Clinical Case Summary

Colorectal lymphomas are a rare cause of colonic neoplasia (0.2-0.6% malignant neoplasms of large bowel). Approximately 10% are primary colorectal lymphomas, while the rest correspond to colonic extension of systemic lymphoproliferative diseases.
We present the case of a 66-year-old woman with a history of rectum and pancreas adenocarcinoma (both in remission). During a follow-up CT, a thickening of the cecal pole was identified, with no adenopathy or other relevant findings (Photo1). The patient had no abdominal pain or B symptoms (night sweats, weight loss or fever).
The diagnosis was completed with a PET-CT that showed pathological uptake in the cecum (Photo2), so a colonoscopy was performed, which revealed a large polypoid lesion (30 mm) at the ileocecal level, with nodular areas with small ulcerations and no clear loss of the glandular pattern (Photo 3), from which multiple biopsies were taken.
Biopsies showed lymphoid proliferation with a ‘starry sky’ pattern, mitosis and apoptosis, and positive immunohistochemistry for CD45, CD20, CD10, BCL6, BCL2 and C-MYC, together with a high proliferation index (Ki-67 > 95%), all compatible with high-grade B-lymphoproliferative syndrome with Burkitt morphology (Photo 4).
Burkitt's lymphoma is a rare B-cell lymphoma (15% of GI lymphomas), associated with chromosomal translocation (8:14, 8:22 and 2:8) and overexpression of c-myc oncogene.
There are three clinical variants: endemic (common in Africa and associated with EBV and malaria), HIV-associated and sporadic (20%).
It is common in children and its most frequent symptoms are abdominal pain and weight loss, so diagnosis is often delayed. Although the yield of endoscopic biopsies is low (<20%), it is a key tool in its diagnosis, along with targeted biopsy of abdominal adenopathies.
Despite its aggressiveness, treatment with targeted chemotherapy achieves rates of more than 90%, and early diagnosis is essential to avoid complications and ensure adequate medical treatment.

References

- Photo 1: Thickening of the cecal pole seen in CT-Scan.
- Photo 2: Pathological uptake in the caecal area as seen on PET-CT Scan.
- Photo 3: Polypoid lesion in ileocecal area at colonoscopy
- Photo 4: Pathological anatomy of endoscopic biopsies: starry sky imaging and immunohistochemistry of Bcl-2 and C-myc

Clinical Case Summary

Introduction: The most common complications of ERCP include acute pancreatitis, post-sphincterotomy bleeding, and intestinal perforation. Traumatic arterio-biliary fistulas, although rare, have been reported following manipulation. This case presents severe haemorrhage secondary to an arterio-biliary fistula.
Case Report: A 61-year-old male, chronic alcoholic with chronic liver disease (BCLC-B) and distal bile duct stricture of filarial aetiology, was admitted for biliary stent replacement. Post-procedure, the patient developed worsening clinical parameters, including abdominal pain, leucocytosis, and elevated cholestasis markers. Imaging revealed the proximal end of the stent was in the cystic duct, requiring a second ERCP for repositioning.
The patient's condition deteriorated with severe acute cholangitis, haemorrhagic rectal bleeding, and haemodynamic instability. CT showed further biliary dilatation and haematic content within the bile ducts. A third ERCP was performed to remove clots and place a covered metallic stent to control the bleeding. Despite this, haemorrhage persisted. CT-angiography revealed a 9 mm pseudoaneurysm from the pancreaticoduodenal arcade and pancreatic artery (Figure 1). Selective embolisation was successful (Figure 2), with follow-up confirming no further aneurysm filling (Figures 3 and 4).
Discussion: Arterio-biliary fistulas are typically iatrogenic or traumatic, often following biliary or hepatic procedures like liver biopsy or cholecystectomy. Post-ERCP incidence is rare, with only three reported cases. Diagnosis requires high clinical suspicion and angiography. Fistulas can cause pseudoaneurysms, which may lead to haemobilia, presenting as gastrointestinal bleeding. Management is multidisciplinary; conservative treatment is suitable for small, non-bleeding fistulas, while endoscopic or radiological interventions are used for severe cases. Early intervention is key to favourable outcomes.

