Background Aortic stenosis (AS) has been established as a precipitating factor in the development of colonic angiodysplasia, resulting in lower gastrointestinal bleeding (LGIB). While the association between AS and LGIB, termed “Heyde syndrome,” has been examined extensively, few studies assess the impact of comorbid AS on rates of LGIB in patients with colorectal cancer (CRC). Our goal is to examine this association. Methods Patients hospitalized from 2001 to 2013 diagnosed with CRC were identified via ICD-9 codes, further stratified by a diagnosis of AS. Continuous and categorical variables were analyzed by independent sample t-tests and chi-squared analyses respectively. Assessed outcomes included mortality, length of stay (LOS), hospital costs, rates of LGIB, colonic obstruction, colonic perforation, iron-deficiency anemia (IDA), and colectomy. Multivariate analysis via binary logistic regression was utilized to control confounding variables. Results Patients with CRC and AS had higher rates of mortality, lower gastrointestinal bleeding, iron deficiency anemia, and colectomy, while those without AS had higher rates of colonic obstruction. Length of stay and total hospital charges were higher in patients with AS. Discussion CRC outcomes were worse in patients with AS. This could be due to higher rates of LGIB secondary to the prevalence of angiodysplasia among AS patients. More retrospective studies are required to assess the impact of comorbid AS in patients with CRC.

D-lactic acidosis (D-LA) is closely associated with short bowel syndrome (SBS). Decreased intestinal absorption results in the delivery of carbohydrates to the colon, where the fermentation by colonic flora leads to D-LA. Systemic absorption of D-lactic acid results in anion-gap metabolic acidosis (AGMA), LA, and neurologic symptoms. In this report, we describe the case of a 43-year-old man with Crohn's disease (CD) and bowel resection who presented with abdominal pain and slurred speech. He was found to have AGMA and persistent LA despite receiving intravenous fluids, which improved after carbohydrate restriction. A high index of suspicion for D-LA should be maintained when encountering patients who have undergone bowel resection and with unexplained AGMA.

Physicians need to recognize the potential complications of endoscopic retrograde cholangiopancreatography (ERCP), which are rare but can be serious. We describe a case of post-ERCP subcapsular hepatic hematoma (SHH). A 39-year-old man with a history of alcohol use, complicated by chronic pancreatitis and common bile duct (CBD) stricture, presented with right upper quadrant pain two weeks after the placement of a stent for CBD stricture. He was managed with pain control and antibiotics. SHH is a rare complication of ERCP. Hematomas can expand, resulting in significant anemia and liver function test (LFT) elevation, or can become infected. Patients with SHH must be carefully monitored in the post-ERCP setting.

Primary cutaneous anaplastic large cell lymphoma (PCALCL) is a subtype of non-Hodgkin lymphoma (NHL) that is localized to the skin. Disseminated disease is rare, and visceral organ involvement is even more so. We report a unique case of PCALCL with gastric metastasis. A 75-year-old man with a history of cutaneous left lower extremity PCALCL status post radiation therapy initially presented with abdominal pain and was found to have diffuse celiac axis and retroperitoneal lymphadenopathy. Endoscopy, initially done to biopsy an involved lymph node (LN), demonstrated a friable gastric nodular lesion with telangiectasias. Biopsy of the lesion and LN revealed anaplastic large cell lymphoma, identical in pathology to the known skin lesion. The patient was treated with systemic chemotherapy with a good response. PCALCL has been thought of as a localized malignancy with a good prognosis and low potential for extracutaneous spread. To our knowledge, this is the first instance of metastatic PCALCL involving the stomach.

Introduction: Whipple's disease (WD) is a rare disorder caused by the pathogen Tropheryma whipplei. It presents with non-specific symptoms which can mimic the presentation of other gastrointestinal pathogens, especially in immunocompromised patients. We report a unique presentation of WD involving an immunocompromised patient who experienced non-specific gastrointestinal symptoms without arthralgia, which is a characteristic symptom of this disease. Case Description/Methods: A 67-year-old man with a history of chronic hepatitis B infection and Human immunodeficiency virus (HIV) infection presented with weight loss, nausea, vomiting and myalgia. Of note, patient did not have arthralgia. Physical exam revealed cervical lymphadenopathy and diffuse abdominal tenderness. Patient was anemic (hemoglobin of 8.6 g/dL) with a normal white count. Endoscopy demonstrated erythema in the gastric body, lymphangiectasia of the duodenum, and increased granularity of the terminal ileum. Mucosal biopsies revealed macrophages in the lamina propria with focal histiocytic aggregates throughout the small bowel and cecum, with positive PAS staining, consistent with Whipple's disease. Confirmatory T. whipplei PCR testing was positive (Figure). Discussion: WD is a rare diagnosis that must be considered in the differential diagnoses of patients presenting with unexplained nausea, vomiting, diarrhea and anemia. Furthermore, in patients with HIV, the possibilities would also include opportunistic gastrointestinal pathogens. Classic WD is characterized by diarrhea, weight loss, abdominal pain and extra-intestinal involvement manifesting as joint pain, endocarditis, dementia, supranuclear gaze palsy, and mediastinal lymphadenopathy. Diagnosis involves biopsy of affected tissue demonstrating foamy macrophages with PAS (1) substance, which can be confirmed by PCR or immunohistochemistry. Treatment involves an initial course of penicillin or ceftriaxone followed by a prolonged course of Bactrim, or a one-year course of doxycycline and hydroxychloroquine, followed by lifelong doxycycline therapy, which is more likely to prevent disease relapse. In the absence of suppressive therapy, relapse of WD is common and may lead to further complications, including neurological involvement.[3494] Figure 1. Periodic Acid-Schiff-Staining Macrophages (circles) Within the Lamina Propria of the Duodenal Bulb (a) and Cecum (b) as Seen Via Light Microscopy with a 20x Objective Lens.