Gastrointestinal Diseases

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• A hepatic manifestation of anorexia nervosa Jodi-Anne M. Wallace, Krizia-Ivana T. Udquim, Thomas A. Starnes, Nila S. Radhakrishnan Views: 417 HTML: 383 PDF: 456

  A 30-year-old woman with a history of anorexia nervosa was admitted with weight loss, hypoglycaemia and electrolyte disturbances. During her admission, transaminases peaked at ALP 457 U/l, AST 817 U/l and ALT 1066 U/l. Imaging and laboratory findings were unrevealing, and she declined liver biopsy. Nutrition was introduced via a nasogastric tube and she demonstrated improvement in her laboratory values over several weeks. Her transaminitis was determined to be secondary to severe malnutrition, which has been previously described, but cases with such profound transaminitis are less common. Studies have demonstrated hepatic autophagocytosis as the likely cause.

• Drug-induced liver injury secondary to turmeric use Ashika Ajitkumar, Gaurav Mohan, Medha Ghose, Sivanaga Yarrarapu, Swara Afiniwala Views: 579 HTML: 815 PDF: 536

  Turmeric is a herbal medication and spice which has been used for thousands of years in traditional Eastern medicine for its flavour, colour, and purported anti-inflammatory, antioxidant, antineoplastic and antimicrobial properties. It has recently garnered interest and popularity worldwide for these reasons. While turmeric supplements are generally safe, some reports of toxicity are emerging. Compounds like piperine are added to turmeric to enhance its bioavailability, potentially contributing to its toxicity. Here, we describe a 55-year-old woman with progressive jaundice and elevated bilirubin and liver enzymes but no evidence of acute liver failure. She was treated with N-acetyl cysteine (NAC) for 24 hours and liver function tests (LFTs) were closely monitored. As a downtrend in LFTs was noted and the patient remained asymptomatic, she was discharged with close outpatient follow-up. LFTs eventually normalized 2 months after the initial presentation. Clinicians must keep this differential in mind when evaluating acute liver injury. With our case report, we question the utility of NAC in non-acetaminophen-related liver injury and encourage further studies.

• Hepatic coma secondary to Fontan Conduit thrombosis João Luís Cavaco, Ana Rita Ferreira, Constança Abecasis Jalles, Inês Matias Lopes, Armando Braz, Ana Oliveira Pedro, António Pais de Lacerda Views: 638 HTML: 68 PDF: 362

  Introduction: The Fontan procedure is used to treat congenital heart defects and has improved long-term survival. Long-term complications include liver disease due to congestive hepatopathy. Fontan-related cirrhosis can manifest with ascites, gastrointestinal bleeding and encephalopathy.

  Case description: A 43-year-old man with history of Fontan surgery was admitted with COVID-19 pneumonia. There was rapid clinical and neurological deterioration, with coma and shock. CT imaging showed thrombosis of the Fontan conduit. The patient was successfully subjected to recanalization of the Fontan circulation, with progressive improvement of coma.

  Discussion: Fontan-associated liver disease is a major complication following the Fontan procedure. Clinicians must be aware of this pathology during patient follow-up.

• COVID-19 related acalculous Groove Pancreatitis João Luís Cavaco, Hélder Diogo Goncalves, Maria José Pires, Ana Furão Rodrigues, Paula Silva, Ana Oliveira Pedro, António Pais de Lacerda Views: 367 HTML: 96 PDF: 323

  Introduction: Groove pancreatitis is a rare form of chronic pancreatitis. Its radiological diagnosis is challenging and it can be difficult to distinguish from pancreaticoduodenal malignancy.

  Case description: A 64-year-old woman was admitted to our internal medicine ward after she contracted severe COVID-19 pneumonia requiring mechanical ventilation. She presented with right upper abdominal pain, and a CT scan showed pancreaticoduodenal inflammatory tissue; malignancy was ruled out.

  Conclusion: Diagnosing groove pancreatitis is challenging and malignancy must be quickly excluded. No cases of COVID-19-associated groove pancreatitis have been previously described.

• Intrathoracic kidney Rosario Blanco Saez, Rafaela Costa Pereira, Ramiro Sá Lopes, Fábio Caleça Emídio, Iryna Lazenko Views: 362 HTML: 45 PDF: 362

  Intrathoracic kidney is a very rare finding, representing less than 5% of all renal ectopias. Because of the location of the liver, thoracic kidney on the right side is much less common than thoracic kidney on the left side. Although an increasing number of case reports are being published in the literature, few describe the impact of the ectopia on kidney function. We report the case of a woman with intrathoracic right kidney and chronic kidney disease that was initially misdiagnosed as pneumonia because of its presentation on chest x-ray. We highlight the need to including this condition in the differential diagnosis as the literature rarely links it to changes in kidney function.

