Clinical Case Summary

A 51-year-old woman with no prior similar illness presented with severe epigastric pain, 6-kg weight loss, fatigue, and hemoptysis over 8 months. Five years ago, she had high fever and right abdominal pain with an elevated eosinophil count of 1147/μL, diagnosed as liver abscesses. Recent gastroscopy and endoscopic ultrasound (EUS) revealed a 4x3 cm hypoechoic mass in the upper stomach, suggesting gastric malignancy. PET/CT scans showed uneven gastric wall thickening up to 3.5 cm and multiple enlarged lymph nodes, indicative of metastatic cancer. Declining surgery, she sought further evaluation.
At our hospital, CT scans revealed indications of metastatic gastric carcinoma, such as irregular thickening of the gastric walls, diffuse involvement in the lower esophagus and gastric cardia, and densely enlarged lymph nodes near the hepatogastric ligament, paraaortic region, and hepatic hilum. Several indistinct lung nodules were also observed. Endoscopic examination showed localized mucosal hyperemia and swelling in the stomach, but gastric biopsies showed only mild chronic inflammation. EUS confirmed thickening of the gastric wall with varied echogenicity. However, EUS-guided fine-needle aspiration (EUS-FNA) from the gastric wall and an adjacent lymph node showed significant eosinophil infiltration but no malignancy. Elevated eosinophils were detected by blood tests and bone marrow analysis, with no other abnormalities.
Given these findings, Hypereosinophilic Syndrome (HES) was diagnosed. Instead of surgery, the patient received intravenous methylprednisolone (80 mg/day for 3 days), followed by tapered oral prednisone, and monthly cyclophosphamide pulses. This regimen significantly improved her symptoms and reduced lesions in the lungs, stomach, and lymph nodes, as confirmed by follow-up imaging. After one year, she achieved full clinical and biochemical remission, confirming extensive stomach and multi-organ involvement from HES.

Clinical Case Summary

A 64-year-old male patient presented with acute epigastric pain over 7 days, worsening after meals, nausea, vomiting 2 times without signs of bleeding, diarrhea 5-6 times/day, high blood pressure 180/100 mmHg. He had a 6-year history of recurrent epigastric pain, after multiple EGDSs was diagnosed as gastric ulcer and atrophic gastritis. The patient had undergone HP eradication and received standard anti-ulcer therapy several times, with no clinical improvement. On physical examination, the patient appeared pale. The abdomen was soft, without pain, guarding or rebound tenderness. The patient's medical history was significant for arterial hypertension. Lab abnormalities included WBC 16.32-10x10⁹/L, ESR 94mm/sec, CRP at 184.3 mg/L, FBG 767 mg, Total protein 50.9 g/L, CREA 147 mmol/L, Urea 13.42 mmol/L, Na 129 mmol/L. Intestinal infections were negative. New EGDS revealed an ulcerative lesion with 0.8cm diameter, in the region from antrum to greater curvature, covered with fibrin. Colonoscopy was normal. Duplex ultrasound revealed a 70% stenosis of the celiac trunk and superior mesenteric artery, with atherosclerotic wall deformation and intima-media thickening. A thrombosis was detected in the region of the aortic bifurcation. CT angiography revealed up to 70% stenosis of the suprarenal abdominal aorta, no contrast enhancement was observed in the origins of the celiac trunk, superior mesenteric artery, left renal artery (left kidney appeared atrophic), total occlusion of bilateral common, external, and internal iliac arteries.
Conclusion: Gastric ulcers are mostly associated with HP. However, in rare cases, underlying vascular pathology may be critical in their pathogenesis. This case highlights an overlooked cause of gastric ulcers, particularly in patients with atherosclerotic risk factors. In patients with persistent symptoms despite medical therapy ischemic ulceration should be included in the differential diagnosis.

