Volume 71 - 2008 - Fasc.4 - Case reports
Eosinophilic gastroenteritis observed by double balloon enteroscopy and endoscopic ultrasonography in the whole gastrointestinal tract
Eosinophilic gastroenteritis is a chronic inflammatory disorder of the gastrointestinal tract characterized by the infiltration of eosinophils. It is a rare disease. There are no reports in the history of eosinophilic gastroenteritis being consecutively observed in the whole gastrointestinal tract by esophagogastroduodenoscopy (EGD), double-balloon enteroscopy (DBE), and endoscopic ultra- sonography (EUS). A 66-year-old woman was admitted to our hos- pital because of abdominal pain and diarrhea. Laboratory findings included peripheral eosinophilia and a high serum immunoglobu- lin E level. We observed the whole gastrointestinal tract by EGD, DBE (antegrade and retrograde approaches), and EUS. DBE showed slightly edematous and reddish mucosa in the jejunum, ileum, and ascending colon, respectively. EUS in all portion of the gastrointestinal tract demonstrated almost normal five-layered structure without ascites. Histologic examination of the biopsy specimens from the stomach, duodenum, jejunum, ileum, colon and rectum revealed eosinophilic infiltration. No evidence of para- sites, granulomas, malignancy, vasculitis or embolism was founded in any of the biopsy specimens. The patient was diagnosed with eosinophilic gastroenteritis with predominant mucosal layer form. She was treated with oral corticosteroid, and her symptoms sub- sided. To the best of our knowledge, this is the first case of eosinophilic gastroenteritis in which the whole gastrointestinal tract was consecutively observed by EGD, DBE, and EUS. (Acta gastroenterol. belg., 2008, 71, 000-000).
Cytomegalovirus colitis in an apparently immunecompetent host after bilio- pancreatic diversion for obesity
CMV colitis in an immunocompetent host is a rare occurrence. We report a case of CMV colitis after biliopancreatic diversion sur- gery. The diagnosis of primary CMV infection with CMV colitis was based on histological examination of tissues biopsies obtained at colonoscopy, serology positive for CMV-IgM and CMV-IgG anti- bodies and a good response to systemic gancyclovir treatment. Malnutrition and colonic mucosal damage, both consequences of biliopancreatic diversion surgery, were thought to be predisposing factors.
To our knowledge this is the first report in the English language literature of an association between CMV colitis and status follow- ing biliopancreatic diversion surgery. (Acta gastroenterol. belg., 2008, 71, 000-000).
Pulmonary embolism due to injection of Histoacryl and Lipiodol during endoscopic sclerotherapy of fundic varices
Pulmonary N-butyl-2-cyanoacrylate embolism is one of the potential risks associated with endoscopic obliteration of fundic gastric varices. Due to its uncommon nature, especially in children, no consensus has been proposed on its optimal management.
Case report : An 11-year-old boy with a longstanding history of lung- and liver fibrosis with portal hypertension causing hae- matemesis underwent endoscopic therapy for fundic varices. Shortly after injection of 0.5 ml of a N-butyl-2-cyanoacrylate (Histoacryl®) and lipid soluble ethiodized oil (Lipiodol®) mixture, he desaturated with secondary hypotension and bradycardia. Pulmonary embolism was confirmed on chest X-ray. The boy was successfully treated conservatively. Clinical symptoms subsided and he was discharged after three days. Pulmonary infiltrations persisted for two weeks.
Conclusion : Patients including children undergoing obliteration of gastric varices with Histoacryl and Lipiodol should be subjected to a close follow-up. Coexisting lung conditions may enhance the risk of pulmonary embolism and can also influence the outcome. (Acta gastroenterol. belg., 2008, 71, 387-389).
Strongyloides Stercoralis infection associated with repititive bacterial meningitis and SIADH : a case report
Strongyloidiasis is an infection by the intestinal parasite Strongyloides Stercoralis, which usually stays asymptomatic. In some situations a hyperinfection or disseminated disease can occur. We report a case of a 49-year-old Congolese man with a medical history of 5 episodes of bacterial meningitis, who presents himself with a paralytic ileus and a low serum sodium. A Strongyloides hyperinfection with a SIADH was diagnosed. After treatment with ivermectine the abdominal symptoms subsided and the serum sodi- um returned to normal values. In comparison to other case reports our patient had no respiratory or gastrointestinal symptoms during the episodes of bacterial meningitis. Screening for Strongyloides stercoralis is indicated in patients with unexplained SIADH, bacterial meningitis or bacterial septicaemia, who origi- nally come from endemic countries. (Acta gastroenterol. belg., 2008, 71, 000-000).
