoid colon is thought to be the pathological elongation of the hindgut and hence subsequently the elongation of the sigmoid colon. Although Dolichocolon largely is due to congenital malformation, there are certain theories that abnormal fecal transport, loss of Cajal cells and dietary habits also play a role in acquired dolichocolon. The imaging modality of choice for diagnosis is Barium enema, although we could still use computerized tomography, colonic transit study or magnetic resonance imaging. Our proposed theory for the cause of patient's symptoms is that the redundant colon increasing pressure on the stomach and hence resulting in symptoms of GERD. This case highlights the importance of Dolichocolon as a cause of abdominal complaints and presents an unusual presentation of a rare pathology.
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