Clinical Case Summary

Pyloric syndrome, characterised by delayed gastric emptying due to mechanical obstruction, is typically associated with peptic ulcers or malignancies. However, parasitic causes are exceptionally rare in adults. We report a singular case of a 46-year-old man presenting with progressive abdominal pain, persistent vomiting, melena, and severe weight loss. Initial clinical suspicion focused on malignancy due to cachexia, pallor, and a distended abdomen. Laboratory findings revealed profound anaemia (Hb 4 g/dL), hypoalbuminemia (2.3 g/dL), and the patient required transfusional support. A contrast-enhanced abdominal CT showed significant gastric distension with narrowed contrast flow through the pylorus, suggestive of an obstructive neoplasm. However, upper endoscopy revealed a large conglomerate of Ascaris lumbricoides obstructing the pyloric and duodenal lumen. Mechanical extraction of the helminths led to immediate symptom relief. Empirical antiparasitic therapy with albendazole and later nitazoxanide was initiated. This case highlights a rare yet critical diagnostic pitfall: parasitic gastrointestinal obstruction in adults mimicking advanced gastric pathology. In endemic regions, clinicians must maintain a broad differential diagnosis and consider parasitic aetiologies, even in adults, especially in patients with poor hygienic or socioeconomic conditions. This report broadens the clinical spectrum of ascariasis and underscores the continued relevance of parasitic infections in global health.

Patient	Main Symptoms	Initial Diagnosis Suspected	Imaging Findings	Endoscopic Diagnosis	Treatment	Outcome
46-year-old male	Abdominal pain, vomiting, melena, weight loss	Gastric tumour with pyloric stenosis	Distended stomach with filiform pyloric passage	Ascaris lumbricoides obstruction	Mechanical extraction + albendazole/nitazoxanide	Rapid recovery

References

• de Silva NR, Brooker S, Hotez PJ, Montresor A, Engels D, Savioli L. Soil-transmitted helminth infections: updating the global picture. Trends Parasitol. 2003;19(12):547–551. doi:10.1016/j.pt.2003.10.002.

• Khuroo MS, Zargar SA, Mahajan R. Hepatobiliary and pancreatic ascariasis in India. Lancet. 1990;335(8704):1503–1506. doi:10.1016/0140-6736(90)93093-r.

• Carney DE, Psoinos C, Rosoff L. Intestinal obstruction due to Ascaris lumbricoides in an adult: a rare cause of acute abdomen. J Surg Case Rep. 2013;2013(8):rjt065. doi:10.1093/jscr/rjt065.

Clinical Case Summary

A 35-year-old woman referred to the emergency department with vomiting, hyporexia, abdominal distension and worsening of her chronic diarrhea.
Laboratory tests revealed neutrophilic leukocytosis (20x10⁹/L), eosinophilia (8.00x10⁹/L) and increased PCR values. The patient was hospitalized and scheduled for further examination:

• CT scan showed intra-abdominal ascites with thickening of some loops of the jejunum.
• Stool tests revealed a C. Difficile infection, which was treated with vancomycin. Calprotectin was in the normal range.
• Esophagogastroduodenoscopy and pancolonoscopy with terminal ileoscopy were within normal limits.
• PET scan revealed an extensive intra-abdominal ascitic effusion with an intense uptake along the jejunum.
• Paracentesis showed an exudate rich in eosinophilic granulocytes and negative for neoplastic cells. Bacterial culture and BK research were negative.

Lastly, a bone marrow biopsy and an anterograde push enteroscopy with biopsies were performed.
The first one showed no signs of myeloproliferative disease, but a normal marrow with an important eosinophilia. On the other hand, the enteroscopy highlited a hyperemic jejunal mucosa without macroscopic lesions. (FIGURE A.)
The histological examination revealed a regular architecture with normal villo/crypt ratio and focally >30x100 intraepithelial enterocytes. (FIGURE B.)
Although not all diagnostic criteria were satisfied for the diagnosis of primary eosinophilic gastroenteritis (diagnostic cut-off limit is >50/HPF), multidisciplinary evaluation diagnosed an idiopathic hypereosinophilic syndrome with prevalent gastrointestinal involvement and steroid therapy (1mg/kg) was started. In just two days of therapy, the blood eosinophils were reduced to normal values and the symptoms were significantly improved.
She has currently tapered steroid therapy to start a treatment with the monoclonal antibody mepolizumab. At latest laboratory tests eosinophils amount to 0.09x10³/µL.

