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Introduction: Aseptic abscess syndrome (AAS) is a rare manifestation of inflammatory bowel disease (IBD). This condition is characterized by sterile neutrophilic infiltration of deep tissues, most often in the spleen, liver, skin, or lymph nodes. Patients commonly present with fever, abdominal pain, and weight loss. We present a case of a 40-year-old female diagnosed with AAS in the setting of IBD. Case Description/Methods: A 40-year-old female with a history of Ulcerative Colitis (UC) not on treatment for past 2 years presented with 2 weeks of bloody diarrhea, left-sided abdominal pain, unintentional weight loss, and fatigue. On exam, she was tachycardic, normotensive, and had left lower quadrant abdominal tenderness. Initial lab work was significant for leukocytosis of 23.3 3 10 9 /L and elevated C-reactive protein. Computed tomography (CT) scan of the abdomen demonstrated diffuse colonic thickening and multiple hepatosplenic abscesses. Broad-spectrum antibiotics were initiated. She underwent colonoscopy which revealed Mayo 2 colitis from rectum to the distal transverse colon. Blood cultures (fungal, bacterial, and mycobacterial) and parasitic serologies were negative. Fluid aspiration from the spleen drained purulent material, but fluid cultures were negative. Despite treatment with broad-spectrum antibiotics, and antifungals, the patient continued to remain febrile with persistent leukocytosis and gastrointestinal symptoms. After ruling out infectious and neoplastic processes, a diagnosis of aseptic abscess syndrome was made. Systemic steroids were initiated with resulting improvement in her symptoms and lab parameters. The patient was discharged home on a steroid taper. Repeat cross-sectional imaging performed 3 weeks post-discharge demonstrated complete resolution of all abscesses. For UC, she was started on Vedolizumab and she remains in clinical remission. (Figure ) Discussion: AAS is a diagnosis of exclusion. This syndrome should be considered in IBD patients in the setting of multiple disseminated abscesses with a negative infectious work-up and lack of clinical improvement with antimicrobial agents. The specific pathophysiology is largely unknown, although similar neutrophilic infiltration can be seen in pyoderma gangrenosum. Antibiotic therapy is universally ineffective for AAS. However, about 95 % of patients respond to corticosteroids. Disease-modifying agents and biologics have been successfully used as maintenance therapy.[2749] Figure 1. Initial and subsequent CT imaging of abdomen/pelvis with contrast demonstrating hepatic and splenic abscesses with interval improvement of abscess.

Introduction: Cecal bascule is a rare form of cecal volvulus, which is characterized by an anterior and superiorly displaced cecum in turn causing large bowel obstruction. It accounts for 0.01% of adult large bowel obstructions. Here we present a case of cecal bascule in a cirrhotic patient. Case Description/Methods: A 63-year-old female with history of alcoholic cirrhosis (MELD 20) and cesarean section presented to the emergency department with intermittent hematochezia and melena. At admission, she was hemodynamically stable with a hemoglobin of 5.7 g/dL. She underwent esophagogastroduodenoscopy (EGD) which demonstrated small esophageal varices without stigmata of a recent bleed, antral gastritis, and duodenitis. Due to a largely unrevealing EGD, she was scheduled to have a colonoscopy. However, the patient had difficulties tolerating the bowel prep due to increasing abdominal pain. An abdominal X-ray demonstrated a large gaseous lucency in the right mid abdomen below the level of the transverse colon which was concerning for cecal bascule. A computed tomography (CT) scan of the abdomen demonstrated a redundant cecum folding anteriorly with superior rotation into the upper right hemiabdomen without definite point of transition and diffuse small bowel dilation up to 4.3 cm. Findings were consistent with a cecal bascule. Patient underwent an exploratory laparotomy with right hemicolectomy. Patient had a prolonged, complicated post-operative course with multiorgan failure and finally died 30 days after the surgery (Figure). Discussion: Cecal bascule involves the upward folding of the cecum as opposed to an axial twisting of the colon as seen in more common types of cecal volvulus. For this phenomenon to occur, a patient will often have a mobile and redundant cecum that causes the volvulus. This may occur as a congenital anomaly secondary to a failed fusion in development between the ascending colon mesentery and the posterior parietal peritoneum. Additionally, this may be acquired from abdominal adhesions, pregnancy or even after a colonoscopy. Like other types of volvuli, treatment of cecal bascule requires surgical detorsion to prevent further complications. It is therefore important that cecal bascule be identified early for proper surgical planning and appropriate intervention. In our case, the poor outcome was due to the underlying decompensated cirrhosis.[1997] Figure 1. Abdominal X-ray demonstrating a large gaseous lucency in the right mid abdomen near the transverse colon CT of the abdomen demonstrating an anteriorly and superiorly rotated cecum into the upper right hemiabdomen.