Cavernous Gastric Hemangioma as an Unusual Cause of Upper Gastrointestinal Bleeding in a Young Woman

Gastric hemangiomas (GHs) are extremely rare vascular lesions of mesodermal origin that may occur in isolation or in conjunction with underlying congenital pathology. Due to the scarcity of these tumors, there is no standardized diagnostic method; however, many have found the combination of endoscopic investigation and radiographic imaging to be most effective, with the presence of phleboliths on computerized tomography as being pathognomonic for GHs. Surgical treatment for symptomatic lesions is curative with no reports of recurrence. We describe a 21-year-old woman who presented with epigastric pain and one episode of 250 mL hematemesis earlier that morning. Under the impression of an upper gastrointestinal bleed due to peptic ulcer disease, esophagogastroduodenoscopy was performed which revealed a 5-cm blood clot-like mass similar in appearance to that of a II-b peptic ulcer, but the presence of a bridging fold led to the suspicion of a possible submucosal tumor. Dynamic computerized tomography scan showed similar findings, and the patient was referred for surgical intervention. Laparoscopic distal gastrectomy was performed with the final diagnosis of cavernous GH made via histological evaluation. The patient was discharged 9 days later with no complications. This case puts emphasis on the importance of considering cavernous GH as a potential cause of severe upper GI bleeding especially in those with atypical demographic profile and history.

A Rare Cause of Gastric Variceal Bleeding

A 68-year-old woman with stage III colon cancer status after right hemicolectomy and adjuvant FOLFOX (5-fluorouracil/leucovorin/oxaliplatin) chemotherapy was hospitalized for melena and found to have new-onset esophageal and gastric varices on esophagogastroduodenoscopy. Her workup did not reveal an underlying liver disease, but her liver biopsy showed noncirrhotic portal hypertension from obliterative portal venopathy (OPV). The development of OPV is likely from her use of oxaliplatin-based chemotherapy.

Acute Herpes Simplex Esophagitis in an Immunocompetent Adult with Eosinophilic Esophagitis

Herpes simplex esophagitis (HSE) represents a rare entity in immunocompetent patients and has infrequently been described in association with eosinophilic esophagitis (EoE). Causality in this rare association remains a debated topic. We present a case of HSE occurring in an immunocompetent adult with EoE and review the literature in support of EoE induced mucosal disruption predisposing to increased risk of HSE.

Colonoscopic Treatment of a Fecaloma at the Anastomotic Site after Colectomy

Fecalomas most commonly occur in constipated patients and are rarely reported after colectomy. A 55-year-old Japanese female presented with a fecaloma after colectomy, which was impacted at a functional end-to-end anastomosis (FEEA) site. Four and a half years ago, she underwent sigmoidectomy for colon cancer. A follow-up computed tomography (CT) scan revealed an 11 cm incidental fecaloma. The patient was advised to undergo surgery, but she desired nonoperative management because of minimal symptoms, and was referred to our institution. On the day of admission (day 1), mechanical fragmentation of the fecaloma was attempted during the first colonoscopy. Although a large block of stool was evacuated after a second colonoscopic fragmentation on day 8, the third colonoscopy on day 21 and CT scan on day 22 showed no significant change in the fecaloma. Frequent colonoscopic fragmentation was performed, with a fourth, fifth, and sixth colonoscopy on days 24, 29, and 31, respectively. After the size reduction was confirmed at the sixth colonoscopy, the patient was discharged home on day 34. The fecaloma completely resolved after the seventh colonoscopic fragmentation on day 44. Sixteen months after treatment, there is no evidence of recurrent fecaloma. According to the literature, risk factors for fecaloma after colectomy include female gender, left-side colonic anastomosis, and FEEA. FEEA might not be recommended for anastomoses in the left colon, particularly in female patients, to avoid this complication. Colonoscopic fragmentation is recommended for fecalomas at an anastomotic site after colectomy in patients without an absolute indication for surgery.

Esophageal Perforation after Using a Single-Use Disposable Duodenoscope

The Food and Drug Administration (FDA) has recently released a safety communication recommending transition to duodenoscopes with innovative designs that facilitate or eliminate the need for reprocessing. Thus, there has been a significant amount of development into disposable duodenoscope components and single-use duodenoscopes, with variable tactile feedback. We describe a case of esophageal perforation after using a single-use disposable duodenoscope (EXALT Model D; Boston Scientific Corporation, Marlborough, MA, USA). To our knowledge, this is the first reported case of an esophageal perforation since FDA approval of this device in December 2019. ERCP was performed with the EXALT Model D single-use duodenoscope (Boston Scientific Corporation) by an experienced gastroenterologist. During the procedure, gentle force applied through the gastroesophageal junction caused a liner perforation in the distal esophagus. An esophageal stent was placed with satisfactory wound healing and no fistula formation. There have been a few reports in the last 2 years showing promising results using this device; however, the differences in the tactile feedback, navigation, and pushability of the device may make it prone to unintended consequences.

