Clinical Case Summary

Anisakiasis is a worldwide re-emerging disease caused by the consumption of raw, lightly cooked, smoked, or marinated fish containing the infective larvae of the Anisakis genus [1]. While most human cases of anisakiasis have been reported in Japan [2], infections are increasing in Western countries as well [3, 4]. Depending on the site of infection and the predominant clinical symptoms, acute Anisakis infections can be classified as gastric anisakiasis, gastro-allergic anisakiasis, and intestinal anisakiasis. Gastric and intestinal anisakiasis typically present with severe gastric or abdominal symptoms, while gastro-allergic anisakiasis may manifest allergic symptoms ranging from mild urticaria to anaphylactic shock [5].
A 44-year-old female patient presented to the Emergency Department of our hospital with melena and anemia. The patient had a history of ingesting raw fish three weeks prior. Her blood pressure was 110/70 mmHg, heart rate was 89 bpm, and hemoglobin level was 6.6 g/dL. The patient was admitted to our department and underwent upper and lower endoscopy. Blood was found within the proximal ileum and colon with no evident bleeding lesions. Small-bowel capsule endoscopy revealed active bleeding within the proximal ileum, whereas the angio-CT scan did not detect active bleeding.
Due to persistent overt rectal bleeding and anemia, the patient was admitted to the Surgical Department and underwent exploratory laparoscopy. A lesion was found in the proximal ileum, and an ileal resection was performed with an end-to-end anastomosis. Postoperative histopathological evaluation showed a focal area of granulomatous and abscess-forming inflammation around fragments of helminthic parasites, suggestive of Anisakis larvae.

References

1. Audı´cana M, Kennedy MW (2008) Anisakis simplex: from obscure infectious worm to inducer of immune hypersensitivity. Clin Microbiol Rev 21: 360-79
2. Yasunaga H, Horiguchi H, Kuwabara K, Hashimoto H, Matsuda S (2010) Clinical features of bowel anisakiasis in Japan. Am J Trop Med Hyg 83: 104–5.
3. Pampiglione S, Rivasi F, Criscuolo M, De Benedittis A, Gentile A, et al. (2002) Human anisakiasis in Italy: a report of eleven new cases. Pathol Res Pract 198: 429–34.
4. Hockberg NS, Hamer DH (2010) Anisakidosis: Perils of deep. Clin Infect Dis 51: 806–12.
5. Daschner A, Alonso-Go´mez A, Caban˜as R, Suarez-de-Parga JM, Lo´pez-Serrano MC (2000) Gastroallergic anisakiasis: borderline between food allergy and parasitic disease-clinical and allergologic evaluation of 20 patients with confirmed acute parasitism by Anisakis simplex. J Allergy Clin Immunol 105: 176–81.

Clinical Case Summary

Secondary aortoenteric fistula (AEF) is an abnormal connection between the aorta and gastrointestinal tract (GT) resulting from reconstructive surgery for an abdominal aortic aneurysm (AAA), including open repair surgery and endovascular treatment. Despite the low incidence (1.6 to 4%) [1–4], it is life-threatening and has a high mortality rate (24 to 45.8%) [5–6].
A 79- year-old man reported to the emergency department of our hospital with overt bleeding from the stoma. The patient had a history of open Dacron graft repair for a ruptured AAA eight months previosly, which became complicated on the 5th postoperative day by sigmoid ishemia that required an emergency Hartmann procedure.
His blood pressure was 90/60 mmHg, heart rate 93/minute and hemoglobin level 7.5 g/dL.
The patient was admitted to our department. He underwent upper and lower endoscopy and no bleeding lesions were found. After endoscopy the patient presented another episode of overt bleeding from the stoma and we decided to perform Small-bowel capsule endoscopy (SBCE) which showed activ bleeding within the proximal ileum. The contrast-enhanced CT demostrated an aneurysm sac enlargement, a close proximity of the small bowel loops with the aneurysm sac in the pelvic cavity and a suspected leakage at the distal part of the aneurysm sac.
The patient was therefore admitted to the Surgical Derpatment and underwent an emergency endovascular repair of the leakage caused by distal detachment of the aorto-aortic prosthesis using a bifurcated stant graft. No more bleeding from the stoma occurred and the patient was discharged three days later with a diagnosis of distal aortic anastomosis leakage with aorto-ileal fistula.
The duplex ultrasound of the graft after one, three and six months showed no sign of endoleak.
This case shows that the SBCE may be useful in patients with history of recostructive surgery for AAA who manifest overt bleeding from the GT and no lesions are found in upper and lower endoscopy.

