Introduction:We present an exceedingly rare case of eosinophilic cholangitis (EC) without stricture. Of the 40 cases of EC reported in the literature, fewer than 10 cases did not involve a stricture. Case Description/Methods: A 60-year-old female with no significant past medical history presented with symptoms of biliary colic for 2 days. Laboratory results were significant for elevated hepatobiliary enzymes including alkaline phosphatase of 300 IU/L and total bilirubin of 3.8 mg/dL. A hepatobiliary iminodiacetic acid scan was performed with an absence of radiotracer excretion into the biliary tract. However, a magnetic resonance cholangiopancreatography showed no obstructing stone, stricture, or lesion. A broad workup including hepatitis and autoimmune serologies was negative. The patient underwent an uncomplicated laparoscopic cholecystectomy, and direct inspection of the gallbladder confirmed significant edema. Histopathology of the gallbladder showed acute and chronic acalculous cholecystitis with eosinophilic rich infiltrates. Notably, the patient had an absolute eosinophil count of 1.2 cells/mL. She was diagnosed with eosinophilic cholangitis and treated with corticosteroids. At her one-month follow-up, her symptoms had resolved. Discussion: Eosinophilic cholangitis is a rare, self-limiting condition featuring eosinophilic invasion of the biliary tree. Laboratory values in EC reflect an obstructive process, but diagnosis is frequently delayed as both symptoms and imaging mimic multiple other biliary conditions including malignancy, primary strictures, primary sclerosing cholangitis, amongst others. Endoscopic dilation of strictures often provides a surprising diagnosis when pathology demonstrates dense infiltration of eosinophils. Although a majority of EC is associated with stricture, EC may also present with obstructive features in the absence of stricture. Likewise, peripheral eosinophilia may or may not be present. Risk factors for EC have not been established. Literature suggests that patients with pre-existing eosinophilic processes such as eosinophilic esophagitis and asthma are more likely to develop EC than the general population. There is no standard treatment, but corticosteroids have demonstrated empiric efficacy, similar to the other eosinophilic processes mentioned. Increased physician awareness of eosinophilic cholangitis will help prevent delays in diagnosis and initiation of effective medical therapy.

Case Description/Methods: An 84-year-old male presented with epigastric abdominal pain. 3-years prior he had wide local excision for cutaneous malignant melanoma of the upper back (R0 resection). His abdominal pain had worsened over the last 4-weeks and was preceded by jaundice and unintentional weight loss. Initial studies were significant for elevated alkaline phosphatase (1295), AST (270) ALT (212), total bilirubin (10.1) and lipase (12085). Computed tomography (CT) showed a 2.4 cm lesion in the pancreatic head along with dilated pancreatic duct and biliary dilation. Carbohydrate antigen 19-9 (CA19-9) was elevated (628). Cholangiogram showed a 15 mm distal biliary stricture with upstream dilation. Brushings of the biliary stricture were unsatisfactory due to insufficient cells. Subsequent endoscopic ultrasound (EUS) demonstrated a 25mm by 25mm mass in the pancreatic head invading the distal CBD. Fine-needle aspiration (FNA) showed a poorly differentiated malignancy with epithelioid and focal spindle cell features with positive S100 and SOX-10 immunophenotype. Findings consistent with melanoma. Additional imaging did not reveal other potential sites of metastasis. The patient has since been discharged and is undergoing further evaluation. Discussion: Approximately one-third of patients with malignant melanoma develop metastases. However, metastatic melanoma of the gastrointestinal system is only seen in 2-4% of patients affected by cutaneous melanoma. This patient had a unique presentation with invasion of his pancreatic lesion into the distal common bile duct which lead to obstructive jaundice and pancreatitis. Pancreatitis as a result of metastatic melanoma is a rare presentation only described in a few case reports. Based on imaging it appears the patient initially had isolated metastatic disease of the pancreas which then invaded into the common bile duct. Isolated pancreatic metastasis represents less than 1% of all metastatic melanomas. It is difficult to differentiate a primary cancer from metastatic disease of the pancreas based on imaging alone. The use of EUS-FNA is essential for diagnosis. Though the exact prognosis of metastatic melanoma of the pancreas is unclear, generally metastatic melanoma carries a poor prognosis.

Introduction: Numerous studies have shown that per oral endoscopic myotomy (POEM) is a very effective treatment for patients with achalasia. Limited data has also indicated that POEM is effective in treatment for some non-achalasia esophageal motility disorders, such as esophageal-gastric outlet obstruction and diffuse esophageal spasm. We report for the first time the outcome of POEM for patients with atypical chest pain. Methods: Three patients were enrolled: a 72yo female, 87yo male and 73yo female. All patients had a long history of chest pain for at least 5 years. They ranked the pain from 2 to 8 on a 1 to 10 pain scale. The pain was not associated with physical activity, but it was occasionally associated with eating. Only one patient had some dysphagia and no patients reported regurgitation symptoms. All patients were evaluated by multiple doctors over the years, including primary care providers, cardiologists, and gastroenterologists. Cardiac chest pain was ruled out by their cardiologists. They all tried maximal anti-acid therapy, including proton pump inhibitors twice a day for a prolonged period, without any significant improvement. They also tried anti-spasmodic medications, such as hyoscyamine, with limited effect. All patients had esophageal manometry without conclusion. Barium swallow studies showed tertiary contraction and therefore suggested esophageal dysmotility. POEM was discussed with the patients who then provided consent to undergo the procedure (Table ). Results: All three POEMs were successful; the average procedure time was 20 minutes. Only circular muscle myotomy was performed and longitudinal muscle was left intact. Each myotomy was 10 cm in length. There were no postprocedural complications. Postop day 1, all patients were chest pain free and were discharged in the afternoon. Follow up times were 93, 42, and 5 days; pts continued to remain chest pain free. One out of 3 patients described a burning type of chest pain consistent with heartburn and was promptly relieved with anti-acid therapy. Conclusion: From this pilot study, POEM may be a therapeutic modality for patients with refractory atypical chest pain. Further studies with increased sample size and long-term outcome assessments are needed to determine the efficacy of POEM in the treatment of atypical chest pain.

Distant metastasis from primary lung cancer is mostly seen in the liver, brain, adrenal glands and bones. Small bowel, specifically duodenum is a relatively unusual site for distant metastasis from lung carcinoma. This case reports a rare scenario of upper gastrointestinal bleeding caused by duodenal metastasis by a primary lung adenocarcinoma. A 43-year-old woman presented to the emergency department with complaints of progressive hemoptysis for the past three weeks. Esophagogastroduodenoscopy (EGD) revealed a 2.5 cm x 2.5 cm fungating villous mass-like structure in the first portion of the duodenum, with a normal-appearing esophagus and stomach. Biopsies were performed, which were histologically consistent with poorly differentiated malignant. The immunohistochemical (IHC) staining was consistent with metastatic disease from primary lung adenocarcinoma. Due to its rarity, there are no solidified guidelines for the management of duodenal metastasis from lung carcinoma. Our case was challenging due to the extensive metastasis and low functional status of the patient and was ultimately managed with home hospice.

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