Case Reports in Gastroenterology

Tsuboi, Akiyoshi; Shigenobu, Shuya; Matsubara, Yuka; Hirata, Issei; Tanaka, Hidenori; Yamashita, Ken; Yuge, Ryo; Urabe, Yuji; Arihiro, Koji; Oka, Shiro

2024 Case Reports in Gastroenterology

doi: 10.1159/000539413pmid: 39015520

AbstractIntroduction: Coronavirus disease 2019 (COVID-19) caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is frequently associated with various gastrointestinal symptoms, including abdominal pain, vomiting, and diarrhea. Moreover, several cases of refractory diarrhea have been reported after COVID-19 recovery. Herein, we present a case of severe refractory diarrhea associated with COVID-19. Case Presentation: A 50-year-old man with no comorbidities was admitted to our hospital with SARS-CoV-2 pneumonia. His respiratory status deteriorated, and ventilatory management, including extracorporeal membrane oxygenation, was needed. The patient’s respiratory condition improved, resulting in a transfer to another hospital for rehabilitation. However, the patient developed diarrhea that worsened to 6,000–7,000 mL/day, and he was transferred to our hospital. We diagnosed the patient with enterocolitis caused by cytomegalovirus infection and treated him with ganciclovir on day 5 after transfer to our hospital. The diarrhea did not improve. We suspected enterocolitis associated with COVID-19 and administered a methylprednisolone pulse (intravenous injection, 1,000 mg/day for 3 days) on day 10 after transfer, resulting in a marked improvement in his symptoms. The prednisolone dose was tapered, and no recurrence of diarrhea was observed thereafter. Conclusion: The prevalence of COVID-19-associated enterocolitis is low, and the pathogenesis of the disease remains unclear. Prednisolone administration should be considered in cases of post-COVID-19 symptoms of severe diarrhea due to a possible abnormal immune response related to COVID-19.

Arai, Toshio; Saito, Seisuke; Kinebuchi, Takahiro; Nishikawa, Koji; Morishima, Yasuyuki; Sugiyama, Hiromu

2024 Case Reports in Gastroenterology

doi: 10.1159/000539304pmid: 39015526

AbstractIntroduction: Anisakiasis is a parasitic disease caused by larvae from anisakid nematodes. In recent years, there has been an increase in cases of anisakiasis, a relatively uncommon medical condition. Case Presentation: A 93-year-old woman with chronic heart failure developed hives and nausea 6 h after eating silver flounder sashimi, leading to suspicion of fish allergy. Despite treatment, symptoms persisted and progressed to abdominal pain. An upper gastrointestinal endoscopy revealed an Anisakis larva in her stomach, an unusual finding given her age. After endoscopic removal of the living worm, the patient’s symptoms were relieved. Conclusion: A case of atypical anisakiasis in a 93-year-old patient was demonstrated. This case underscores the importance of considering atypical presentations in clinical decision-making.

Prince, Sean-Patrick; Huang, Qitan; Dayto, Denisse Camille; Sephien, Andrew; Patel, Varun; Chandrupatla, Sreekanth

2024 Case Reports in Gastroenterology

doi: 10.1159/000538970pmid: 39015524

AbstractIntroduction: Colon cancer has seen a steady decline in incidence due to increased colonoscopy use. We can assume that this increased use, results in a higher incidence of post-colonoscopy complications such postpolypectomy syndrome, perforation and post-colonoscopy appendicitis (PCA). In this report, we present a case of PCA presenting to the emergency department within 12 h of a screening colonoscopy. Case Presentation: Our patient, a 77-year-old male, underwent an uncomplicated screening colonoscopy and was discharged home after briefly being monitored without any complaints. Later that day, the patient presented to the emergency department complaining of acute generalized abdominal pain. On presentation, the patient was found to be hypertensive and febrile with a distended abdomen with right lower quadrant tenderness on examination. Laboratory investigations noted an elevated white blood cell count with no evidence of acute appendicitis or focal inflammatory changes on contrast-enhanced abdominal and pelvic computer tomography. The patient was subsequently admitted and developed worsening right lower quadrant abdominal pain and distention overnight. Due to this worsening clinical condition, the decision was made to proceed with a diagnostic laparoscopy. After frank pus was found laparoscopically around the cecum and appendix, it was then converted to an exploratory laparotomy. Subsequently, a perforated gangrenous appendix was found with an erythematous and indurated cecum. Conclusion: Major complications of colonoscopy can include perforation and/or post-colonoscopy bleeding which have been shown to have a respective incidence of 0.21% and 0.1%. With the anticipated rise in the number of colonoscopies, much rarer complications such as PCA with an incidence of less than 0.05% will be seen more frequently. Due to its nonspecific presentation, it is necessary for providers to consider PCA as an important differential for all patients presenting with abdominal pain after a colonoscopy.

