A 79-year-old woman and a 92-year-old woman were referred to the gastroenterology department for management of persistent colovaginal fistula despite surgical and non-surgical management. Both patients had several hospitalisations for recurrent urinary tract infections. After failed surgical management and endoscopy using over-the-scope clipping, both patients underwent endoscopic closure using the Amplatzer cardiac septal occluder device. Both patients underwent successful closure and had no recurrence of symptoms at 6-month follow-up. Although there are several therapies available for persistent colovaginal fistulas, most involve multiple sessions and have high recurrence rate. There have been reports in the literature of cardiac septal occluders being used in the management of upper gastrointestinal tract fistulas, but few cases exist explaining their role in the management of colovaginal fistulas. Our cases demonstrate that cardiac septal occluders may be a viable option for management of fistulas and warrants further studies to reproduce its effectiveness and safety.

Ascending cholangitis is a bacterial infection of the extra-hepatic biliary system and presents as a life-threatening systemic condition. Increased bacterial loads and biliary obstruction favor bacterial translocation into the vascular and lymphatic systems. Common organisms isolated are Escherichia Coli , Klebsiella , Enterococcus species, and Enterobacter species . Methicillin-resistant Staphylococcus aureus (MRSA) is a rare isolate in ascending cholangitis. We present a case of a 24-year-old patient with cystic fibrosis who presented with epigastric abdominal pain, low-grade fever, jaundice, dark urine, and nausea for two days. Initial workup revealed elevated liver enzymes, hyperbilirubinemia, leukocytosis, and an ultrasound which showed common bile duct dilation to 14 mm with choledocholithiasis. He underwent endoscopic retrograde cholangiopancreatography (ERCP) with stone extraction and bile fluid culture. Cultures grew out MRSA and the patient was treated with appropriate antibiotic therapy. The mainstay of therapy for ascending cholangitis is adequate hydration, antibiotics, and biliary decompression. Early recognition of the offending organism is critical in guiding therapy. Current guidelines focus on the empiric treatment of Gram-negative and anaerobic bacteria. Clinicians should be aware of the possibility of less common pathogens (such as MRSA), especially in a patient who is decompensating despite antibiotic therapy.

Gastrointestinal lipomas are rare, often colonic tumors. The stomach is an unusual site of involvement of lipomas, accounting for less than 5% of all gastrointestinal lipomas and less than 3% of all benign gastric neoplasms. They are usually asymptomatic, and symptoms develop as the tumor grows. Gastric lipomas can present with massive bleeding from an ulcerating tumor and can be life-threatening if left untreated. We present a case of an ulcerating gastric lipoma that presented as an acute upper gastrointestinal hemorrhage. The patient was treated with Billroth II procedure and final pathology showed an ulcerating submucosal lipoma. The diagnosis of gastric lipoma is often suspected incidentally on imaging, then confirmed via biopsy. Definitive treatment of large lesions typically requires surgery, however, newer endoscopic techniques are being utilized for resection of these benign tumors.

Bilirubin 9.3 mg/dL (Direct 4.3 mg/dL, Indirect 3.5 mg/dL). CT scan of the abdomen and pelvis showed hepatomegaly with a normal biliary tree. The EBV viral capsid antigen (VCA) IgM was positive at .160 u/ML. Patient underwent a liver biopsy on hospital day 3 which showed sinusoidal patterns of inflammation and an in-situ hybridization study confirmed the diagnosis of EBV hepatitis. She was started on Solumedrol 1 mg/kg with improvement of symptoms and resolution of hepatic and hemolytic anemia lab abnormalities. Discussion: Hepatic involvement due to Epstein-Barr virus infection can be common but is typically subclinical or mild in presentation with only 5% of patients presenting with jaundice. The pathological manifestations can be extensive, as patients can also present with hemolytic anemia, specifically cold agglutinin autoimmune hemolytic anemia. The pathogenesis is believed to be due to EBV IgM antibodies cross reacting with RBC antigens. The pathogenesis of cholestasis in EBV hepatitis involves direct damage of hepatic cells by autoantibody free radical activation and the inflammation of bile ducts. The majority of cases are self-resolving; however, antivirals such as ganciclovir in conjunction with corticosteroids can provide benefit in severe cases. Due to the high global prevalence of Epstein-Barr virus, healthcare professionals should be aware of the diagnosis, management and complications of hepatic manifestations. Introduction:We present a case of acute on chronic liver failure in a patient on chronic Augmentin and total parenteral nutrition (TPN). We highlight the mechanisms and key findings of liver injury associated with intestinal failure and Augmentin, which are relevant for evaluating the risks and benefits of such therapies. Case Description/Methods: A 49-year-old woman with a history of cervical cancer treated with chemoradiation complicated by vaginal stenosis with reconstructive surgery complicated by short gut syndrome with chronic TPN dependency and chronic pelvic infections on Augmentin suppression therapy presented with hyperbilirubinemia and acute renal failure. Initial laboratory results include bilirubin 29.4 (predominantly direct), mildly elevated liver enzymes, normal alkaline phosphatase, INR 1.6, and creatinine 3.64. Her TPN and Augmentin were held. Evaluation for autoimmune markers and acute viral hepatitis serologies were negative. Genetic testing showed heterozygous C282Y mutation. Urinary copper was high with low serum ceruloplasmin, however ophthalmology exam was not concerning for Wilson's disease. Abdominopelvic non-contrast CT showed new abdominopelvic ascites. Liver biopsy revealed cholestatic hepatitis and cirrhosis. Her presentation was likely secondary to acute Augmentin hepatotoxicity in the setting of chronic intestinal-failure associated liver disease (IFALD). The patient ultimately expired due to septic shock. Discussion: Augmentin is a known cause of DILI, with clavulanic acid established as the causative agent. Onset occurs days to months following use and liver...

bowel and dilated loops of small bowel upstream of the mass. The patient was diagnosed with primary enterolithiasis proximal to a radiation induced stricture, causing chronic recurrent partial small bowel obstruction. Two weeks later, she underwent elective robotic-assisted small bowel resection with the retrieval of a brown, green enterolith measuring 5.5x3.8x3.5 cm. The patient was discharged on post-operative day 3 without complications. Discussion: Primary enterolithiasis should be considered as a rare etiology of chronic abdominal pain and bowel obstruction in patients with pre-disposing factors that promote intestinal stasis. Treatment depends on the timely recognition of this entity and endoscopic or surgical management. With the technological advances, better patient outcomes as well mortality rates are expected.[3449] Figure 1. CT enterography showing a large lamellated intraluminal mass in the mid small bowel A) Coronal view, B) Axial view.