Painful perianal mass, presumed to be an abscess or hemorrhoids Flexible sigmoidoscopy Colonoscopy with bx MRI EUA Refractory perirectal and rectovaginal fistula with abscess IBD medications: Adalimumab Methotrexate Non-IBD medical therapies: Ciprofloxacin Metronidazole Amoxicillin-Clavulanic acid Prednisone I&D Seton placement Fistulectomy with sphincterotomy Diverting sigmoid colostomy Fistulotomy Non-healing cryptoglandular anal fistula complicated by surgery Discontinue IBD therapy Surgical f/u with consideration for clinical trial of stem cell injection or transperitoneal repair (2) 34M Abdominal pain, diagnosed with sigmoid diverticulitis Colonoscopy with bx MRI MRE CT scan EUA Refractory perianal fistula with abscess IBD medications: Infliximab Ustekinumab Tacrolimus Azathioprine Non-IBD medical therapies: Metronidazole Ciprofloxacin I&D Seton placement Isolated perianal disease in the setting of presumed CD Chronic treatment with chronic, cyclical abx (Ciprofloxacin or Amoxicillin-Clavulanic acid IBD-directed therapy (Azathioprine 1 Infliximab; will consider Upadacitinib once approved by the FDA) Planning for surgical f/u (3) 43M Painful perianal mass, presumed to be a rectal abscess Colonoscopy with bx MRI EUA Refractory perianal abscess Non-IBD medical therapies: Amoxicillin-Clavulanic acid I&D Isolated cryptoglandular abscess with potential hemorrhoids No need for chronic antibiotics Sitz baths and PrepH as needed If symptoms worsen will plan for EUA and surgical f/u (4) 24F Perianal pain, diagnosed as perianal abscess with fistula Colonoscopy with bx MRI EUA Refractory perianal abscess, inflammatory arthropathy IBD medications: Adalimumab Infliximab Azathioprine Non-IBD medical therapies: Ciprofloxacin Metronidazole I&D Seton placement Presumed CD with perianal disease and inflammatory arthropathy IBD-directed therapy (Azathioprine 1 Infliximab) Planning for surgical f/u (5) 50F Diarrhea and rectal ulcers, presumed to have CD Colonoscopy with bx MRI CT EUA Refractory perianal fistula with abscess IBD medications: Infliximab Non-IBD medical therapies: Colchicine Prednisone I&D Seton placement Perineal debridement Lay open fistulotomy Presumed CD with perianal disease IBD-directed therapy (Infliximab)Abbreviations: Bx 5 biopsies. CD 5 Crohn's disease. EUA 5 exam under anesthesia. F 5 female. F/U 5 follow up. I&D 5 incision and drainage. IBD 5 inflammatory bowel disease. M 5 male. MRE 5 magnetic resonance elastography. MRI 5 magnetic resonance imaging S2712
Introduction: Arsenic toxicity may not be apparent on initial presentation given its myriad of effects across many body systems and its rarity in developed countries. Case Description/Methods: A 29-year-old woman with history of gastroesophageal reflux disease, irritable bowel syndrome, gastroparesis, post-traumatic stress disorder, obsessive-compulsive disorder, and generalized anxiety disorder presented with abdominal pain, nausea, and vomiting. Her recent medical history included 7 months of progressive sensorimotor polyneuropathy, bowel and bladder incontinence, vision decline, skin rash and flaking, poor oral intake with 25% weight loss, and recent hospitalization for stress-induced cardiomyopathy and ventricular tachycardia. She was found to have coagulopathy, hemolytic anemia, and elevated transaminases, alkaline phosphatase, direct and indirect bilirubin, and serum ammonia. She developed encephalopathy with rising ammonia requiring scavenger therapy. She underwent diagnostic evaluation for alcohol-related, metabolic, inflammatory, and vascular causes of liver disease. Liver biopsy revealed non-cirrhotic portal fibrosis, severe and mostly macrovesicular steatosis, ductular proliferation, and canalicular cholestasis. Initial labs showed high urine orotic acid and low serum citrulline, so empiric treatment for ornithine transcarbamylase deficiency was initially given. Whole exome sequencing was negative. Urine and serum heavy metal testing was negative. However, arsenic was highly elevated in hair and nail samples, most consistent with chronic arsenic exposure. Discussion: We present a case of hepatic steatosis and acute liver injury in chronic arsenic exposure. Recent work has associated arsenic toxicity with non-cirrhotic portal fibrosis and elevated risk of nonalcoholic fatty liver disease in humans, previously seen in mice. 1 In this patient, arsenic exposure may explain the hepatic steatosis, either directly or indirectly via rapid weight loss. Arsenic toxicity also explains the hepatic injury and portal fibrosis, encephalopathy, polyneuropathy, hair loss, and skin changes. Recognizing metal toxicity as a cause of liver injury was crucial, as arsenic testing dramatically altered our course of management and patient care.
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