References

1. Rai R. Potentially fatal haemobilia due to inappropriate use of an expanding biliary stent. World Journal of Gastroenterology. 2003;9(10):2377.
2. Berry R, Han J, Mohit Girotra, Tabibian JH. Hemobilia: Perspective and Role of the Advanced Endoscopist. 2018 Jul 12;2018:1–12.
3. Delayed Massive Hemobilia After Biliary Stenting. Endoscopy. 2003 Nov;35(11):976–7.
4. Siu, W. T., Chau, C. H., Ka Bo Law, B., Yau, K. K., Luk, Y. W., & KaWah Li, M. Non-operative management of endoscopic iatrogenic haemobilia: case report and review of literature. Acta gastro-enterologica Belgica. 2005;68(4): 428–431.
5. Panno, C., Gutiérrez, S. C., Echeverría, R., Garbe, C., Milocco, M., Ianniccillo, H., Valenzuela, M., Cubilla, A., Alvarez, F., & Alvarez, E. Hemobilia secundaria a pseudoaneurisma de la arteria hepática [Hemobilia secondary to hepatic artery pseudoaneurysm]. Acta gastroenterologica Latinoamericana. 2015;45(2):133–136.

Clinical Case Summary

A 32-year-old male with a history of mild alcohol consumption and previous alcohol-related pancreatitis presented to the emergency department with 24 hours of typical abdominal pain. Blood tests revealed elevated pancreatic enzymes in the pancreatitis range. The patient denied any recent alcohol or drug intake. He reported his last bowel movement was 24 hours prior. An abdominal X-ray showed colonic loop dilation and rectal gas, but no signs of bowel obstruction. He was admitted with a diagnosis of a second episode of mild acute pancreatitis, likely alcohol-related.
Abdominal ultrasound was performed but was limited by significant bowel gas; however, a large anechoic collection was noted in the pancreatic area. After 48 hours of hospitalization, the patient’s condition worsened with abdominal distension and vomiting. An adynamic ileus was suspected, and a nasogastric tube and prokinetic agents were administered, with partial clinical improvement.
Due to sudden clinical deterioration with severe pain despite analgesia, increased abdominal distension, and high-pitched metallic bowel sounds, a new abdominal X-ray was performed, showing dilated small bowel loops with air-fluid levels. An urgent abdominal CT scan revealed findings consistent with small bowel obstruction due to cecal volvulus, with no signs of acute pancreatitis. The patient underwent emergency surgery with favorable outcome.
Discussion: Amylase and lipase may also be elevated in extra-pancreatic conditions, highlighting the importance of thorough history-taking, physical examination, and complementary imaging—especially when alarm signs are present or the diagnosis is unclear. Other pancreatic enzymes have been evaluated in clinical trials, but none have demonstrated superior diagnostic value. There is currently no consensus on the appropriate upper limit of normal.

References

1. Beij A, Verdonk RC, van Santvoort HC, de-Madaria E, Voermans RP. Acute Pancreatitis: An Update of Evidence-Based Management and Recent Trends in Treatment Strategies. United European Gastroenterology Journal. John Wiley and Sons Inc; 2025
2. Tenner S, Vege SS, Sheth SG, Sauer B, Yang A, Conwell DL, et al. American College of Gastroenterology Guidelines: Management of Acute Pancreatitis. American Journal of Gastroenterology. 2024 Mar 1;119(3):419–37.
3. Jacquemin Q, Coulier B, Rubay B. Acute volvulus of the cecum. J Belgian Soc Radiol. 2020;104(1):40,1-3.
4. Naveed M, Jamil LH, Fujii-Lau LL, Al-Haddad M, Buxbaum JL, Fishman DS, et al. American Society for Gastrointestinal Endoscopy guideline on the role of endoscopy in the management of acute colonic pseudo-obstruction and colonic volvulus. Gastrointest Endosc. 2020;91(2):228-35