Giant Adrenal Lipoma with Hemorrhage Requiring Extended Surgical Resection

Adrenal lipoma is a rare, benign tumor, reported to account for 0.7% of primary adrenal tumors. A 69-year-old man presented with left lateral abdominal pain. Computed tomography (CT) was performed, and a huge, irregularly shaped retroperitoneal tumor of uneven internal density was identified, with the border between the tumor and the pancreas and kidney being unclear. Active hemorrhage was also depicted. The tumor consisted mainly of fat, with the exception of the hematoma; it measured 200 mm; and the boundary between it and nearby organs, such as the pancreas, was unclear. Despite angiography being performed twice, the responsible vessel was not identified. Thus, for the purpose of both diagnosis and treatment, we resected the tumor, and considering the possibility of a malignancy, such as liposarcoma, we also resected the pancreatic body and tail and the spleen. The final histopathologic diagnosis was benign adrenal lipoma with hemorrhage, with no invasion to surrounding tissue. Hemorrhage within an adrenal tumor is rare. Most adrenal lipomas are small “incidentalomas” and asymptomatic. With development of a large adrenal lipoma comes the possibility of hemorrhage along with the possibility of features suggestive of malignancy. We encountered a giant adrenal lipoma with hemorrhage and, because of the aforementioned features, performed extended surgical resection, seen in retrospect as oversurgery. The widespread use of CT has led to an increased number of reported cases of adrenal lipoma. We anticipate an accumulation of case reports, which will allow for development of an appropriate treatment algorithm.

Giant Gastric Folds in Juvenile Polyposis

To advance the diagnostic accuracy of juvenile polyposis syndrome, an important yet often difficult diagnosis, we describe in detail a new and medically significant presentation. This hereditary and high-risk GI cancer syndrome is often associated with hereditary hemorrhagic telangiectasia, as in this 47-year-old female patient with a <i>SMAD4</i> germline pathogenic mutation. Total gastrectomy revealed giant gastric folds with inflamed foveolar hyperplasia consuming most of the gastric cardia and body but sparing the antrum. Together, this gross and histologic pathology mimics Ménétrier’s disease, an exceedingly rare and acquired protein-losing hypertrophic gastropathy. Classical gastric juvenile polyposis almost always and principally involves the antrum with multiple distinctive inflammatory <i>polyps</i> rather than the newly illustrated <i>giant gastric folds</i> of this case. No reports of giant gastric folds in juvenile polyposis have appeared in the literature. The distinction between juvenile polyposis and Ménétrier’s disease is essential due to their disparate clinical outcomes and management. The differential considerations for giant gastric folds and inflamed gastric foveolar hyperplasia are fully reviewed. On the basis of this report, the differential for giant gastric folds must now expand to include juvenile polyposis syndrome. Genetic testing for pathogenic germline mutations of the 2 known causative genes of this syndrome, namely <i>SMAD4</i> and <i>BMPR1A</i>, are readily available and should become part of the evaluation of giant gastric folds, particularly in view of the neoplastic and hereditary aspects of juvenile polyposis syndrome.

Omphalitis with Umbilical Abscess in an Adult with a Urachal Remnant

Omphalitis is an inflammation of the umbilicus and is seldom diagnosed in adults. It is even rarer when it results from an infection of the urachus, an embryological remnant that connects the umbilicus to the dome of the bladder. Patients with omphalitis present with erythema, edema, tenderness, and purulent discharge form the umbilical stump. Workup includes ultrasonography and CT scan of the abdomen and pelvis. Management consists of antibiotics and incision and drainage of the umbilical abscess, followed by surgical resection of the urachal remnant. In this article, we report a case of omphalitis complicated by umbilical abscess in a 20-year-old female with a urachal remnant.

Brown Bowel Syndrome: An Exceedingly Rare Condition with Longstanding Malabsorption and an Unusual Cause of Colon Pseudo-Obstruction

Brown bowel syndrome (BBS) is an exceedingly rare condition usually associated with longstanding malabsorption of any etiology. As a result of vitamin E deficiency and subsequent mitochondrial degeneration due to oxidative stress induced by free radicals, lipofuscin granules accumulate in the smooth muscles of the gastrointestinal tract resulting in myopathy and dysmotility with underlying disease aggravation. The current study reports a BBS case in a 64-year-old female patient who had undergone jejunoileal bypass surgery as a bariatric procedure. The patient was admitted with signs of malabsorption and ileus in computed tomography imaging. Endoscopic workup revealed no stenosis or obstruction. The colon histologically showed periodic acid-Schiff-positive lipofuscin granules in the lamina muscularis mucosa consistent with BBS. The vitamin E level in the patient was extremely low. Moreover, clinical improvement was documented following high-dose substitution. BBS should be considered in patients with malabsorption of any cause especially with signs of gastrointestinal dysmotility. Vitamin E substitution may improve clinical status and prevent further deterioration.

Metastasis of Testicular Choriocarcinoma in the Stomach, Complicated by the Development of Choriocarcinoma Syndrome

Choriocarcinoma (CC) is a very rare and aggressive neoplasm. The characteristic feature of this disease is a rapid hematogenous spread, mainly to the lungs and brain, which largely defines clinical signs of the disease and complicates the diagnosis. Gastrointestinal metastases are rare, and of those, only few cases with gastric location have been reported. There are publications describing choriocarcinoma syndrome (CCS). As a rule, it presents in patients with an advanced disease and is characterized by hemorrhage from metastatic foci, leading to hemoptysis and gastrointestinal bleeding. CCS development is associated with poor prognosis and high mortality. This article describes a case of testicular CC with rare few gastric metastases, complicated by CCS.