Yartsev, Alex; Nguyen, Jessica T.

2024 Case Reports in Gastroenterology

doi: 10.1159/000539439pmid: 39015523

AbstractIntroduction: Although terlipressin is known to cause bradycardia, this adverse effect is usually described in association with hypertension and is considered a benign compensatory response mediated by arterial baroreceptors. Cardiac monitoring for patients receiving terlipressin is not routinely recommended. Case Presentation: A 77-year-old female patient with no history of coronary artery disease and no other coexisting risk factors for cardiac arrhythmias or conduction disturbances was admitted to intensive care unit with severe cholangitis, complicated by variceal bleeding. She developed severe sinus bradycardia following the use of terlipressin, which was associated with significant hypotension that required the infusion of norepinephrine. The bradycardia occurred again when terlipressin therapy was reattempted. Conclusion: Vasopressin is known to sensitize baroreceptor reflexes by a central mechanism though its actions on V1a receptors in the area postrema, and we speculate that vasopressin analogues such as terlipressin may act in the same manner. That this effect is not widely described in terlipressin safety literature may be due to the overall younger age range of the trial population. This raises the possibility that cardiac monitoring may be warranted for elderly patients receiving terlipressin.

Wilson, Harry; Macdonald, Douglas; Bryce, Kathleen

2024 Case Reports in Gastroenterology

doi: 10.1159/000539646pmid: 39015527

AbstractIntroduction: Patients with advanced hepatocellular carcinoma (HCC) have limited treatment options in the context of decompensated cirrhosis. HCC occurs in patients with hepatitis C virus (HCV) infection and cirrhosis at 1–4% per year. Direct-acting antiviral (DAA) efficacy is decreased in the presence of HCC. We present a case where immunotherapy may have resulted in HCV clearance, when DAA therapy had been ineffective. We hypothesise that immune checkpoint inhibitors targeting the PD-1/PD-L1 pathway can reverse T-cell exhaustion and aid in the clearance of chronic HCV. Case Presentation: This case study describes a male in his 40 s identified by a re-engagement initiative for HCV, who had been unaware of his diagnosis. On further investigation he was found to have compensated for liver cirrhosis and HCC. He was treated with HCV DAA therapy (sofosbuvir/velpatasvir) and then systemic immunotherapy for HCC with atezolizumab and bevacizumab, in an attempt to downstage the disease. Hepatitis C therapy did not achieve sustained virological response, with viral relapse after the end of treatment. This, combined with ongoing alcohol use, resulted in hepatic decompensation and cessation of immunotherapy after the fifth cycle. The HCV RNA subsequently became undetectable without further DAA re-treatment. Conclusion: To our knowledge, this is the first case of HCV clearance after DAA relapse and the timing of this event after immunotherapy suggests a causal link. We hypothesise that this may be due to the reversal of antiviral T-cell exhaustion. This would therefore support further investigation into other chronic viral infections that create tumour associated with immunosuppressive microenvironments.

Jamali, Arsia; Ajumobi, Adewale

2024 Case Reports in Gastroenterology

doi: 10.1159/000539500pmid: 39144823

AbstractIntroduction: Involvement of the gastrointestinal system is less common in Turner’s syndrome. Hepatic derangements have been reported in individuals with Turner’s syndrome due to nonalcoholic steatosis, steatohepatitis, and less commonly due to viral hepatitis and alcoholic hepatitis. Portal hypertension is typically associated with cirrhosis; however, in a minor fraction of individuals, it occurs in the absence of cirrhosis. Portal hypertension is rare in Turner’s syndrome and is even more rarely observed in the absence of cirrhosis in individuals with Turner’s syndrome. Case Presentation: Herein, we report a case of liver biopsy-proven non-cirrhotic portal hypertension due to portosinusoidal vascular disease. Conclusion: High index of clinical suspicion can lead to early diagnosis and treatment of portal hypertension in individuals with Turner’s syndrome, reducing the burden of complications of portal hypertension.

