Autoimmune pancreatitis (AIP) is a rare, often‐missed disease that involves inflammation of the pancreas and strictures of the pancreatic duct. Its prevalence and incidence in the United States remain scarce. The disease has a varied presentation and often mimics pancreatic malignancy, which can make the diagnosis challenging. Most patients have an excellent response to corticosteroid therapy. Immunomodulators may be used in some cases. Rituximab is an effective, emerging treatment in steroid‐refractory cases. This study aims to review the two distinct types of AIP and provide a detailed analysis of the diagnostic approach and treatment modalities.
Patient: Male, 23-year-old Final Diagnosis: Foreign body ingestion Symptoms: Abdominal pain • nausea Medication: — Clinical Procedure: — Specialty: Gastroenterology and Hepatology • General and Internal Medicine • Psychiatry • Toxicology Objective: Rare disease Background: Recurrent intentional foreign body (RIFB) ingestion is a complex and costly issue among patients in prison and those with psychiatric disorders. Risk factors for RIFB ingestion include male sex, incarceration, and the presence of a psychiatric disorder. Most patients can be managed with observation and endoscopy. Surgery is indicated in cases involving perforation or obstruction. The literature on preventative strategies for RIFB ingestion is scarce. Case Report: A 23-year-old man required 6 admissions in 1 calendar year for intentional foreign body ingestions. The patient was living in prison and had a history of bipolar I disorder, schizophrenia, and borderline personality disorder. He underwent 9 endoscopic procedures that retrieved a total of 64 objects. The primary imaging modalities were abdominal X-ray and abdominopelvic contrast-enhanced computed tomography scan. The patient was managed with endoscopy and, in 2 cases, with observation alone. Serial abdominal examinations and abdominal films were used to monitor the progress of foreign bodies that were difficult to retrieve. A bowel regimen with polyethylene glycol facilitated the passage of the objects. The patient never required surgical intervention. The mean length of stay was 4.17 days. The recurrent ingestions may have been related to compulsions and family stress. Conclusions: Interdisciplinary collaboration is paramount in formulating effective treatment plans and limiting recurrence. Proposed strategies to prevent RIFB ingestion include the removal of ingestible objects from the environment, specialized prison units for close monitoring, early psychiatric intervention with appropriate pharmacologic/ behavioral therapy, and limiting hospital admissions to prevent secondary gain. Further studies are needed to determine the most effective approach to manage and prevent RIFB ingestion.
The ongoing pandemic resulting from severe acute respiratory syndrome—caused by coronavirus 2 (SARS-CoV-2)—has posed a multitude of healthcare challenges of unprecedented proportions. Intestinal enterocytes have the highest expression of angiotensin-converting enzyme-2 (ACE2), which functions as the key receptor for SARS-CoV-2 entry into cells. As such, particular interest has been accorded to SARS-CoV-2 and how it manifests within the gastrointestinal system. The acute and chronic alimentary clinical implications of infection are yet to be fully elucidated, however, the gastrointestinal consequences from non-SARS-CoV-2 viral GI tract infections, coupled with the generalized nature of late sequelae following COVID-19 disease, would predict that motility disorders are likely to be seen in these patients. Determination of the chronic effects of COVID-19 disease, herein defined as GI disease which is persistent or recurrent more than 3 months following recovery from the acute respiratory illness, will require comprehensive investigations comprising combined endoscopic- and motility-based evaluation. It will be fascinating to ascertain whether the specific post-COVID-19 phenotype is hypotonic or hypertonic in nature and to identify the most vulnerable target portions of the gut. A specific biological hypothesis is that motility disorders may result from SARS-CoV-2-induced angiotensin-converting enzyme 2 (ACE2) depletion. Since SARS-CoV-2 is known to exhibit direct neuronal tropism, the potential also exists for the development of neurogenic motility disorders. This review aims to explore some of the potential pathophysiologic mechanisms underlying motility dysfunction as it relates to ACE2 and thereby aims to provide the foundation for mechanism-based potential therapeutic options.
Neurofibromatosis-1 (NF-1) is an autosomal dominant condition characterized by cutaneous pigmentation and tumour formation along nerves in the brain, skin, and other organs. Gastrointestinal stromal tumours (GIST) are rare mesenchymal tumours involving the gastrointestinal tract (GI) associated with NF-1. We present a case of life-threatening GI bleeding from GIST in a patient with NF-1. In NF-1 patients presenting with GI bleeding, GISTs should be part of the differential. Clinicians must have a low threshold for urgent abdominal imaging if endoscopy does not detect the source of GI bleeding.
Introduction: Epiploic appendagitis (EA) is a rare cause of acute abdominal pain that has a relatively benign course. The importance of identifying EA as a clinical mimicker is crucial to avoid unnecessary hospitalizations, antibiotic use, and surgery. Although no trigger has been established as a cause for EA, it is hypothesized that systemic inflammation can lead to an EA attack. Case Description/Methods: A 43-year-old White female with no significant GI history presented with 2 days of sudden onset, sharp, non-radiating, worsening left lower quadrant (LLQ) with nausea. Initial blood work was unremarkable. CT abdomen revealed a hyper-attenuating ring lesion along the anti-mesenteric margin adjacent to the distal descending colon, along with mesenteric lymph nodes consistent with epiploic appendagitis. She was managed conservatively with complete resolution of symptoms. A few years later, she presented again, with similar abdominal complaints. Repeat abdominal imaging showed recurrence of EA in the same location. Few shotty mesenteric lymph nodes were identified. She was treated conservatively for EA. A few more years passed, and she now had another episode of recurrent LLQ pain, CT abdomen showed findings consistent with EA along with a short segment of mural thickening and mild hyper-enhancement in the mid descending colon. Colonoscopy revealed a large circumferential mass in the sigmoid colon with an apple core lesion in the proximal sigmoid colon with luminal narrowing. Biopsy revealed an adenocarcinoma. No lymph node involvement was noted. As the TNM staging was pT3 N0 M0, she underwent a sigmoidectomy with left colon and rectal end-to-end anastomosis (Figure). Discussion: Epiploic appendages are fat-filled serosal outpouchings of the colonic surface. They are connected to the colon by a vascular stalk. Acute epiploic appendagitis is theorized to be caused by torsion, underlying inflammation, or venous occlusion of the appendage. CT scan is the gold standard for diagnosing EA and helps rule out other intra-abdominal pathologies. Recurrent and persistent EA is very rare and may mask an underlying occult abdominal pathology. There have not been any reported cases of CRC that are associated with and possibly trigger EA. In patients with recurrent EA, after common causes of acute abdominal pain are ruled out, evaluation for intestinal/intraluminal pathologies, especially colorectal malignancy should be considered as they are not readily apparent on CT scans.[2029] Figure 1. A: Red arrow showing an inflamed epiploic appendage during initial presentations. B: Red arrow showing epiploic appendagitis. Green arrow with colonic wall thickening in the descending colon, with adjacent EA. 3: Colonoscopy showing the large friable mass in the sigmoid colon.
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