Introduction

Iatrogenic gastrointestinal perforation (IGP) is a rare but critical complication of endoscopy, traditionally managed surgically. Recent advances have allowed nonsurgical treatment to emerge as a viable alternative. However, predictive models for successful nonsurgical management remain limited.

Aims & Methods

This study aimed to identify independent predictors of nonsurgical success and develop a visual nomogram to predict which patients with IGP can be treated successfully without surgery. We retrospectively reviewed cases of IGP from three tertiary centers in China between 2011 and 2022. Patients were divided into two groups: those successfully managed nonsurgically and those requiring surgical intervention. Multivariable logistic regression identified predictors of nonsurgical success, and a nomogram was developed and validated to predict outcomes. Data analysis included patient demographics, perforation characteristics, and treatment details.

Results

Of 1,034,706 endoscopic procedures performed during the study period, 80 cases of IGP were identified (incidence rate: 0.008%). The median patient age was 58.4 years (±15.1), with a slight male predominance (55%). Nonsurgical management succeeded in 66.3% (53/80) of cases, while 33.8% (27/80) required surgery.
Successful nonsurgical management was associated with shorter hospital stays (median: 12 vs. 16.5 days, P=0.005) and fewer in-hospital complications, such as septic shock (0% vs. 50%, P<0.001). Independent predictors of nonsurgical success included the absence of missed muscular injury (odds ratio [OR]=0.146, 95% confidence interval [CI] 0.034-0.622, P=0.009), upper gastrointestinal perforation (OR=7.182, 95%CI 1.446-35.668, P=0.016), use of endoscopic treatment (OR=12.152, 95%CI 1.705-86.588, P=0.013), and early intravenous antibiotics administered within 5 hours (OR=6.040, 95%CI 1.391-27.218, P=0.016) (Table 1).
The nomogram assigned weighted points to each predictor, and the total score (ranging from 0 to 300 points) was calculated by summing the points assigned to each predictor. The total score demonstrated a nonlinear association with the probability of nonsurgical success: 0 points corresponded to a 0.1 (10%) probability of success; 50 points to 0.3 (30%); 100 points to 0.5 (50%); 150 points to 0.8 (80%); 200 points to 0.9 (90%); 250 points to 0.95 (95%); and 300 points to 0.99 (99%).
Internal validation using bootstrap resampling (C-index = 0.876) and fivefold cross-validation (C-index = 0.850) confirmed the model’s reliability. Calibration curves showed high agreement between predicted and observed outcomes, and decision curve analysis supported the clinical utility of the model.
Table 1. Predictors and associated numeric points from the nomogram for predicting the success of nonsurgical treatment.

Variable		P	OR	Beta coefficient	Score
Missed muscular injury	Yes	0.009	0.098 (0.022-0.442)	-1.927	0
	No				77
Upper GI perforation	Yes	0.016	7.587 (1.431-40.212)	1.972	79
	No				0
Endoscopic treatment	Yes	0.013	14.452 (1.960-106-569)	2.498	100
	No				0
Early intravenous antibiotic	Yes	0.016	6.042 (1.325-27.562)	1.798	72
	No				0

Conclusion

This study presents a validated nomogram integrating critical predictors to estimate nonsurgical success in IGP management. These findings highlight the importance of clinician vigilance, timely interventions, and the utility of tailored endoscopic treatments in optimizing patient outcomes.

Disclosure

All authors have no conflicts of interest or financial ties to disclose.

Clinical Case Summary

A 42-year-old male patient was admitted to our department due to a chronic abdominal pain and symptoms of gut-brain dysfunction (bloatedness, belching, stomach fullness and mixed bowel habits) that lasted for years. He also suffered of ventricular extrasystoles that were more prominent during stomach fullness and for which he underwent two ablation procedures. Five years prior to hospitalization extensive outpatient assessment was performed (laboratory check-up, gastroscopy, abdominal ultrasound, esophageal manometry, 24h pH-metry, occult blood testing, microbiome testing), but, except for insufficient cardia and reduced biodiversity, there were no other pathological findings. The symptomatic therapy was given, but yielded inadequate relief. Due to severe insomnia and worsening of aforementioned symptoms, the patient underwent cognitive behavioural therapy. Although insomnia improved, bloatedness and postprandial pain persisted. At that point, patient contacted our department and was subsequently hospitalized. Extensive laboratory check-up was redone, as well as functional tests, MR enterography and CT scan of the thorax, abdomen and pelvis. Except for distal esophageal spasm and defecatory dyssynergia, findings were normal. Finally, we decided to perform an abdominal vascular ultrasound. An impression in the celiac trunk was noted - especially prominent during the expiration with a peak systolic velocity of 3m/s. Based on the ultrasound finding and clinical scenario, the diagnosis of mean arcuate ligament syndrome (MALS) was established. Surgical decompression procedure was performed and the patient reported improvement in postprandial pain and cessation of bloatedness. Having given the diagnosis, the patient finally entered the way to recovery. However, the issue of determining the optimal timing for integrating symptoms of gut-brain interaction into the framework of rare diagnoses and for modifying the diagnostic approach remains unresolved.

