Clinical Case Summary

A 52-year-old hysterectomized woman presented at the primary health care with nonspecific abdominal pain for three months; the abdominal examination was unremarkable.
Colonoscopy showed five 10-20mm luminal wall bulges in the proximal descending colon, covered by normal mucosa, with no points of mucosal disruption. There was apparent "deflation" of one of the bulges during biopsies (which results had no significative changes).
The initial diagnostic suspicion was pneumatosis cystoides intestinalis (PCI), but even so urgent abdominopelvic CT was advised. CT showed multiple cystic images with gaseous content located in the subserosal layer with 8.5cm of longitudinal extension at the splenic angle of the colon and the proximal descending colon.
The patient was sent to our Gastroenterology appointment, and a case of PCI with mild-to-moderate symptoms was assumed. A trial of metronidazole for three months was carried out with clinical and imaging resolution.
PCI is a rare condition of benign pneumatosis intestinalis that can occur throughout the entire gastrointestinal tract. It is characterized by gas-filled cysts in the intestinal submucosa and subserosa; its prevalence is difficult to determine as most patients are asymptomatic. Various predisposing factors have been associated with PCI, such as post-surgery with mucosal disruption.
There is no standard treatment for PCI - most patients are treated conservatively; surgery is usually reserved for complications. One of the treatment options for PCI until clinical and radiological resolution is achieved is antibiotic therapy, typically using metronidazole to inhibit the growth of harmful bacteria.
This case aims to raise awareness of a rare and not well-known disorder, whose appearance might be worrisome and be confused with some life-threatening conditions. It is recommended that PCI patients are closely monitored to promptly identify any emergent signs or symptoms suggestive of complications.

References

Di Pietropaolo M, Trinci M, Giangregorio C, Galluzzo M, Miele V. Pneumatosis cystoides intestinalis: case report and review of literature. Clin J Gastroenterol. 2020 Feb;13(1):31-36. doi: 10.1007/s12328-019-00999-3. Epub 2019 Jun 3. PMID: 31161540.
Ling F, Guo D, Zhu L. Pneumatosis cystoides intestinalis: a case report and literature review. BMC Gastroenterol. 2019 Nov 6;19(1):176. doi: 10.1186/s12876-019-1087-9. PMID: 31694581; PMCID: PMC6836417.

Clinical Case Summary

A 53 year-old woman complained of chronic diarrhea, lack of appetitis and weight loss, that started two years before her admission. She described watery stools without bleeding or pus, as well as a 14 kg weight loss, but she had no fever, pruritus or night sweating. She had received a previous treatment for Graves’ disease during her pregnancy. Her physical examination was unremarkable, but she had a calprotectin fecal of 1028. Her last colonoscopy (performed 1 month before her admission) revealed an unspecific ileocolitis saving the sigmoid colon and the rectum, showing a friable and diffuse enanthematous mucous with some raised areas simulating a polypoid aspect. First she was empirically treated for parasitosis, and images were obtained, in addition to a wide range of laboratory tests. She presented a mild anemia associated with a thickened biliary tree and a pancreatic volume prominence with loss of its lobulations, as well as parietal enhancement of the ascending colon and enlarged mesenteric lymph nodes with hypodense centers suggesting necrosis.Upper GI biopsies were negative for H pylori infection, but biopsies of the colons showed a diffuse atypical lymphoplasmacytic infiltrate in the lamina propria. Medications and infectios were ruled out, and a PET-CT scan showed diffuse thickened wall of the colons (particularly cecum and transverse colon), as well as a mild thickened biliary tree, an enlarged thyroid and both mesenteric and pericolic lymphadenopathies - all of these areas showed a glycolytic activity slightly increased. IgG4 disease was also excluded after a normal IgG4/IgG relation from biopsy samples. Finally, a immunophenotyping study of the colons' samples was conducted, confirming a MALT lymphoma. The patient received rituximab for 9 months and a tumor restaging was conducted afterwards. A post-treatment PET-CT showed complete remission of the disease, with no areas of abnormal glycolytic metabolism, in addition to a fecal calprotectin of 11mcg/g.

