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Patient: Female, 67Final Diagnosis: IVC filter perforation through duodenumSymptoms: Abdominal painMedication: —Clinical Procedure: EsophagogastroduodenoscopySpecialty: Gastroenterology and HepatologyObjective:Challenging differential diagnosisBackground:The number of IVC filter-related complications has increased with their growing utilization; however, IVC filter perforation of the duodenum is rare. It can manifest with nonspecific abdominal pain, gastrointestinal bleeding, cava-duodenal fistula, or small bowel obstruction.Case Report:A 67-year-old female presented with several years of right upper quadrant abdominal pain which was exacerbated by movement and food intake. She had a history of hepatic steatosis, cholecystectomy, and multiple DVTs with inferior vena cava filter placement. Physical exam was unremarkable. Laboratory tests demonstrated elevated alkaline phosphatase and transaminases. Esophagogastroduodenoscopy revealed a thin metallic foreign body embedded in the duodenal wall and protruding into the duodenal lumen with surrounding erythema and edema, but no active hemorrhage. Further evaluation with non-contrast CT scan revealed that one of the prongs of her IVC filter had perforated through the vena cava wall into the adjacent duodenum. Exploratory laparotomy was required for removal of the IVC filter and repair of the vena cava and duodenum. Her post-operative course was uneventful.Conclusions:In patients with history of IVC filter placement with non-specific abdominal pain, a high clinical suspicion of IVC filter perforation of the duodenum should be raised, as diagnosis may be challenging. CT scan and EGD are valuable in the diagnosis. Excellent outcomes have been reported with open surgical filter removal. Low retrieval rates of IVC filters have led to increased complications; hence, early removal should be undertaken as clinically indicated.

Mesenteric vascular disease has been diagnosed increasingly over the past 25 years. This rise in incidence has been attributed to the advanced mean age of the population, an increasing number of critically ill patients and a greater clinical recognition of the condition. Although surgical revascularization and resection has long been the standard of treatment, medical management can also play an important adjunctive role. Early diagnosis before irreversible bowel damage, which may occur within 6-8 hours after the insult, is necessary to improve survival and reduce morbidity. Even in the presence of irreversible bowel ischemia, perioperative medical treatment may reduce disease progression, enabling more limited bowel resection. This article outlines the appropriate pharmacologic management of ischemic disorders of the intestine, with an emphasis on the pharmacologic treatments presently being used in clinical practice and those being studied in the laboratory.

The adverse effects of mycophenolate mofetil on the colon are well known. However, isolated small intestinal involvement resulting in diarrhea and severe weight loss is infrequently reported in the literature. We present the case of a 45-year-old woman on mycophenolate mofetil following renal transplant, who presented with abdominal pain and weight loss. An esophagogastroduodenoscopy and colonoscopy with biopsies were normal. A small bowel capsule study revealed extensive enteropathy of jejunum and ileum that was confirmed on a push enteroscopy with biopsies. Her symptoms completely resolved after being switched to enteric-coated mycophenolic acid.

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