INTRODUCTION: Primary pancreatic lymphoma (PLL) is a very rare type of pancreatic malignancy and accounts for less than 1% of all pancreatic masses. Presenting symptoms are non-specific and may lead to delay in diagnosis. CASE DESCRIPTION/METHODS: A 71-year-old man with diabetes mellitus and hypertension presented to hospital with epigastric pain, nausea, and vomiting for 3 days. He had loss of appetite and weight loss for 2 months. On physical examination, his vital signs were normal, and he had tenderness on palpation at epigastric area without signs of peritonitis. Complete blood counts were within normal limits. He had transaminitis and elevated total bilirubin and alkaline phosphatase. Serum amylase and lipase were 123 IU/L (normal: 13-53) and 864 IU/L (normal: 13-60), respectively. Tumor markers, including CA 19.9 and CEA, were normal. Magnetic resonance imaging (MRI) of the pancreas showed a large mass at the pancreatic head measuring 8.3 × 7.6 cm in maximum diameter with peripancreatic and retroperitoneal adenopathy (Figure 1). Endoscopic ultrasound demonstrated the mass in the pancreatic head and malignant-appearing peripancreatic lymph nodes. Computer tomography (CT) guided biopsy of the pancreatic mass was performed. Pathology revealed a high grade B-Cell Lymphoma. Bone marrow biopsy did not show atypical cells. Staging CT scans revealed a 9 mm sized mediastinal node. He was diagnosed with stage III high grade B-Cell primary pancreatic lymphoma. An International Prognostic Index was 2 which predicts a 5-year survival of 51%. He received R-CHOP regimen for treatment and currently on cycle 5 with a good response. DISCUSSION: Primary pancreatic lymphoma is a rare malignancy accounting for 0.7% of all pancreatic malignancies and 1% of extranodal lymphomas. The disease is male predominant about 7 times more frequent than in females.2 Non-specific gastrointestinal symptoms are the most common presentations, including abdominal pain, obstructive jaundice, or acute pancreatitis. Imaging of the pancreas by MRI or CT scan may help to distinguish PPL from the more common pancreatic adenocarcinoma. However, cytohistology of the mass is required for diagnosis and to guide definitive treatment. Surgery has a limited role in management, and chemotherapy is the main treatment.

INTRODUCTION: Rectus sheath hematoma (RSH) is a very rare complication after abdominal paracentesis especially in patients who do not take antiplatelet or anticoagulants. We presented a case of rectus sheath hematoma post paracentesis in a patient without obvious risk factors. CASE DESCRIPTION/METHODS: A 56-year-old male with past medical histories of chronic diastolic congestive heart failure and end-stage renal disease (ESRD) on hemodialysis presented with abdominal pain after abdominal paracentesis for ascites. 4.3 L of yellow ascitic fluid was drained in the first attempt of ultrasound-guided paracentesis. Abdominal distension on the right flank was also noticed. Vital signs were stable. Abdominal exam showed moderate tenderness on right flank, no guarding, no rebound tenderness, no bruising. ESRD was believed to be the cause of ascites. He received hemodialysis one day prior to the procedure. He is not on any antiplatelet or anticoagulation therapy. Computed tomography scan of abdomen showed right rectus sheath hematoma 14 × 9 cm (Figure 1). Labs on admission showed Hemoglobin (Hb) of 9.2 g/dL (compared to baseline Hb of 10.8 g/dL), Platelet count 192000 /uL, PT 13.9 secs, PTT 34.6 secs, and INR 1.22, BUN 42 mg/dL, Creatinine (Cr) 5.6 mg/dL (similar to baseline Cr). Interventional radiologist was emergently consulted and performed embolization which found extravasation from the right iliolumbar artery (Figure 2). Coil embolization was done successfully. On post-embolization day 3, Hb continued to drop to 5.7 g/dL. He developed hypotension. Surgery team was notified and brought the patient to operation room for exploratory laparotomy. Intraoperative findings revealed that 2 L of hematoma was evacuated from the patient’s rectus sheath. No active bleeding was immediately noted. Upon the exploration of the anterior wall toward the medial side of the incision, a small bleeding vein was noted and ligated. Vital signs became stable after the operation. He was discharged without postoperative complications. DISCUSSION: Large RSH is a rare complication of paracentesis. It can also develop in a patient without obvious bleeding risk factors. Clinicians should watch for this potential complication when a patient presents with an abdominal mass or abdominal pain without other particular symptoms after paracentesis. RSH is a self-limited condition; however, our case suggests that RSH may take an unpredictable course and may not be successfully managed with a conservative approach.

INTRODUCTION: Achalasia has wide range presentations including gastrointestinal and respiratory symptoms. Septic shock is less common. CASE DESCRIPTION/METHODS: We report a case of a 59-year-old Caucasian woman who presented with 1-month history of dyspnea and cough worsening for one week. She reported intermittent vomiting, dysphagia and unintentional weight loss for the past 2 months. Upon admission, she was hypoxemic and developed septic shock. Computer tomography showed multifocal pneumonia and severe distension of the esophagus filled with debris (Figure 1) measuring 9.5 × 6 cm at the largest diameter. She was intubated and given board spectrum antibiotics and then transferred to the medical intensive care unit. Upper endoscopy demonstrated dilation in the entire esophagus filled with food and scattered whitish esophageal plaques, consistent with esophageal candidiasis. Four weeks of oral fluconazole was initiated to treat esophageal candidiasis. Propionibacterium species grew in one out of two blood cultures but the respiratory culture was negative. She required vasopressors for two days and then successfully extubated two days later. She underwent a barium esophagography showing dilated esophagus with distal narrowing “bird beak’s” appearance (Figure 2). Esophageal manometry confirmed type I achalasia demonstrating apersistalsis of the entire esophagus and hypertensive lower esophageal sphincter (Figure 3). She recovered from aspiration pneumonia and weaned off oxygen. She was scheduled to come back in 2 weeks for perioral endoscopic myotomy evaluation and was discharged home with oral fluconazole. DISCUSSION: Achalasia is an esophageal disease caused by loss of relaxation in the distal esophagus and lower esophageal sphincter. Most common presentations are dysphagia (90%), heartburn (75%) and regurgitation or vomiting (45%). Respiratory symptoms including cough or chronic aspiration account for 20-40%. However, septic shock as initial presentation is not common. Our patient had chronic aspiration to the lungs and developed aspiration pneumonia progressing to septic shock. Patients presenting with respiratory symptoms are reported to have a more dilated esophagus with an average mean diameter of 4.3 ± 2 cm. Our case has an esophagus double the average size. Perioral endoscopic myotomy has gained universal acceptance to treat achalasia and shows safety and efficacy.