References

1.Wilson WR, Bower TC, Creager MA, Amin-Hanjani S, O’Gara PT, Lockhart PB, Darouiche RO, Ramlawi B, Derdeyn CP, Bolger AF, et al. Vascular Graft Infections, Mycotic Aneurysms, and Endovascular Infections: A Scientific Statement From the American Heart Association. Circulation. 2016;134(20): e412–60
2.Champion MC, Sullivan S, Coles J, Goldbach M, Watson WC. Aortoenteric fistula. Incidence, presentation recognition, and management. Ann Surg. 1982;195(3):314–7
3.Hallett JW Jr, Marshall DM, Petterson TM, Gray DT, Bower TC, Cherry KJ Jr, Gloviczki P, Pairolero PC. Graft-related complications after abdominal aortic aneurysm repair: reassurance from a 36-year population-based experience. J Vasc Surg. 1997;25(2):277–84. discussion 285-276
4.Chenu C, Marcheix B, Barcelo C, Rousseau H. Aorto-enteric fistula after endovascular abdominal aortic aneurysm repair: case report and review. Eur J Vasc Endovasc Surg. 2009;37(4):401–6
5.Malik MU, Ucbilek E, Sherwal AS. Critical gastrointestinal bleed due to secondary aortoenteric fistula. J Community Hosp Intern Med Perspect. 2015;5(6):29677
6.Gnus J, Ferenc S, Koscielna M, Paprocka-Borowicz M, Dawidczyk P, Dziewiszek M, Witkiewicz W. Secondary Aortoenteric Fistula After Abdominal Aortic Graft Implementation in Our Own Material. Adv Clin Exp Med. 2016;25(6):1265–71

Clinical Case Summary

Leiomyosarcoma (LMS) originating from the smooth muscle cells of the muscolaris mucosa or muscolaris propria, is extremely rare and accounts for about 1 % of malignant mesenchymal lesions in the gastrointestinal tract [1, 2]. Due to its aggressive nature and slow growth, it is often diagnosed at the late stage when curative treatment is impossible [3].
A 79-year-old woman presented at the emergency department of our hospital complaining chronic diarrhea, abdominal pain and weight loss. No lesions were found in upper and lower endoscopy. Contrast-enhanced CT demostrated a pedunculated polypoid lesion of 2.5 cm in diameter within an ileal loop which was confimed by the magnetic resonance enterography. We suspected a neuroendocrine neoplasm (NEN) and the laboratory tests showed increased serum levels of gastrin, chromogranin A and neuron specific enolase.
The patient was scheduled for Small Bowel Capsule Endoscopy but 5 days later she presented vomit and sub acute intestinal obstruction and underwent emergency laparoscopy. An ileal mass was found 30 cm from the ileocecal valve and an ileal resection was performed with LL anastomosis. Postoperative histopathological evaluation showed a tumour of 4 × 2.3 cm in diameter with high mitotic activity and high degree of necrosis; immunohistochemical staining revealed positivity of actin, desmin, calponin, caldesmon, AE1AE3, chrmogranin, synaptophysin, CD117, DOG1, CD34, S100. Diagnosis of ileale leiomyosarcoma was made and the patient was discharged on day 6 after surgery in good clinical conditions.
After consulting the oncologist, the patient was disqualified from adjuvant chemotherapy.
Ileal LMS is a rare tumor originating from the smooth muscle cells. Immunohistochemistry is essential to confirm the diagnosis and surgery is the only curative treatment although the prognosis is poor.

