The first case of adenocarcinoma developing in a continent ileostomy is reported. A healthy, 39-year-old man with a continent ileostomy for 17 years developed subacute obstructive symptoms and was found on endoscopy to have a large adenocarcinoma involving the intussusception valve. At operation, he was found to have a large tumor originating in the valve, extending through the reservoir, and involving the afferent ileal limb. A number of metastatic lymph nodes were identified in the mesentery of the small bowel. He underwent excision of the pouch and formation of an end ileostomy. He is currently undergoing adjuvant chemotherapy. Biochemical and morphologic changes in the ileal pouch, both in the pelvis and the continent ileostomy, are discussed. The implications of this apparent de novo cancer arising in an ileal pouch are discussed.

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A 27-year-old Caucasian female was hospitalized three times over a four-month period for recurrent, intermittent abdominal pain associated with nausea and diarrhea. No signs or symptoms of gastrointestinal (GI) bleeding were present. A stool occult blood test and stool enteric pathogen tests were negative. A complete blood count (CBC) revealed a peripheral blood eosinophil count of 1080 cells /µL without any inflammatory reaction. An upper endoscopy showed grossly normal-appearing esophageal and duodenal mucosa; however, a gastric mucosal biopsy showed an eosinophil infiltration of ≥20 eosinophils/high power field (HPF). Based on these findings, she was diagnosed with eosinophilic gastroenteritis (EGE). A definitive diagnosis of EGE should be confirmed with both an analysis of gastrointestinal mucosal biopsy and an elevated peripheral blood eosinophil count. Specifically, histological evaluation of the mucosal tissue must show an eosinophilic infiltration rate of 20 eosinophils/HPF. The diagnosis should be followed by an extensive review of the patient's allergic disease history.

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Introduction: Autonomous cortisol secretion (ACS) is found in approximately 10% of patients with an adrenocortical incidentaloma (AI). The majority of these cases are due to non-ACTH-dependent ACS. 2% of patients with AI have adrenocortical cancer. ACS is associated with cardiovascular morbidity, includes arterial stiffness, hypertension, coronary heart disease, and fatal or nonfatal myocardial infarction. Case presentation: A 62-year-old Caucasian male with a history of hypertension (HTN), hyperlipidemia (HLD) and poorly controlled type-2 diabetes mellitus (T2DM) and a recent myocardial infarction (MI) status post (s/p) coronary artery bypass graft (CABG) who presented to the endocrine clinic for evaluation of left adrenal mass. Family history was significant for adrenal carcinoma of his brother at the age of 60. The patient denied any facial flushing, palpitations, tremors, heat or cold intolerance, abnormal sweating, diarrhea, constipation, abdominal pain, recent weight change. Physical examination was unremarkable except midline sternal scar s/p CABG. Vital signs were remarkable for a blood pressure of 142/90. Labs were unremarkable. CT adrenal revealed a left adrenal mass 4.9 x 3.5 x 2.3 cm with HU -3 to 28 heterogeneous. HbA 1C was 8.2 %. Adrenal incidentaloma workup revealed a normal 24-hour urine cortisol level of 29 mcg, abnormal mid-night salivary cortisol of 0.13 mcg/dL and 0.31 mcg/dL, elevated cortisol after 1 mg dexamethasone suppression test (DST) of 343 mcg/dL, elevated cortisol after 8 mg DST of 90 mcg/dL, normal metanephrines of 10 pg/mL and normal normetanephrine of 49 pg/mL, normal aldosterone of 6.1 ng/dL, normal renin activity of 0.36 ng/ml/hr (Aldo/ PRA ratio 16). ACTH was 4.5 pg/ml. The endocrine surgeon was consulted for left adrenalectomy. The pathology showed atypical adrenal cortical neoplasm which does not clearly fulfill the criteria for adrenal cortical carcinoma confirmed by two pathologists. Upon six months follow-up, a 24-hour urine cortisol level was normal, 1mg overnight DST was normal, and no evidence of left adrenal on adrenal CT. Discussion: Adrenal incidentaloma (AI) is a common endocrine diagnosis affecting ~2% of the general population. Up to 10% of patients with AI have autonomous secretion of adrenal hormones. Pheochromocytoma and autonomous cortisol secretion should be excluded in every case and aldosteronism in patients with underlying hypertension and/or hypokalemia. ACS in patients AI has been associated with hypertension, insulin resistance, type 2 diabetes mellitus, obesity, metabolic syndrome, coronary artery disease, and increased mortality. Adrenalectomy is recommended for patients with a functional unilateral adenoma, with clinically significant hormone excess. Metabolic improvement after adrenalectomy, including weight loss, blood pressure lowering, glucose tolerance, lower lipids have been reported.

INTRODUCTION: Endometriosis is characterized by implantation of endometrial epithelium outside the uterus. The prevalence is about 10-15% in women of reproductive age. The most common extra-pelvic site is the GI tract, affecting 4–37% of women with endometriosis. The sigmoid colon and rectum are the most common sites followed by the ileum, appendix and cecum. CASE DESCRIPTION/METHODS: Here we present a very rare case of severe intestinal endometriosis involving multiple GI sites including the terminal ileum, appendix and recto-sigmoid colon in the past 5 years. 4.5 years ago, the then 27 year old otherwise healthy female presented with worsening RLQ pain. She had leukocytosis of 15K WBC with CT scan showing a dilated and thickened distal appendix consistent with appendicitis. She underwent laparoscopic appendectomy without complications. Pathology reported endometriosis (Figure 1). After appendectomy, she continued to have diffuse abdominal pain with nausea and constipation. As part of GI workup, she underwent EGD and colonoscopy about 3 years ago with findings of two recto-sigmoid strictures with biopsies showing endometriosis. The patient was then lost followup until she was readmitted with multiple GI complaints including nausea/vomiting, abdominal pain, with alternating diarrhea and constipation. It appears that she had been treated for IBS and also received hormonal treatment for endometriosis in the past two years. On admission, she had leukocytosis of 16K and a CT scan showing a 3 cm focal apple-core lesion in the distal sigmoid colon. Colonoscopy showed a very severe stricture at the distal sigmoid colon with nodular mucosa in the proximal rectum. Pathology was negative for malignancy or endometriosis. She then underwent laproscopy with findings of 2 strictures in the recto-sigmoid colon together with another stricture 5 cm proximal to the IC valve in the distal ileum. Partial resection of the recto-sigmoid colon together with a right hemicolectomy was performed. Pathology of both TI and recto-sigmoid colon showed endometriosis (Figure 2). During the one-month post-op followup, she reported resolution of constipation. DISCUSSION: Our patient represents a rare case of symptomatic multi-focal gastrointestinal endometriosis with mucosal involvement at different times mimicking appendicitis and sigmoid malignancy. Endometriosis should be considered in the differential diagnosis in any young woman with lower GI symptoms.

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