Clinical Case Summary

Peritoneal dissemination from cancer of extraperitoneal origin is rare^1,2.We report a patient who presented with symptoms and signs of small bowel obstruction(SBO)due to breast metastasis in the omentum.A 73-year-old female complained of irregular bowel movement,flatulence and abdominal pain.Her past medical history was significant for breast examination 2 years earlier with suspicion of tumor,but without confirmation of any tumor on control breast ultrasound and radiography.After upper and lower endoscopy showed no significant pathology, her initial presentation was characterized as irritable colon syndrome.After worsening of the symptoms with nausea and vomiting and weight loss for the period of one year, the patient was referred to our Clinic.Initial magnetic resonance enterography showed slight dilatation of small bowel loops,without other pathology.She was sent to the surgeon who excluded indication for surgery.Three months later,the patient came back to the GI with same symptoms of suboclusion.Repeat MRE showed small bowel loops dilatation(40 mm),slight ascites and again no other pathology was detected.The patient had undergone explorative laparotomy when marked dilatation of small bowel loops was noted as well as thickening and multiple secondary lesions of the omentum.Ex-tempore biopsy of the omentum confirmed malignancy.The patient was treated for adhesion-induced ileus and a biopsy of the omentum was performed.Histopathology and immunohistochemistry were consistent with peritoneal dissemination from the breast cancer.The surgery was uneventful, and the patient was started with hormonal therapy(letrozole).At the latest follow up 6 months after the surgery, no oclusion episodes were reported.Diagnosis of peritoneal metastasis is challenging and may require surgical exploration as it was shown in our case.Physicians should be aware of the possibility of SBO caused by metastasis from the breast cancer, particularly in patients with a related history of cancer.

References

1. Bertozzi S, Londero AP, Cedolini C, Uzzau A, Seriau L, Bernardi S, Bacchetti S, Pasqual EM, Risaliti A. Prevalence, risk factors, and prognosis of peritoneal metastasis from breast cancer. Springerplus. 2015 Nov 10;4:688.
2. Flanagan M, Solon J, Chang KH, Deady S, Moran B, Cahill R, Shields C, Mulsow J. Peritoneal metastases from extra-abdominal cancer - A population-based study. Eur J Surg Oncol. 2018 Nov;44(11):1811-1817. doi: 10.1016/j.ejso.2018.07.049. Epub 2018 Jul 26. PMID: 30139510.

Clinical Case Summary

A 53 year old gentleman was admitted following clinic review for unintentional 15 kg weight loss within 7 months with associated non-bloody loose stools and poor appetite with no significant past medical history and no family history of cancer, no smoking or alcohol consumption in the past. Initial examination revealed fullness in the lower abdomen with generalised abdominal tenderness, no enlarged lymph nodes. Tumour markers reported as CEA 5.9 (normal 0- 4.7), AFP 2 (normal 0-5.8), CA 19-9 90 (normal 0-34) and PSA 0.21 (normal 0-3.8). Contrast-enhanced computed tomography (CT) revealed peritoneal thickening raising concerns for serosal disease and suggested aspiration of ascites for cytology which showed scanty and poorly preserved groups of epithelial cells. The clusters of epithelioid cells showed positive immunostaining for BerEP4 and MOC31. However, malignancy could be excluded.
NJ feeding was not tolerated due to a malrotated stomach and difficulty locating the pylorus with a severely inflamed gastric and oesophageal mucosa on gastroscopy then switch to TPN.
Repeat (CT) of his abdomen and pelvis showed appearances highly suspicious for disseminated malignancy. There was peritoneal thickening with ascites and some soft tissue noted within the lower sigmoid colon and around the distal stomach which could represent serosal disease or intraluminal malignancy at all sites. There was associated dilatation of the large bowel, more prominent within the right abdomen and increased subcutaneous oedema possibly due to arm low protein state. Blood cultures showed Nakaseomyces glabrata. T spot- tuberculosis (TB) assay came back negative and tuberculosis (TB) microscopy showed no acid fast bacillus and culture did not grow Mycobacterium sp.
Repeat CTAP was done which showed soft tissue thickening of the peritoneum. pneumoperitonuem, without source of perforation. Emergency laparotomy for peritoneal biopsy with tissue histology confirmation of peritoneal adenocarcinoma.

References

1. Anwar A, Kasi A. Peritoneal Cancer. [Updated 2022 Sep 26]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan.
2. Yun WS, Bae JM. Primary peritoneal serous carcinoma, an extremely rare malignancy: A case report and review of the literature. Oncol Lett. 2016 Jun;11(6):4063-4065. doi: 10.3892/ol.2016.4525. Epub 2016 May 5. PMID: 27313741; PMCID: PMC4888242.
3. Löffler, M.W., Schuster, H., Zeck, A. et al. Ann Surg Oncol (2017). doi:10.1245/s10434-017-5790-x
4. Yun WS, Bae JM. Primary peritoneal serous carcinoma, an extremely rare malignancy: A case report and review of the literature. Oncol Lett. 2016 Jun;11(6):4063-4065.
5. Ploug M, Graversen M, Pfeiffer P, Mortensen MB. Bidirectional treatment of peritoneal metastasis with Pressurized IntraPeritoneal Aerosol Chemotherapy (PIPAC) and systemic chemotherapy: a systematic review. BMC Cancer. 2020 Feb 10;20(1):105.
6. Shmueli E, Leider-Trejo L, Schwartz I, Aderka D, Inbar M. Primary papillary serous carcinoma of the peritoneum in a man. Ann Oncol. 2001;12(4):563-7.

