Common diagnoses associated with right upper quadrant and epigastric pain include cholecystitis, peptic ulcer disease (PUD), biliary colic, gastroesophageal reflux disease (GERD) and irritable bowel syndrome (IBS). Multiseptate gallbladder is a rare congenital anomaly that can cause symptoms of biliary colic, however it may present with atypical symptoms, which can prolong definitive diagnosis and treatment. We present a case of multiseptate gallbladder in a 21-year-old female who initially presented with GERD and IBS. After multiple failed treatment regimens for IBS, she ultimately was found to have multiseptate gallbladder and was successfully treated with cholecystectomy.

Introduction: Fusobacterium species are an extremely uncommon cause of pyogenic liver abscess (PLA) and are rarely isolated in the clinical setting. Herein, we report a rare case of cryptogenic Fusobacterium nucleatum-associated liver abscess and septic thrombophlebitis in an apparently immunocompetent patient. Case Description/Methods: A 51-year-old male patient presented to the emergency department with a two-week history of abdominal pain, distension, nausea and chills. His physical exam revealed a distended abdomen with tenderness to palpation over the right upper and lower quadrants, and palpable hepatomegaly. Laboratory evaluation revealed WBC of 13,360 cells/mm3, lactic acid of 5.2, hemoglobin 8.0 g/dL, ALT of 73 IU/L, AST of 171 IU/L, ALP 625 IU/L, total bilirubin of 1.9 mg/dL and direct bilirubin 1.3 mg/dL. Magnetic resonance imaging (MRI) of the abdomen with and without contrast revealed innumerable multiseptated cystic hepatic masses with an associated portal vein thrombosis. The largest of these cystic lesions was measured at 9.0 cm x 5.4 cm. Patient received empiric intravenous antibiotics and therapeutic intravenous heparin. He underwent a CT-guided liver biopsy with aspiration of abscess material. Blood cultures and aspirate culture were negative. Next generation sequencing 16S PCR of the aspirate was positive for Fusobacterium nucleatum. Unfortunately, the patient passed away due to cardiac arrest before the etiology of the liver lesions could be established. (Figure ) Discussion: Fusobacterium nucleatum is a rare cause of PLAs with only 20 cases reported in literature. Risk factors for development include recent pharyngitis, periodontal disease or otherwise cryptogenic. Fusobacterium can cause a unique GI variant of Lemierre's syndrome (LS) presenting with an intra-abdominal infection and associated septic thrombophlebitis of the portal venous system known as pylephlebitis. Main presenting symptoms in most patients include fever, chills, right upper quadrant abdominal pain, vomiting and shortness of breath. The gold standard for diagnosis of PLA is fine needle aspiration for culture, however aspirate cultures are positive in only 70-80% of cases. Ribosomal RNA (rRNA) gene PCR can be used for detection and identification of bacterial pathogens, as shown in this case. We provided this case report to increase awareness of Fusobacterium-species associated GI variant of LS and to add knowledge to the literature about its presentation, diagnosis, and available treatment options.[3002] Figure 1. MRI of the abdomen, showing numerous cystic hepatic lesions throughout the grossly enlarged liver indicated by white arrowheads (A). White arrows point to an area of increased attenuation within the portal vein indicative of thrombus (B).

Introduction: Gastro-cutaneous fistulas that develop at prior gastrostomy sites are usually successfully closed by the use of endoscopic suturing or the over-the-scope clips (OTSC). However, the endoscopic suturing device and the OTSC device measure approximately 16 mm and 14 mm, respectively, resulting in them not able to pass through narrow esophageal strictures. The endoscopic tack suture system is a novel technique that includes a through the scope suture-based device that was recently designed for the closure of large and irregular defects in the gastrointestinal tract. Even more advantageous is the ability for the tack suture system to be passed through the working channel of a standard gastroscope. Case Description/Methods: A 61-year-old male with past medical history of head and neck cancer presented with persistent gastro-cutaneous fistula drainage following gastrostomy tube removal. On endoscopic evaluation, a benign appearing esophageal stenosis in the upper esophagus required downgrading the scope from a therapeutic scope to a gastroscope. A gastric fistula was noted in the gastric body, but the exact site of the fistula was unclear as there were 2 defects side by side (Figure A). Both defects were treated with APC and the entire area was closed with a single tack suture system with 4 tacks drilled in healthy tissue surrounding the defect (Figure B). Following tack placement, a single suture was used to cinch down and close the defect (Figure C). On follow up the patient had no further fistula drainage. Discussion: Our case presents the use of a novel tack suturing system to close a persistent gastro-cutaneous fistula in the setting of an esophageal stricture. Commonly used defect closing devices such as the OTSC and endoscopic suturing device can be too large to navigate severe esophageal strictures. The endoscopic tack suture system has the ability to aid in the closure of fistulas, perforations, anastomotic leaks and submucosal dissections. While preclinical data reported no adverse events, possibilities include wound dehiscence, delayed perforation, and bleeding if the tacking system is improperly placed. Mahmoud et al. conducted the first and only multi-center study describing the feasibility and safety of the endoscopic tack suturing device in the clinical setting and found successful closure of defects in approximately 90% of cases. This novel tack suture system is a useful tool in cases that are confined to the parameters of a standard gastroscope.[2834] Figure 1. A: Gastric fistula. B: Fistula following APC with 4 tacks drilled in healthy tissue surrounding the defect. C. Cinching of single suture with closure of gastric fistula.