References

1. Image of vascular ultrasound performed prior to decompression procedure
2. Image of postoperative vascular ultrasound - performed 3 months postoperatively

Disclosure

The Authors have nothing to disclose.

Clinical Case Summary

A 72 years old caucasian women with no relevant medical history presented to the emergency department with two weeks history of abdominal pain in the upper quadrants associated with fullness, vomiting and a significant weight loss and nighttime hypersweating. On physical examination, abdomen was painful on epigastric and periumbilical region. Analytically, hemoglobin 11.1g/dL, leukocytes 9200/mm3, platelet count 315000/μL, CRP 8.22mg/dL. Tests for HIV and EBV were negative. Computed Tomography (CT) of the abdomen and pelvis revealed stomach with thickened walls, densification of adjacent fat and heterogeneous adenopathies. She was admitted to the department of Gastroenterology for investigation. The upper gastrointestinal endoscopy revealed extensive neoplasia of the body and gastric antrum. Biopsies revealed gastric mucosa with infiltration by atypical lymphoid proliferation with a "starry sky" pattern suggestive of high-grade B-cell non-Hodgkin's lymphoma (NHL). FISH analysis revealed t(8;14) c-myc positive. Once morphological and immunohistochemistry feature favors Burkitt’s lymphoma, she was transferred to the department of Hematology. Patient was treated with a full dose CHOP (cyclophosphamide, hydroxydaunorubicin, vincristine, prednisone) and 3 cycles of dose adjusted EPOCH-R (etoposide, prednisone, vincristine, cyclophosphamide, doxorubicin, rituximab). Complete remission was documented on positron emission tomography (PET).
Sporadic Burkitt's lymphoma is rare (1-2% of all lymphomas in adults), being one of the most aggressive forms of B-cell NHL. Primary gastric involvement is extremely rare. With the advancement of medicine and greater survival, we must consider this diagnosis, even in the absence of risk factors, atypical location and age group. This case emphasizes the importance of clinicopathological correlation and the importance of early diagnosis for immediate and aggressive intervention, fundamental in reducing morbidity and mortality.

References

1. Zhimin Bai, Yong Zhou. A systematic review of primary gastric diffuse large B-cell lymphoma: Clinical diagnosis, staging, treatment and prognostic factors, Leukemia Research,
Volume 111, 2021, 106716, ISSN 0145-2126, https://doi.org/10.1016/j.leukres.2021.106716.
2. Čubranić A, Golčić M, Fučkar-Čupić D, Brozović B, Gajski D, Brumini I. BURKITT LYMPHOMA IN GASTROINTESTINAL TRACT: A REPORT OF TWO CASES. Acta Clin Croat. 2019 Jun;58(2):386-390. doi: 10.20471/acc.2019.58.02.25. PMID: 31819338; PMCID: PMC6884372.
3. Usman A. Pirzada, Kishore Kumar, Hassan Tariq, Masooma Niazi, Jasbir Makker; Case of Gastric Diffuse Large B-Cell Lymphoma. Case Rep Oncol 6 May 2019; 12 (1): 39–46. https://doi.org/10.1159/000496332
4. Khan A, Khan S, Arshad U. Primary Gastric Burkitt's lymphoma. Pak J Med Sci. 2017 Sep-Oct;33(5):1294-1297. doi: 10.12669/pjms.335.13002. PMID: 29142583; PMCID: PMC5673752.