References

1. Yamamoto H, Handa M, Tobo T, Setsu N, Fujita K, Oshiro Y. Clinicopathological features of primary leiomyosarcoma of the gastrointestinal tract following recognition of gastrointestinal stromal tumours. Histopathology. 2013;63:194–207.
2. Agaimy A, Wünsch PH. True smooth muscle neoplasms of the gastrointestinal tract: morphological spectrum and classification in a series of 85 cases from a single institute. Langenbecks Arch Surg. 2007;392:75–81.
3. Samaiya A, Deo SVS, Thulkar S, Hazarika S, Kumar S, Parida DK, et al. An unusual presentation of a malignant jejunal tumor and a different management strategy. World J Surg Oncol. 2005;3:3

Clinical Case Summary

Case Report: A 77-year-old male had four hospital admissions over eight weeks due to recurrent occult gastrointestinal (GI) bleeding & symptomatic anaemia, found to be due to a Dieulafoy lesion.
Dieulafoy lesions account for 1-2% of all GI bleeds, with the majority (75%) found in the stomach (1,2).
He initially presented with melaena, haemoglobin (Hb) 46g/L & urea 17mmol/L. Gastroscopy was normal; colonoscopy identified five large angioectasias treated with argon plasma coagulation (APC) & haemostatic clips.
He represented 18 days later with symptomatic anaemia (Hb 63g/L); repeat colonoscopy placed clips at prior APC sites.
A month later, he represented with melaena & Hb 38g/L. Gastroscopy was again normal, colonoscopy showed angioectasias that were not treated. Video capsule endoscopy (VCE) found fresh blood in the proximal jejunum, however no active bleeding source identified. Double balloon enteroscopy (DBE) did not identify a bleeding source, with extent tattooed.
He represented 4 days later with melaena & Hb 63g/L. Repeat VCE identified fresh blood in the proximal jejunum (fig 1). A DBE was performed & did not identify active bleeding source. CT Angiogram identified active bleeding ~30cm distal from the duodenojejunal flexure (fig 2). An antegrade DBE did not identify a source of bleeding & proceeded to have a laparoscopic assisted on-table enteroscopy. An enterotomy was performed 10cm distal to the DBE tattoo & gastroscope advanced through the enterotomy. Intermittent brisk bleeding Dieulafoy’s lesion (fig 3) was found 20cm from the duodenojejunal flexure - treated with APC & two haemostatic clips. Since discharge he had no recurrence of gastrointestinal bleeding & Hb incremented to 124g/L.
Conclusion: This case demonstrates a rare cause & difficult to identify location of GI bleeding. A small bowel Dieulafoy lesion should be considered in recurrent occult GI bleeding, as this could be difficult to identify when not actively bleeding.

References

References

1. Nojkov B, Cappell MS. Gastrointestinal bleeding from Dieulafoy's lesion: Clinical presentation, endoscopic findings, and endoscopic therapy. World J Gastrointest Endosc. 2015 Apr 16;7(4):295-307
2. Baxter M, Aly EH. Dieulafoy's lesion: current trends in diagnosis and management. Ann R Coll Surg Engl. 2010 Oct;92(7):548-54. doi: 10.1308/003588410X12699663905311. PMID: 20883603; PMCID: PMC3229341.

Clinical Case Summary

Introduction: Non-occlusive mesenteric ischemia (NOMI) is a rare but critical condition resulting from insufficient mesenteric blood flow without arterial occlusion. When complicated by portal venous thrombosis and small bowel obstruction, NOMI presents significant diagnostic and therapeutic challenges, requiring early recognition and multidisciplinary management to improve outcomes.
Methods: This study retrospectively analyzed a NOMI patient with portal venous thrombosis and small bowel obstruction, reviewing clinical history, imaging, treatment strategies, and outcomes. The effectiveness of catheter-directed thrombolysis with anticoagulation and surgical intervention for recurrent ischemia was assessed, including recurrence rates and treatment outcomes.
Results: A 60-year-old male with atrial fibrillation, presented with prolonged abdominal pain and bloating. Imaging showed mesenteric and portal venous thrombosis causing small bowel obstruction. He underwent catheter-directed thrombolysis with initial improvement. However, symptoms recurred one month later, necessitating small bowel resection due to chronic ischemia. Postoperatively, the patient recovered well with no further recurrence.
Conclusions: This study emphasizes the need for early diagnosis and multidisciplinary management in NOMI with portal venous thrombosis. Catheter-directed thrombolysis with anticoagulation effectively restores mesenteric blood flow, while surgical intervention is key for recurrent ischemia. Tailored, evidence-based approaches are crucial for optimizing outcomes.
The poster will include specimen images, immunohistochemical images, and abdominal CT images.