Burkitt lymphoma is an aggressively growing tumor commonly found in African children, involving the jaw and facial bones. Most non-Hodgkin lymphoma tumors involve extra nodal sites like the nervous system and gastrointestinal tract. A rare variant of this type of lymphoma is found in immunocompromised patients specifically in the gastrointestinal tract with accompanying gastrointestinal symptoms. Burkitt lymphoma is a malignancy that has commonly presented in GI tract but rarely in the duodenum. This clinical variant can commonly involve stomach, ileum, and cecum. However, there is very limited data available regarding the duodenal growth of this tumor. Duodenal involvement of Burkitt lymphoma is extremely rare and accounts for < 1% of all lymphomas. We present a case report of an older patient with a duodenal Burkitt lymphoma diagnosed by biopsy. A high suspicion should be present while treating immunocompromised patients with chronic abdominal symptoms especially with complications such as bleeding or occult positive testing. Early endoscopy intervention with biopsy can help identity and treat these conditions with improved outcomes for the patients.

Ibuprofen-induced acute pancreatitis, a diagnosis secondary to the use of non-steroidal anti-inflammatory drugs (NSAIDs), is an extremely rare occurrence. Common culprits, such as gallbladder obstruction, alcohol consumption, infection, direct trauma, and medication (i.e. NSAIDs), can be attributable to the majority of cases reported. This case report describes a patient with acute pancreatitis that developed due to a three-week course of daily ibuprofen use for chronic shoulder pain. Alternative causes of acute pancreatitis were excluded through the patient’s clinical history, laboratory findings, and diagnostic imaging. Although a rare risk factor, our aim is to further demonstrate that patients with chronic NSAIDs use can develop these complications and this should be considered among the differential diagnoses.

INTRODUCTION: All that looks like cancer is not always cancer. Esophageal Actinomycosis is a fine example that frequently mimics malignancy. Actinomyces is a bacteria acting like fungi which extremely rarely infects the esophagus in immunocompetent hosts. Risk factors are unknown due to paucity of data. CASE DESCRIPTION/METHODS: A 79-year-old African American woman was admitted with mild hematemesis. She had progressive, painless dysphagia for solids for 6 weeks and had lost 12 lb. She had curative lobectomy for lung cancer and quit smoking 10 years ago. She had COPD and GERD. Medications included Budesonide-Formoterol and Albuterol inhalers. She had no history of chemo/radiotherapy, tuberculosis, HIV, or diabetes. Physical exam was normal. CBC, renal function and LFTs were normal. CT chest with contrast showed air-fluid levels within the esophagus and wall thickening. EGD revealed a 1 cm friable mass in distal esophagus. Biopsy confirmed actinomycosis and candida esophagitis. She was discharged on Ceftriaxone 2 g/day for 4 weeks and oral Fluconazole 200 mg/day for 3 weeks. At 1-month follow up, dysphagia had improved and she was switched to oral Amoxicillin for 6 months. DISCUSSION: Actinomyces is an anaerobic, gram-positive, filamentous, branching rod. It grows as normal flora in the mouth and GI tract. Esophageal Actinomycosis is exceedingly rare in immunocompetent people with only 28 cases indexed in PubMed in English. 13 cases were reported in the US. 2/3 of patients were immunocompromised. It invades the esophagus following mucosal breach, and presents as a mass, esophagitis, ulcer, abscess, fistula, or stricture causing dysphagia/odynophagia. It is a great imitator, often misleading physicians, thereby triggering malignancy work-up. Diagnosis involves imaging and biopsy. Microscopy reveals yellow sulfur granules in 50% of cases. Actinomyces is difficult to isolate with culture yield as low as 24%. RNA sequencing can provide a quick, accurate diagnosis in future. Patient education and counseling is the cornerstone of successful prolonged antibiotic therapy. An initial course of IV penicillin G or Ceftriaxone for 4-6 weeks is followed by oral penicillin V or amoxicillin for 6-12 months. Necrotic ulcer, fistula, or abscess is managed surgically. We believe that inhaled corticosteroids may have created the milieu for the growth of Actinomyces and Candida in the esophagus by impairing local defenses. 43% of inhaled corticosteroid is deposited in the esophagus according to Gamma scintigraphic studies.