Disclosure

None

Clinical Case Summary

Introduction: Amebiasis is not a diagnosis of endemic regions anymore. It should be included in the list of differential diagnoses of erosive and ulcerative changes of the intestine.
Case presentation: A 38-year-old woman came to a gastroenterologist because of flatulence and abdominal cramping during the past two years. In 2019 the patient was urgently hospitalized in a surgical department with suspicion of appendicitis. Ultrasound found a thickening wall of the caecum and appendix without laboratory abnormalities. After symptomatic treatment, the patient underwent ileocolonoscopy: aphthous changes of mucosa were in the transverse colon. Undifferentiated colitis was diagnosed. A pharmacological therapy with 5-aminosalicylic acid was initiated. In 2021 the ileocolonoscopy underwent again because there was no effect of treatment: mucosal ulcerations of the caecum and ascending colon. The biopsy and stool examination (a method of formalin-ether sedimentation) showed Entamoeba hystolytica. Metronidazole was the drug of choice with a good clinical effect in this case. But three months later, the symptoms returned. It was the first relapse with positive results in feces analysis. The second line of therapy was tinidazole. Again, three months after, she had a relapse in laboratory tests. Ultrasound showed a wall thickening in the caecum and ascending colon. We achieved long-term clinical and endoscopic remission only after treatment with paromomycin (not registered in Russian Federation).
Discussion: Due to a large amount of travel to endemic regions, protozoal infections are not a problem in developing countries. Infectious lesions of intestine mucosa often mimic inflammatory bowel disease. It leads to late diagnosis, incorrect treatment, and complications.
Conclusion: This case outlines the difficulty of diagnosing and treating chronic protozoal infection because of the absence of characteristic symptoms.
Disclosure: Nothing to disclose.

References

1. Gomes Tdos S, Garcia MC, de Souza Cunha F, et al. Differential diagnosis of Entamoeba spp. in clinical stool samples using SYBR green real-time polymerase chain reaction. Thescientificworldjournal. 2014 ;2014:645084. DOI: 10.1155/2014/645084. PMID: 24693242; PMCID: PMC3944400.
2. Yue, B., Meng, Y., Zhou, Y. et al. Characteristics of endoscopic and pathological findings of amebic colitis. BMC Gastroenterol 21, 367 (2021). https://doi.org/10.1186/s12876-021-01941-z
3. Herrera, G. C., Herrera, A. C., Pontón, P. et al. (2019). Amebiasis, a rare cause of acute appendicitis. Journal of surgical case reports, 2019(3), rjz076. https://doi.org/10.1093/jscr/rjz076
4. Kafadar, M.T., Bakan V., Çaviş T. (2017). Chronic amebiasis presenting as appendicitis and preliminary diagnosed as a mucocele: A diagnostic dilemma and unexpected histopathological finding after surgery. https://doi.org/10.5505/VTD.2017.71463 Corpus ID: 54639273
5. Richard D. Pearson MD, University of Virginia School of Medicine Overview of intestinal Protozoan and Microsporidia infection, 2020 https://www.msdmanuals.com/professional/infectious-diseases/intestinal-protozoa-and-microsporidia/overview-of-intestinal-protozoan-and-microsporidia-infections
   

Clinical Case Summary

Introduction: Cap polyposis is a rare benign inflammatory condition characterized by inflammatory polyps covered with a fibrinopurulent exudate. It is more commonly observed in women and the elderly, although it can present at any age. The disease typically affects the rectum and sigmoid colon. The most frequent symptoms include mucous diarrhea and rectal bleeding. It has been associated with mucosal prolapse due to altered intestinal motility, Helicobacter pylori infection, and even intestinal dysbiosis.
Endoscopy: A 46-year-old male with no relevant personal or family medical history presented with altered bowel habits, characterized by increased stool frequency, decreased consistency, and the presence of mucus and blood, along with tenesmus and urgency. H. pylori testing was negative. Colonoscopy revealed numerous sessile and pedunculated polyps with an inflammatory appearance distributed throughout the colon, predominantly in the sigmoid and rectum. Most polyps were covered at their apex by a fibrinopurulent exudate (Figures 1–4). The colonic mucosa adjacent to the polyps appeared normal. Multiple biopsies were taken, confirming inflammatory polyps. A first therapeutic colonoscopy was performed, during which multiple polyps consistent with cap polyps were resected (Figure 5). Additional sessions were scheduled to complete polyp resection. Furthermore, a molecular study was performed using next-generation sequencing (NGS) with a multigene panel including genes associated with polyposis, with negative results.
Conclusions: The clinical course of cap polyposis remains unclear. The need for and timing of colonoscopy should be individualized based on the number of polyps and symptom severity. Initial treatment should be conservative, focusing on resolving constipation and eradicating H. pylori. In cases with persistent symptoms, endoscopic resection of the lesions should be considered.