• Acute onset of bullous skin rash and acute kidney injury after exposure to radiocontrast: Sweet's syndrome Mahmoud Abdelnabi, Annia Cavazos, Corley Pruneda, Jerapas Thongpiya, Pitchaporn Yingchoncharoen, Sierra Sullivan, Jesus Davalos , Michele Tarbox Views: 759 HTML: 431 PDF: 517

  Sweet's syndrome or acute febrile neutrophilic dermatosis is characterized by an acute inflammatory skin eruption of oedematous and erythematous papules, plaques or nodules, accompanied by fever, and leucocytosis with possible extracutaneous involvement. Aetiologies include infections, inflammatory bowel disease, pregnancy or malignancy, or the syndrome may be drug-induced by many classes of medications or very rarely, radiocontrast exposure. Herein, the authors report a case of radiocontrast-induced bullous Sweet's syndrome and contrast-induced acute kidney injury in a woman in her 60s with a complex medical history.

• Reversible 'unstable' abdominal angina caused by ruptured plaque of the superior mesenteric artery: clinical and radiological correlations Shaul Yaari, Nurith Hiller, Yacov Samet, Samuel Noam Heyman Views: 394 HTML: 115 PDF: 349

  Unstable angina, characteristic of coronary artery disease, is caused by in-situ clot formation complicating ruptured atheromatous plaque. Abdominal angina, however, usually reflects chronic mesenteric ischaemia, caused by multi-vessel stable plaques involving mesenteric arteries. Herein, we describe a patient with new-onset abdominal pain caused by a ruptured atheromatous plaque at the superior mesenteric root. The diagnosis was based on an evident reversible epigastric bruit and high-degree eccentric stenosis caused by a non-calcified atheroma. Symptoms and bruit resolved within 3 weeks on aspirin and statins with regression of the stenotic lesion. Although the condition is likely common, this is the first clear-cut report compatible with 'unstable' abdominal angina, resolved by conservative treatment.

• An 84-year-old patient with Caroli syndrome: what is the prognosis of this condition? Fabio Caleça Emidio, Rafaela Costa Pereira, Rosário Blanco, Pedro Santos, Teresa Abegão, Claudia Fitas Views: 429 HTML: 115 PDF: 348

  Caroli disease is a rare congenital pathology caused by mutation of the PKHD1 gene (polycystic kidney and hepatic disease 1), also responsible for autosomal recessive polycystic kidney disease. Characterized by segmental and multifocal dilatation of the large intrahepatic bile ducts, classic disease involves only malformation of the biliary tract. The association with congenital hepatic fibrosis is called Caroli syndrome. We describe the case of an 84-year-old man with Caroli syndrome diagnosed in 1997 by liver biopsy. The CT scan revealed massive hepatomegaly, extending to the pelvic region, and almost total replacement of the parenchyma by numerous cystic formations, no evidence of bile duct dilatation, and no ascites or splenomegaly suggestive of portal hypertension. The atypical clinical presentation, with no reported complications, resembles that of a space-occupying lesion with an indolent course, previously misdiagnosed as metastatic neoplasm.

• Leptospirosis and liver abscess: an unusual association Pedro Ribeirinho Soares, Miguel Souto, Jorge Almeida Views: 385 HTML: 106 PDF: 474

  Leptospirosis is a zoonotic infection infrequently reported in non-tropical regions. Although classically described as a biphasic illness, unusual clinical manifestations have been reported, including a previous case of a lung abscess associated with this causative agent. We present the case of a 49-year-old man with a new diagnosis of two liver abscesses associated with leptospirosis.

• Recurrent sepsis in a patient with biliary hamartomas Maria Beatriz Santos, Magda Ponta Garça, Bárbara Vieira, Paulo Ávila, Alexandra Freitas Views: 220 HTML: 82 PDF: 263

  Biliary hamartomas or von Meyenburg complexes (VMCs) are hepatic tumour-like lesions related to congenital malformation of the ductal plate, and are part of the ciliopathy spectrum of disorders. The exact pathogenesis of VMCs is unclear and it remains controversial whether they have the potential for malignant transformation. Patients are often asymptomatic and VMCs are usually encountered as an incidental finding on imaging.
  We report a case of recurrent sepsis with an unidentified focus. It was later confirmed that biliary hamartomas were acting as a sanctuary for the persistent pathogenic agent. The authors hope to draw attention to the existence of this unusual focus of recurrent sepsis.