Solid pseudopapillary tumor of the pancreas as a cause of recurrent pancreatitis
Solid pseudopapillary tumor (SPT) of the pancreas is a rare pan- creatic tumor mostly seen in young women. We here report a twelve-year-old girl presenting with recurrent attacks of pancreati- tis. No history of a systemic disease, trauma, drug usage or infec- tion was present. All other etiologic factors like familial, hyper- triglyceridemia, hypercalcemia, cystic fibrosis, medications were excluded. On abdominal ultrasound a heterogeneous mass was noticed at the tail of pancreas. Computerized tomography and magnetic resonance imaging proved that the mass was cystic. The mass was surgically removed. The diagnosis was pancreatic solid cystic papillary epithelial neoplasm. Although acute pancreatitis due to SPT was exceptionally reported, this is the first description of SPT leading to recurrent pancreatitis especially in children. (Acta gastroenterol. belg., 2008, 71, 390-392).
Jaundice as a misadventure of a green tea (camellia sinensis) lover : a case report
The case of a 76-year-old retired surgeon and lover of green tea (camellia sinensis) infusions who developed a clinical, sero-bio- chemical and histological picture of severe subacute hepatitis is reported. The clinical presentation was that of jaundice with asthe- nia and weight loss. Abnormal liver function tests were associated with hyper-gammaglobulinemia, and the transient presence of anti-smooth-muscle antibodies and ANCA. Liver histology showed mixed features of lobular hepatitis with central collapses, portal inflammatory cells infiltration and interface hepatitis. All other potential causes of hepatitis were excluded on the basis of clinical, biochemical and serological data. Herbal preparation withdrawal resulted in a slow and continuous improvement with a complete clinical and sero-biochemical resolution after 7months. (Acta gastroenterol. belg., 2008, 71, 000-000).
Lymphocytic colitis in a child with non-responsive celiac disease
In celiac disease, symptoms usually improve with strict adher- ence to diet. Some patients however do not show improvement despite of diet therapy. We here report a girl with non-responsive celiac disease whose diarrhea did not improve despite of a gluten free diet. A 12-year-old girl with recurrent diarrhea and failure to thrive was diagnosed with celiac disease. After six months of gluten-free diet her symptoms persisted. Adherence to diet was considered as correct and complete by a dietitian evaluation and by anti-endomysial antibodies that had become negative. Treatment with pancreatic enzymes, metronidazole or lactose free diet did not improve her symptoms. Colonoscopy was performed and lympho- cytic colitis was diagnosed on histology from colonic biopsies. After mesalamine therapy diarrhea ceased, and weight and height z scores increased. Lymphocytic colitis, which is uncommonly seen in children compared to adults, should be considered in non- responsive celiac disease in children. (Acta gastroenterol. belg., 2008, 71, 393-395).
An unusual presentation of Tangier disease with gallbladder involvement
Tangier disease is a rare, autosomally inherited disorder of lipoprotein metabolism characterized by absence or marked deficiency of normal high density lipoprotein (HDL) cholesterol in plasma resulting in the accumulation of cholesterol esters in various organs. A 57-year old male with a past medical history of hypertension, coronary artery disease and splenectomy admitted to our hospital for rectal bleeding. In routine laboratory tests thrombocytopenia, hypocholesterolemia and low HDL levels were detected. Colonoscopy revealed 1-3 mm sized, brownish, spotty lesions spread throughout the colonic mucosa. Histopathologically accumulation of foam cells which showed lipid vacuoles and myeline figures on electron microscopy were observed. Bone marrow biopsy was also suggestive of lipid storage disease. The laparoscopic operation performed for acute cholecystitis showed similar appearances in the gall bladder and liver. The case was diagnosed as rare presentation of Tangier disease with gallbladder involvement in view of the low HDL cholesterol level and systemic lipid deposition. (Acta gastroenterol. belg., 2008, 71, 397-400)
Primary pancreatic neoplasia or metastasis from colon carcinoma ?
Introduction: The pancreas is an unusual but occasionally favored target for metastasis from other primary cancers. Metastases have been described for various non-hematologic neoplasms, such as renal-cell carcinoma, pulmonary small-cell carcinoma, melanoma and gastric carcinoma.
Case report : We report the case of a 77-year old man with a mass in the pancreatic head five years after anterior resection for adenocarcinoma of the colon and three years after resection of a lung metastasis. The patient underwent pylorus-preserving pancreaticoduodenectomy (Longmire-Traverso) and lymph-node dissection of compartment II.
