SummaryAcquired fistulas between the tracheobronchial tree and the gastrointestinal tract are rare but serious complications of laparoscopic sleeve gastrectomies with significant morbidity and mortality. With the rising popularity and widespread acceptance of bariatric surgery techniques, the occurrence of gastrobronchial fistulas is being increasingly recognised. We present the case of a 26-year-old woman who underwent laparoscopic sleeve gastrectomy for morbid obesity and presented later with a history of chronic productive cough. Upper gastrointestinal series showed the presence of a communicating fistula between the stomach and the lung, with extravasation of contrast into the lung. The aim of this paper is to highlight the importance of considering the diagnosis of a gastrobronchial fistula in cases of persistent respiratory infections in the postoperative period following bariatric surgery and to review its incidence, clinical manifestations and treatment. BACKGROUND
Blastocystis hominis and Endolimax nana exist as two separate parasitic organisms; however co-infection with the two individual parasites has been well documented. Although often symptomatic in immunocompromised individuals, the pathogenicity of the organisms in immunocompetent subjects causing gastrointestinal symptoms has been debated, with studies revealing mixed results. Clinically, both B. hominis and E. nana infection may result in acute or chronic diarrhea, generalized abdominal pain, nausea, vomiting, flatulence and anorexia. We report the case of a 24-year-old immunocompetent male presenting with chronic diarrhea and abdominal pain secondary to B. hominis and E. nana treated with metronidazole, resulting in symptom resolution and eradication of the organisms. Our case illustrates that clinicians should be cognizant of both B. hominis and E. nana infection as a cause of chronic diarrhea in an immunocompetent host. Such awareness will aid in a timely diagnosis and possible parasitic eradication with resolution of gastrointestinal symptoms.
A 91-year-old African American man was admitted with sudden onset diffuse abdominal pain which radiated to the right flank. CT of the abdomen with contrast showed diverticula in the jejunum with adjacent inflammation and microperforation that was contained. Conservative therapy similar to colonic diverticulitis was effective. Although rare, our case highlights the importance of having an early and high suspicion for jejunal diverticulitis when patients present with non-specific abdominal symptoms in order to avoid perforation.
The term ‘antibiomania’ refers to manic episodes that occur after a patient starts taking antibiotics. We report the case of a 49-year-old male who developed acute psychosis secondary to initiation of triple therapy for Helicobacter pylori eradication. Unlike with proton pump inhibitors, there have been several reported cases of central nervous system side effects and psychiatric consequences due to amoxicillin, however evidence points to clarithromycin as the likely culprit. On average onset of symptoms occurred within 1–5 days of initiating therapy. In all cases, symptoms resolved upon cessation of clarithromycin, mostly within 1–3 days. Unfortunately, the mechanism through which clarithromycin causes neurotoxicity remains unclear. Clinicians should be cognizant of psychiatric side effects secondary to clarithromycin, and discontinuation should be prompt for rapid recovery of mental status.
Endoscopic hemorrhoidal band ligation is a well-established nonoperative method for treatment of bleeding internal hemorrhoids (grade 1 to 3). It is a safe and effective technique with a high success rate. Complications with this procedure are uncommon. Although rectal ulceration due to band ligation is a rare complication, it can cause life-threatening hemorrhage especially when patients are on medications which impair hemostasis like aspirin or non steroidal anti-inflammatory drugs. We present 2 cases of massive lower gastro-intestinal bleeding in patients who had a band ligation procedure performed 2 wk prior to the presentation and were on aspirin at home. Both the patients were hemodynamically unstable requiring resuscitation. They required platelet and blood transfusions and were found to have rectal ulcers on colonoscopy done subsequently. The rectal ulcers corresponded to the site of band ligation. The use of aspirin by these patients would have caused defects in the hemostasis and may have predisposed them to massive bleeding in the presence of rectal ulcers occurring after the band ligation procedure. Managing aspirin before and after the ligation may be difficult especially since adequate guidelines are unavailable. Stopping aspirin in all the cases might not be safe and the decision should be individualized.
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