Acquired tracheoesophageal fistula (TEF) is a rare complication of esophageal or lung cancer. A 57-year-old male presented with complaints of vomiting, cough, 20 lb weight loss, and progressive dysphagia. Early laryngoscopy and CT chest showed a normal pharynx with an irregular thickness of the thoracic esophagus. The upper gastrointestinal endoscopy (UGIE) and upper endoscopic ultrasound (EUS) revealed a hypoechoic mass evolving as complete obstruction. During the procedure, minimal CO2 was used for insufflation; however, when attempts were made to traverse the obstruction, capnography revealed an end-tidal CO2 (EtCO2) estimating 90 mmHg indicating possible TEF. This case depicts the use of capnography during UGIE in diagnosing an acquired TEF.

Discussion: CL should be considered as a differential in patients with multiple aggregated mucosal lesions that appear as polyps on endoscopy. Speculation on etiology has ranged from developmental (failure to establish connections to lymphatic drainage sites), or seen secondarily after trauma, prior surgeries, radiation, lymphatic obstruction possibly secondary to adjacent mass lesion, or previous inflammatory processes. Free intraperitoneal air may suggest impending clinical decline in such patients. Surgical resection is the treatment of choice in symptomatic patients.[1990] Figure 1. (a) Gross image of the sigmoid colon, bottom aspect showing partial deroofing of the mucosa of a simple cystic cavity (b) Hematoxylin and Eosin (H&E) stain 40X (c) D2-40 positivity (brown membranous and cytoplasmic staining) 100X.

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We present a rare case of perinephric hemorrhage causing hypertension & clinically significant bleeding after initiation of antiplatelet therapy.CASE PRESENTATION: A 44-year-old male with history of medulloblastoma, status post resection & irradiation, presented with slurred speech & ataxia. Cerebral angiogram showed bilateral vertebral artery & proximal basilar artery occlusion, for which he underwent emergent thrombectomy & stenting. He was then started on aspirin & clopidogrel. A day after, he complained of newonset severe left flank pain with fever, tachycardia, & hypertension. Nicardipine drip was given to control his blood pressure. Hemoglobin dropped from 15.7 to 11.4 g/dL. Serum creatinine increased to 1.7 from a baseline of 1.2 mg/dL. Urinalysis showed RBC of 10-20/high-power field. Computed tomography (CT) of the abdomen showed a large left renal subcapsular hematoma measuring 3.0 x 5.7 x 6.3 cm in size, with delayed nephrograms from recent endovascular stent placement, indicative of delayed renal function, but no evidence of contrast extravasation or subcapsular rupture. Given the patient's recent stenting, antiplatelet therapy was continued. Urology & interventional radiology were consulted. The hematoma was managed conservatively with serial hemoglobin checks. Interval CT of the abdomen showed a stable hematoma. Patient later had resolution of hypertension & acute kidney injury, & was discharged home with close follow-up.DISCUSSION: Wunderlich syndrome is a rare phenomenon characterized by sudden onset of spontaneous renal or perinephric hemorrhage. Due to extrinsic compression of the renal parenchyma, renin-angiotensin-aldosterone system is activated & can result in systemic hypertension in a phenomenon known as Page kidney. Up to 60% of cases of perinephric hemorrhage are caused by a neoplasm, & a smaller portion is attributed to vasculitis, renal artery aneurysm, arteriovenous malformation, renal vein thrombosis, nephritis, cystic renal disease, & coagulopathy. In our patient's case, there was no appreciable mass on CT. It was thought to be secondary to initiation of antiplatelets. Contrast-enhanced CT of the abdomen has 100% sensitivity & is the goldstandard in identifying perinephric hemorrhage & can aid in renal embolization as treatment. Management includes selective arterial embolization & surgery. Embolization is minimally invasive; however, surgical intervention is used when tumor resection is needed & can prevent recurrent tumor bleeding.CONCLUSIONS: Wunderlich syndrome can be a life-threatening emergency. A high index of suspicion is warranted in a patient who has acute onset of flank pain, tachycardia, fever, & new-onset hypertension, especially after initiation of antiplatelet agents.

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