Discussion : It is rare to have solitary metastases to the pancreas which clinically may mimic a primary neoplasm of the pancreas. Clinical features, as well as MRI and PET findings in patients with pancreatic metastasis from colon carcinoma are similar to those of primary pancreatic ductal adenocarcinoma. The diagnosis of metastasis should be considered when patients have a pancreatic mass and a history of non-pancreatic malignant lesions. Radical resection may prolong survival in patients if the pancreas is the only locus for metastasis at the time of diagnosis. (Acta gastro- enterol. belg., 2008, 71, 401-408).
Jaundice as a misadventure of a green tea (camellia sinensis) lover : a case report
The case of a 76-year-old retired surgeon and lover of green tea (camellia sinensis) infusions who developed a clinical, sero- biochemical and histological picture of severe subacute hepatitis is reported. The clinical presentation was that of jaundice with asthe- nia and weight loss. Abnormal liver function tests were associated with hyper-gammaglobulinemia, and the transient presence of anti-smooth-muscle antibodies and ANCA. Liver histology showed mixed features of lobular hepatitis with central collapses, portal inflammatory cells infiltration and interface hepatitis. All other potential causes of hepatitis were excluded on the basis of clinical, biochemical and serological data. Herbal preparation withdrawal resulted in a slow and continuous improvement with a complete clinical and sero-biochemical resolution after 7months. (Acta gastroenterol. belg., 2008, 71, 409-412).
Strongyloides Stercoralis infection associated with repititive bacterial meningitis and SIADH : a case report
Strongyloidiasis is an infection by the intestinal parasite Strongyloides Stercoralis, which usually stays asymptomatic. In some situations a hyperinfection or disseminated disease can occur. We report a case of a 49-year-old Congolese man with a medical history of 5 episodes of bacterial meningitis, who presents himself with a paralytic ileus and a low serum sodium. A Strongyloides hyperinfection with a syndrome of inappropriate secretion of the antidiuretic hormone (SIADH) was diagnosed. After treatment with ivermectine the abdominal symptoms subsided and the serum sodium returned to normal values. In comparison to other case reports our patient had no respiratory or gastrointestinal symptoms during the episodes of bacterial meningitis. Screening for Strongyloides stercoralis is indicated in patients with unex- plained SIADH, bacterial meningitis or bacterial septicaemia, who originally come from endemic countries. (Acta gastroenterol. belg., 2008, 71, 413-417).
Eosinophilic gastroenteritis observed by double balloon enteroscopy and endoscopic ultrasonography in the whole gastrointestinal tract
Eosinophilic gastroenteritis is a chronic inflammatory disorder of the gastrointestinal tract characterized by the infiltration of eosinophils. It is a rare disease. There are no reports in the history of eosinophilic gastroenteritis being consecutively observed in the whole gastrointestinal tract by esophagogastroduodenoscopy (EGD), double-balloon enteroscopy (DBE), and endoscopic ultra- sonography (EUS). A 66-year-old woman was admitted to our hos- pital because of abdominal pain and diarrhea. Laboratory findings included peripheral eosinophilia and a high serum immunoglobu- lin E level. We observed the whole gastrointestinal tract by EGD, DBE (antegrade and retrograde approaches), and EUS. DBE showed slightly edematous and reddish mucosa in the jejunum, ileum, and ascending colon, respectively. EUS in all portion of the gastrointestinal tract demonstrated almost normal five-layered structure without ascites. Histologic examination of the biopsy specimens from the stomach, duodenum, jejunum, ileum, colon and rectum revealed eosinophilic infiltration. No evidence of para- sites, granulomas, malignancy, vasculitis or embolism was founded in any of the biopsy specimens. The patient was diagnosed with eosinophilic gastroenteritis with predominant mucosal layer form. She was treated with oral corticosteroid, and her symptoms subsided. To the best of our knowledge, this is the first case of eosinophilic gastroenteritis in which the whole gastrointestinal tract was consecutively observed by EGD, DBE, and EUS. (Acta gastroenterol. belg., 2008, 71, 418-422).
Cytomegalovirus colitis in an apparently immunecompetent host after bilio- pancreatic diversion for obesity
CMV colitis in an immunocompetent host is a rare occurrence. We report a case of CMV colitis after biliopancreatic diversion surgery. The diagnosis of primary CMV infection with CMV colitis was based on histological examination of tissues biopsies obtained at colonoscopy, serology positive for CMV-IgM and CMV-IgG antibodies and a good response to systemic gancyclovir treatment. Malnutrition and colonic mucosal damage, both conse- quences of biliopancreatic diversion surgery, were thought to be predisposing factors.
To our knowledge this is the first report in the English language literature of an association between CMV colitis and status follow- ing biliopancreatic diversion surgery. (Acta gastroenterol. belg., 2008, 71, 423-426).
