Figure 1. a & b. Some lipogranulomas are shown in portal tracts (left). In addition, hepatocyte focal necrosis evidenced by hepatocyte dropout and replaced with mononuclear cells and macrophages mixed with lipogranulomas are identified in the lobule (right). No dense lymphoid aggregate was identified, a typical feature for HCV. An unusual finding in acute cellular rejection, points to the recurrent HCV infection. c. Mild to focal moderate mixed inflammatory cell infiltrate seen in most portal tracts/areas, including neutrophils, mononuclear, eosinophils, and plasma cells, associated with scattered interface hepatitis. Focal endotheliitis is evidenced by inflammatory cells undermining the endothelial cells. Interlobular bile duct injury is focal and mild. Feature of Mild acute cellular rejection. d. Trichrome stain shows no delicate periportal strands of "chicken wire" like pericellular fibrosis; an early fibrosing cholestatic hepatitis is still under consideration.

Introduction: Obstructive sleep apnea (OSA) is a sleep disorder involving repeated apneic episodes during sleep due to an obstruction of the airflow. OSA predisposes individuals to community-acquired pneumonia due to upper airway microaspiration. Furthermore, hypoxia due to intermittent pharyngeal collapses is shown to cause a pro-inflammatory state and reduced NK cell cytotoxicity and maturation, which can increase the risks of infections due to suppression of immune response. Increased incidence of infections in the OSA subgroup leads to increased use of antibiotics. Antibiotic exposure is the primary risk factor for developing Clostridium difficile (C. diff) infection. In synchrony with this notion, the primary purpose of this study was to determine the association between OSA and C. diff infection. Methods: A retrospective analysis was conducted using the Healthcare Cost and Utilization Project-Nationwide Inpatient Sample (HCUP-NIS). Patients without C. diff were analyzed (control) and were randomly selected and matched to each patient who did have C. diff. Weighted logistic regression models were used to calculate the association between OSA and C. diff for different comorbidities. Results: A total of 7,135,090 patients were included in our analysis. The prevalence of C. diff was significantly higher in patients with OSA (1.19% vs. 1.00%, p, 0.0001). In addition, multiple comorbidities were significantly elevated in the OSA group compared to those without OSA, including alcohol and obesity (p, 0.0001). Conclusion:This study uses ICD-10-CM codes with a specific search code for OSA. Our large population database shows a significant association between OSA and C. diff. One of the hypotheses describing this increased association could be more antibiotic exposure in OSA subgroup leading to C. diff. Additional studies are needed to confirm or refute this association.

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Introduction: Inferior mesenteric arteriovenous fistulous malformations are a rare yet reversible cause of ischemic colitis. They can cause increased outflow of blood in the venous circulation and predispose to colon ischemia. We report a case of inferior mesenteric arteriovenous fistula causing ischemic colitis in an atypical distribution in the IMA territory. Case Description/Methods: A 50-year-old gentleman presented to the emergency room with a 3-week history of abdominal pain and bloody diarrhea. His symptoms started with a dull pain, 8/10 in intensity, with radiation to his lower back. He had also been having a low appetite for the duration of his abdominal pain. He described having around 10 bowel movements daily with blood mixed with mucus. CT abdomen showed diffuse circumferential thickening involving the entire sigmoid colon, extending to the upper rectum suggesting non-specific colitis. He came to the hospital 2 weeks prior to his presentation and underwent a colonoscopy which grossly showed diffuse severe inflammation in the distal descending colon, sigmoid colon and proximal rectum, till 30 cm from the anal verge suggesting left-sided colitis. Biopsied from the region showed evidence of ischemic colitis. His CT-angiography showed engorgement of the IMA and IMV, with an early contrast in IMV which suggested IMA to IMV AV fistula within the left hemipelvis. That suggested vascular malformation as the cause of the colorectal findings. Patient subsequently underwent embolization of 2 branches of IMA with stent placement in IMA, causing closure of the AV fistula. Patient tolerated the procedure without any complication (Figure). Discussion: Ischemic colitis is most commonly seen in the watershed areas of the colon such as splenic flexure and rectosigmoid junction due to arterial anastomosis between the mesenteric arteries supplying the colon. In these situations, the colonic involvement is focal involves these specific segments. In this case, patient had diffuse gross ischemic findings from the distal rectum extending to descending colon involving the whole part of ischemic artery supply which is atypical for the distribution of colonic ischemia. In such situations, CT angiography comes as a diagnostic tool for identifying the pathology and in this situation it showed AV fistula between IMA and IMV which hampered the colonic blood supply to the extent to cause ischemic colitis with symptoms.

Introduction:The development of extranodal NHL can be a diagnostic challenge despite the fact that 30% of the cases are extranodal and involve the gastrointestinal tract. The incidence of a primary colonic lymphoma is rare, especially in young patients. Case Description/Methods: A 21-year-old man initially presented to our emergency department (ED) with abdominal pain, weakness, rectal bleeding, and anemia. Two months prior to this admission, he presented to an ED in Colorado with rectal bleeding and abdominal pain. He was diagnosed with gastroenteritis and discharged with antibiotics. He was evaluated in Ohio for syncope and profound anemia (hemoglobin of 4.2) 2 weeks later. A CT scan of the abdomen and pelvis demonstrated right colon wall thickening. He was diagnosed with inflammatory bowel disease and discharged on prednisone. At this presentation, he reported a 15-pound weight loss and CT imaging demonstrated significant right colon wall thickening with a 19 cm "mass-like" lesion. A subsequent colonoscopy showed a large, ulcerated, partially obstructing right colon mass consistent with malignancy. Histology demonstrated a high-grade B-cell lymphoma that was CD20 positive by immunohistochemical staining. Unfortunately, the patient was discharged from our facility at his request before definitive therapy could be undertaken. Two weeks later, he presented to a different ED with bloody diarrhea, abdominal pain, and vomiting and was found to have perforation of the cecum with free air. He underwent an exploratory laparotomy with a stormy postoperative course and eventually died from post-surgical complications (Figure). Discussion: Although a primary colonic lymphoma is exceedingly rare, especially in the young population, this case is instructive as it is common to overlook malignancy in the young that presents with gastrointestinal symptoms. The patient was seen in 2 separate hospitals and treated symptomatically even when he presented with profound anemia (hemoglobin of 4) and an abnormal CT scan of the right colon. Presentation of the disease can vary, however, should be considered and recognized in younger patients to avoid delays in proper management, which could lead to severe complications, as illustrated by this case. Given its rarity, no large trials have been conducted to evaluate optimal treatment.[2110] Figure 1. An ulcerated partially obstructing large mass in the ascending colon. The mass was circumferential, measured 10 cm in length and 10 cm in diameter. Oozing was present.