INTRODUCTION: Energy Therapy has been a well known non-surgical, minimally invasive treatment option for symptomatic grades I and II internal hemorrhoids. This treatment has not yet been studied in anal fissures refractory to medical therapy. Anal fissures, like hemorrhoids, can severely disrupt the quality of life for patients. Currently, only a few non-surgical treatments are available for anal fissures which involve conservative and supportive measures that include: increasing dietary fiber intake, stool softeners, sitz baths, topical analgesics or vasodilators. The gold standard for chronic anal fissures (CAF) refractory to medical therapy is treatment with internal sphincterotomy. Unfortunately with this treatment there is a chance of relapse and a risk of anal incontinence. We propose the use of hemorrhoid energy therapy (HET) with bipolar cautery as a safer, less invasive and effective therapy for recurrent anal fissures refractory to conservative management. CASE DESCRIPTION/METHODS: 53 year old obese heterosexual man presented with bright red blood per rectum for two months managed outpatient for chronic constipation. Rectal examination revealed a large clot with anal tenderness and few internal hemorrhoids. Colonoscopy revealed 3 internal non-bleeding hemorrhoids and slow oozing bleeding anterior anorectal fissure. The anal fissure exhibited characteristics of chronicity with base exposing to the internal anal sphincter, hypertrophic anal papilla and sentinel pile. HET therapy with bipolar cautery was applied to the bleeding anal fissure. The tissue consisting of anal fissure in bowel wall was compressed in a parallel fashion and bipolar radiofrequency energy was delivered until the temperature reached 55 C or 131 F (5-20 seconds) for approximately 1.5 to 2 seconds. DISCUSSION: The delivery of energy to a targeted region with temperatures between 50 to 55 C along with compression of the tissue can help obtain homeostasis for bleeding or CAF along with change of histology to mild scarring with fibrosis and occlusion of blood supply which would result in healing of the fissure. This intervention using bipolar cautery which could be an alternative treatment as a safer, less invasive and effective therapy for recurrent anal fissures refractory to conservative management prior to considering surgery. Our patient was followed up 2 years after the procedure with no recurrences of anal fissures or rectal bleeding, and reported improved quality of life with no complications from the procedure.

A 79-year-old African American woman presented with acute hematemesis after progressive dysphagia for 6 weeks and 12-pound weight loss. She had no predisposing immunocompromising comorbidity such as the human immunodeficiency virus or active malignancy. Computed tomography showed air-fluid levels within the esophagus with partial obstruction. Upper endoscopy revealed a 1-cm mass lesion in the midthoracic esophagus, and biopsy results surprisingly showed esophageal actinomycosis. The patient's symptoms resolved on antimicrobial therapy at a one-month follow-up, and the lesion was not seen on repeat endoscopy with biopsy at 3 months. We believe that inhaled corticosteroids for chronic obstructive pulmonary disease may have created the growth milieu by impairing local defenses. Correct inhaler technique, avoiding swallowing the water after mouth rinsing, and a spacer device are recommended to reduce esophageal corticosteroid exposure.

INTRODUCTION: Clostridium Difficile Infection (CDI) occurs predominantly in the intestinal tract due to alteration of normal gut flora often due to antibiotics. Testing for CDI is common on the inpatient setting. However, we recognized that over 95% of ordered stool tests are negative for CDI which indirectly was associated with an increased length of hospital stay, the unnecessary use of antibiotics and placing patients on isolation precautions. A hospital initiative led by our team that included provider education and a special electronic order set increased the accuracy of testing for CDI at our institution. METHODS: A one-year retrospective study was done evaluating the number of symptomatic and asymptomatic patients that were tested by the toxin A/B EIA and PCR assays. Similar data was obtained from the following year after the initiation of our hospital initiative. The hospital initiative included education for all hospital prescribers as well as the creation of a special electronic order set including alerts and special restrictions implementing the Infectious Disease Society of American (IDSA) guidelines. CDI cases were reported and compared between the two groups. RESULTS: During the first study period, there were a total of 877 CDI Antigen & Toxin tests ordered for inpatients. This resulted in 712 or 81% negative results for both antigen & toxin. Out of 877 tests, 120 were found to have antigen positivity but negative for CD toxin (indeterminate results). These 120 patients were further analyzed by polymerase chain reaction (PCR). Only 45 out of 877 were truly positive for CDI antigen & toxin (5% of total ordered tests). During the second study period, post intervention a total of 828 total CDI tests were ordered. This result showed 678 CDI tests or 82% ordered tests were negative for CDI antigen & toxin. Out of 828, 101 tests were antigen positive but negative for toxin which were further analyzed by PCR. Only 49 resulted positive for CDI antigen & toxin (6% of total tests ordered with positive for CDI). CONCLUSION: Our hospital initiative that included guideline-based education for ordering physicians as well as implanting an electronic order set enforcing testing criteria was effective at identifying more true positive results of CDI. We can infer that the underlying cause for the majority of symptomatic patients resulted from an etiology other than CDI. Further practitioner education with stricter measures must be enforced to reduce excessive testing.

Energy therapy is a well-known, minimally invasive treatment for internal hemorrhoids. This treatment has not yet been studied in anal fissures refractory to medical therapy. Anal fissures, such as hemorrhoids, can disrupt the quality of life for patients. Currently, nonsurgical treatments available for anal fissures are only supportive measures. Definitive for chronic anal fissures refractory to medical therapy is internal sphincterotomy. This treatment has chances of relapse and a risk of anal incontinence. We propose the use of hemorrhoid energy therapy with bipolar cautery as a safer, less invasive, and effective therapy for recurrent anal fissures refractory to conservative management.

Patients that are followed by internal medicine residents at our urban outpatient teaching clinic did not receive higher rates of CRC screening nor did rates of screening vary with their PGY level.