Kawakami, Masayo; Nakazato, Hidetsugu; Tokisawa, Hiromi; Tomiyama, Takeshi; Miyagi, Jun; Nagayoshi, Seiji; Tamashiro, Koichi; Yoshimi, Naoki; Ohmine, Yasushi

2024 Case Reports in Gastroenterology

doi: 10.1159/000539978

AbstractIntroduction: Mixed neuroendocrine-nonendocrine neoplasms (MiNENs) of the digestive tract are rare. They contain both neuroendocrine and nonendocrine components. We here report a rare case of a metastatic MiNEN originating in the ascending colon. Case Presentation: An 80-year-old man presented with abdominal pain and vomiting. Colonoscopy showed an obstructing mass in the ascending colon, and a biopsy resulted in diagnosis of an adenocarcinoma. A CT scan revealed multiple liver metastases. Thus, our diagnosis was stage IV colon adenocarcinoma (cT4aN1bM1a according to TNM Classification of Malignant Tumors). The primary lesion was resected to alleviate symptoms. Histopathological and immunohistochemical examination revealed a well-differentiated adenocarcinoma and a small-cell neuroendocrine carcinoma, leading to the diagnosis of a MiNEN. The patient declined postoperative treatment and died approximately 2 months after the surgery. Conclusion: The incidence of MiNENs may be underestimated because they lack typical symptoms or imaging features and are therefore often only diagnosed after resection. Awareness of colonic MiNENs and further accumulation of cases are necessary to improve the outcomes.

Kim, Kain; Llanos, Danielle; Ramos, Christopher; Shahnavaz, Nikrad; Adhyaru, Bhavin B.

2024 Case Reports in Gastroenterology

doi: 10.1159/000540128pmid: 39144821

AbstractIntroduction: Despite heightened risk of venous thromboembolism (VTE) in hospitalized patients with inflammatory bowel disease (IBD), pharmacologic prophylaxis remains underutilized, particularly in those presenting with hematochezia. Although placement of retrievable inferior vena cava filters (rIVCF) may be considered in those with contraindications to anticoagulation and VTE risk, current recommendations from clinical guidelines are incongruent, leading to wide variation in practice. Case Presentation: This report highlights a case of rIVCF used in the management of recurrent VTEs in a patient hospitalized for persistent gastrointestinal bleeding. Conclusion: Our case demonstrates the need for a lower threshold for initiating VTE prophylaxis in patients with active IBD, even when hematochezia is the presenting symptom. A small group of patients with recurrent VTE and clear contraindications to anticoagulation may require IVCFs, necessitating close follow-up and monitoring for filter complications.

Soussi, Daniella; Alharahsheh, Batool Helmi Ahmad; Boshier, Piers Robert; Hoare, Jonathan; Direkze, Natalie; Thomas, Robert; Peters, Christopher John; Stevens, Sophie

2024 Case Reports in Gastroenterology

doi: 10.1159/000540694

AbstractIntroduction: Boerhaave syndrome is a rare condition associated with high morbidity and mortality. Prompt intervention greatly improves outcomes, with surgery traditionally being the mainstay of management. Recent advances in therapeutic endoscopy have led to increasing interest in endoluminal vacuum therapy (EVT), a minimally invasive technique, allowing wound debridement and drainage, encouraging granulation tissue formation. EVT has been associated with positive clinical outcomes, including lower mortality rates compared to surgery and stenting for the management of anastomotic leaks, and to a lesser extent, oesophageal perforations. EVT has been adopted into practice across Europe; however, only few cases have been reported from the UK. Case Presentations: We report three cases of Boerhaave syndrome, successfully managed with EVT, using the Eso-SPONGE ® (B.Braun Medical Ltd, Sheffield, UK). EVT involves the placement of a polyurethane sponge into the wound cavity. The cavity is initially assessed, then an overtube is introduced through which the sponge is inserted, and then the overtube is removed. Sponge position is confirmed and adjusted if necessary. The sponge is connected via a trans-nasal drain to continuous negative pressure suction and is changed every 3–5 days. Having been deemed surgically unfit, all 3 patients were referred for EVT. All patients made excellent recovery and were discharged home. Conclusion: EVT is an effective management strategy for surgically unfit Boerhaave syndrome patients. Eso-SPONGE use aided drainage of the septic focus and closure of the defect, leading to complete recovery. Our findings support the existing evidence that EVT is a promising solution for Boerhaave syndrome.

2024 Case Reports in Gastroenterology

doi: 10.1159/000540535