Clinical Case Summary

Post-procedural haemorrhage following percutaneous liver biopsy is a rare yet potentially life-threatening complication, with fistulisation of a hepatic haematoma into the gastrointestinal tract being an exceedingly rare event.
A 75-year-old lady with suspected autoimmune liver disease underwent an ultrasound-guided percutaneous liver biopsy with a 16G needle, performed in a single pass and no immediate complications. Two hours later, the patient developed haemorrhagic shock and was transferred to the ICU, where a contrast-enhanced CT scan revealed a 10 × 9 cm hepatic haematoma in the right lobe with active arterial extravasation and haemoperitoneum (Figure 1). Angiography confirmed active bleeding from a segmental branch of the right hepatic artery (Figure 2), which was successfully embolised with microcoils (Figure 3).
Follow-up CT scan 45 days later showed persistent encapsulated haematoma with fistulisation to duodenal bulb (Figure 4). Gastroscopy showed no haemorrhagic content through the fistula (Figure 5). Given the patient's stable condition and reviewed by a multidisciplinary team, surgery was not required. Radiological control after three months, shows near-complete haematoma resolution and fistula closure (Figure 6). Autoimmune hepatitis was confirmed, and immunosuppressive therapy deferred until resolution of the acute complication.
Percutaneous liver biopsy is safe, with ultrasound guidance reducing complication risk. The most common adverse event is pain, in up to 25% of cases. Haemorrhagic complications, including haemoperitoneum, hepatic haematoma, or haemobilia, occur in 0.01–0.5% of cases. Haemobilia, the rarest complication (~0.006%), presents with abdominal pain, jaundice, and melaena. In cases of active bleeding, selective arterial embolisation is preferred. Fistulisation into the gastrointestinal tract is rare and usually associated with large haematomas. Early diagnosis and intervention were key to preventing a fatal outcome in this case.

References

Tian G, Kong D, Jiang T, Li L. Complications After Percutaneous Ultrasound‐Guided Liver Biopsy. Journal of Ultrasound in Medicine. 2020 Jan 30;39(7):1355–65.

Introduction

Despite the progress in advanced therapies (AT) for ulcerative colitis (UC), selecting a second-line treatment after failure remains challenging. Recent guidelines recommend Ustekinumab (UST), Tofacitinib (TOFA), or Upadacitinib (UPA) as high-efficacy options after prior AT failure. However, no real-world studies have compared all three therapies.

Aims & Methods

Retrospective multicenter study (8 centers) of UC patients who failed ≥1 advanced therapy. Patients were stratified into UST, TOFA, or UPA groups and assessed at 16 and 52 weeks. The primary outcome was steroid-free clinical remission (SFCR) based on the Patient Reported Outcomes-2. Secondary outcomes included biochemical remission (fecal calprotectin ≤ 250 µg/g) and endoscopic remission (Mayo Endoscopic Subscore=0). Time to remission was assessed using Cox regression analysis. A subanalysis was performed including only second-line use after anti-TNF failure. Multivariate analysis was performed, adjusted for duration of disease, extent and number of prior therapies.

Results

We evaluated 259 cases [54.4% (n=141) female; diagnostic age 32.3 ± 15.1 years] who initiated UST (n=105; 40.5%), UPA (n=87; 33.6%) or TOFA (n=67; 25.9%). The groups were similar in disease duration (UST: 11.6 ± 8.0; UPA: 9.8 ± 6.4; TOFA: 10.4 ± 5.4 years) and 49.8% (n=129) had failed ≥2 previous AT
At week 16, UPA showed higher SFCR compared to UST (OR 2.1; p=0.014) and TOFA (OR 2.1; p=0.040), with no difference at week 52. Biochemical remission was higher with UPA at week 16 vs UST (OR 2.3; p=0.015) and TOFA (OR 2.1; p=0.039) and at week 52 vs UST (OR 4.7; p=0.010) and TOFA (OR 4.6; p=0.013). At week 16, endoscopic remission was higher with UST (OR 3.5; p=0.036) and UPA (OR 3.1; p=0.041) compared to TOFA; and at week 52, UPA was associated with higher endoscopic remission vs UST (OR 3.6; p=0.036).
In Cox regression, UPA achieved earlier biochemical remission than UST (HR 1.9; p<0.001) and TOFA (HR 1.8; p=0.011). JAK inhibitors led to earlier endoscopic remission than UST (vs UPA: HR 3.2; p<0.001; vs TOFA: HR 1.4; p=0.002).
In the subanalysis, UPA as second-line therapy demonstrated higher SFCR than TOFA (OR 3.6; p=0.035) and higher endoscopic remission at week 52 than TOFA (OR 12.0; p=0.017), and trend-wise compared to UST (OR 4.5; p=0.090).

Conclusion

Even though all three medication demonstrated high efficacy in bio-exposed UC patients, UPA achieved better results in this real world study.

References

Singh, Siddharth, et al. "AGA living clinical practice guideline on pharmacological management of moderate-to-severe ulcerative colitis." Gastroenterology 167.7 (2024): 1307-1343.