Lung cancer is a common malignancy which is frequently found to metastasize to distant sites including bone, liver, and adrenal glands. There are rare reports of metastases to the gastrointestinal (GI) tract, with the duodenum being the most uncommon. We present a rare case of a poorly differentiated lung carcinoma metastasizing to the duodenum. This case enhances the medical literature as it provides additional distinct features to the clinical and histological presentation of metastatic lung carcinoma to the GI tract. A 61-year-old male with a history of poorly differentiated lung carcinoma presented with worsening dizziness, fatigue, and early satiety. He had extensive workup done in the past for hemoptysis including a computerized tomography scan of the chest which showed a new lobulated, apical lesion and hilar Case Ahmed et al.: Poorly Differentiated Lung Carcinoma Metastasis to the Duodenum 187lymphadenopathy. He ultimately had a transthoracic fine-needle aspiration (FNA) of the mass and was later diagnosed with poorly differentiated lung carcinoma. On examination, the patient was noted to be pale, tachycardic, and hypotensive. The patient was noted to have an acute drop in his hemoglobin requiring fluid resuscitation, multiple blood transfusions, and evaluation with an esophagogastroduodenoscopy. He was found to have an oozing ulcer in the third portion of the duodenum whose biopsies showed poorly differentiated carcinoma with areas of neuroendocrine differentiation, similar to his lung biopsy results, which was consistent with metastatic lung carcinoma.
Wearable cardioverter defibrillators (WCDs) are external devices capable of continuous cardiac rhythm monitoring as well as automatic detection and defibrillation of potentially life-threatening arrhythmias such as ventricular tachycardia (VT) and ventricular fibrillation (VF). They are an alternative approach for patients when an implantable cardioverter defibrillator (ICD) is not appropriate. Although treatment with ICD is considered highly effective for the primary and secondary prevention of sudden cardiac death (SCD) in high-risk patients susceptible to VT and VF, patients may still experience psychological difficulties such as fear of shock, avoidance of normal behaviors and reduced quality of life. One of these phenomena is phantom shock (PS), which is defined as a perception of having received a shock with no evidence of recorded defibrillation upon device interrogation. While PS has been reported in the ICD literature, to the best of our knowledge, we present the first known case of WCD-related PS. We also present a review of the current literature to explore the prevalence of PS, the factors associated with its pathogenesis and interventional studies aimed at reducing its occurrence. We highlight this case because PS is considered a phenomenon that few recognize, which should be discriminated from real device shocks before clinicians initiate treatment, device reprogramming or device discontinuation. We describe the psychosocial factors associated with PS to emphasize the importance of managing any associated psychiatric disorders and psychosocial factors both before and after initiation of device treatment.
INTRODUCTION: It is very rare for head and neck squamous cell carcinoma (HNSCC) to metastasize to the duodenum or the peritoneum. Only a few cases have been reported for each metastatic site, however, there have been no reported cases of concurrent duodenal and peritoneal metastasis (PM) from HNSCC. Such a presentation enhances the literature on HNSCC and illustrates the need for further studies to understand the mechanism of HNSCC metastasis. CASE DESCRIPTION/METHODS: 68-year-old male with history of HNSCC presented with worsening nausea, postprandial vomiting, and abdominal pain for over 2 months. 3 months prior he was worked up for several postauricular lumps, with computerized tomography (CT) scan showing a supraglottic mass and excisional biopsy of a nodule confirming metastatic HNSCC. Imaging upon admission showed new peritoneal carcinomatosis and worsening diffuse lymphadenopathy (LAD). Esophagogastroduodenoscopy (EGD) showed a large nodular lesion occupying one third of the lumen circumference. Like the neck nodule, biopsies of the mass showed metastatic, poorly differentiated SCC that was strongly positive for p63 and p16. The patient was not deemed a candidate for chemotherapy due to poor prognosis and poor functional status and was eventually discharged on home hospice. DISCUSSION: We hereby described the first case of concurrent duodenal and peritoneal metastasis from a HNSCC, with both being independently rare sites of metastasis. The patient’s history of chronic tobacco use increased his risk of SCC. Chemotherapy and peritoneal excision, in certain cases, have shown to be a viable treatment option and have a beneficial impact on survival and quality of life. In select cases of obstruction, palliative stenting can be an option to improve quality of life. Due to rapid disease progression and the patient’s poor functional status, these treatment options were deemed not feasible. There are many speculated mechanisms regarding intestinal and PM such as direct extension, tumor rupture or trauma leading to seeding of the peritoneum, hematogenous dissemination, and even via the lymphatics. In our case, the patient did not have any abdominal surgeries and had multiple metastatic sites, including the duodenum, making hematogenous or lymphatic spread more likely. In any case, further studies are needed to understand the mechanism involved in HNSCC metastasis.
INTRODUCTION: Colorectal anastomotic strictures are common complications of low anterior resection. Strictures in the lower rectum can be treated with direct digital dilation, but if in the upper rectum, endoscopic balloon dilation or electrocautery can be done. However, both procedures depend on the advancement of the wire through the circumferential scar/narrowed lumen. We present a unique case of endoscopic dilation of a severe anastomotic stricture using an innovative method. CASE DESCRIPTION/METHODS: A 44-year-old male with a history of rectal adenocarcinoma s/p low anterior resection with colorectal anastomosis and loop ileostomy formation presented to the GI clinic for constipation. Barium enema study revealed a stricture at the anastomotic site. A flexible sigmoidoscopy confirmed a severe anastomotic stricture, which could not be traversed nor lumen distal to the stricture visualized. And despite multiple attempts the guidewire could not pass through the stricture. Ten weeks after surgery, a pediatric colonoscope was passed through the ileostomy and advanced to the area of the stricture. Position was confirmed with fluoroscopy. At the same time an adult upper endoscope was inserted into the rectum and advanced to the stricture. The pediatric colonoscope was used to transilluminate the stricture and a needle was then used to puncture through the stricture under direct visualization. A guidewire was advanced through the newly created lumen retrograde and the tract was dilated up to 8 mm. A double pigtail plastic stent was inserted across the newly created tract. On repeat colonoscopy three weeks later, the double pigtail stent was removed and the stricture was dilated up to 15 mm. On subsequent colonoscopy, the stricture was dilated to 18 mm and the patients loop ileostomy reversed. The stricture was dilated again to 20 mm via Flexible sigmoidoscopy a month after the reversal after which constipation and bowel habits significantly improved. DISCUSSION: In patients who develop severe colorectal anastomotic strictures after a low anterior resection, endoscopic dilation can be challenging. In such patients ileoscopy and colonoscopy can be done simultaneously and using transillumination, position can be confirmed and a needle can be used to create a lumen through which a guide wire can be passed, allowing for serial dilation. Endoscopic dilation, should be tried and exhausted before considering surgical correction of a stricture, which can be difficult and increase morbidity.
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