Abstractsof the benign masses resected from the bladder and prostate provided further evidence to support the diagnosis of PL. The patient continued standard therapy for constipation with pelvic rehabilitation/biofeedback, however with only minimal improvement. Surgical consultation was obtained and the patient opted for perivesicular lipoma extirpation. Discussion: Pelvic lipomatosis is associated with high morbidity and poor quality of life. There should be a high clinical suspicion in patients who present with a simultaneous onset of constipation and urinary incontinence. To date, no formal guidelines for treatment exist. Salvage therapies to include surgery, radiation, steroids, and chemotherapy have not been proven to be effective. Urinary diversion may be required to prevent fulminant renal failure. This is a unique case of PL presenting with a primary chief complaint of constipation. difficult case esophageal cancer with TEF treated with SEMS placement involving a multidisciplinary approach requiring laparoscopic assisted. A 63-year-old male with advanced squamous cell carcinoma of the proximal esophagus complicated by TEF formation was referred to our institution due to worsening inability to swallow secretions. In order to place a fully covered self expandable metal stent, attempts were made to pass a guidewire under endoscopic and fluoroscopic guidance from above the tumor into the distal esophagus. Due to the altered anatomy from the tumor, the large TEF and airway stents, the guidewire placement was not successful with wire preferentially going into the airway despite numerous attempts. The GI surgery team, Interventional pulmonary team was consulted and a combined laparoscopic and endoscopic approach was chosen. The patient already had a J tube but no G tube to access the stomach. As a result, laparoscopic access to the stomach was provided via a 14mm trocar. A gastroscope was then inserted through the trocar and then retrograde up the esophagus. From the retrograde approach the wire was now able to traverse tumor and enter into the proximal esophagus and mouth where it was retrieved. The gastroscope was then backloaded onto the guidewire and a 10 cm x 10 mm fully covered biliary stent was deployed in the esophagus in an anterograde fashion, bridging the tumor. Placement was confirmed with fluoroscopy and direct visualization. The interventional pulmonary team performed bronchoscopy and airway stents were not compromised by the placement of the esophageal stent. The patient reported market improvement in his ability to swallow secretions and has also been able to enjoy a liquid diet. Collaboration with the surgical and pulmonary teams was essential for successful esophageal stent placement in this case. This method of retrograde guidewire and endoscopic insertion can be considered as an option in patients with advanced esophageal cancer for whom conventional stent deployment is not possible.
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INTRODUCTION: Cocaine use is associated with arterial vasoconstriction and enhanced thrombus formation. Rarely, these effects on the intestinal blood supply result in intestinal ischemia. Cocaine-induced ischemic colitis is a relatively poorly-defined variant of this phenomenon, but some studies suggest it may be associated with higher morbidity and mortality than other etiologies. Therefore, timing is critical in both diagnosis and initiating treatments to prevent poor outcomes. We present a case of a middle-aged patient who had an unusual presentation for ischemic colitis due to cocaine abuse. CASE DESCRIPTION/METHODS: A 49-year-old male with a history remarkable only for alcohol and cocaine use disorders presented with a two day history of hematemesis with syncope and severe abdominal pain. Urine drug screen was positive for cocaine on admission, and initial workup with EGD was grossly unremarkable. An abdominal CT scan showed extensive circumferential submucosal fat but without colonic wall thickening or other signs of acute process, and a mesenteric angiography was similarly unrevealing. However, his clinical condition continued to deteriorate over the next 48 hours with worsening abdominal pain, and he began passing large melanic stools with occasional frank red blood. He subsequently became septic; due to concern for ischemic bowel, a colonoscopy was emergently performed. Diffuse severe ischemic changes with deep cratered ulcers in the descending, transverse, and ascending colon were noted. Emergent laparotomy was performed for a near-total colectomy, after which the patient began to stabilize. DISCUSSION: Long-term cocaine abuse is associated with multiple vascular morbidities, including bowel ischemia. Our patient presented in extremis due to bowel ischemia of both SMA and IMA territories requiring intensive care and emergent colectomy. Interestingly, despite the widespread vascular compromise, initial symptoms were nonspecific without blood per rectum and imaging was unremarkable, including CT and angiography. This illustrates the importance of maintaining clinical suspicion and the utility of colonoscopy in diagnosis, as his unusually diffuse disease eventually necessitated a colectomy in this middle-aged man with otherwise unremarkable medical history.
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