Unlike in infancy, where intussusception is an abdominal emergency, diagnosis of intussusception could be tricky in adults as most of these patients present sub-acutely with vague abdominal symptoms. Early diagnosis could impact these patients significantly in decreasing morbidity and mortality along with reduction in healthcare expenses. Colo-colonic intussusception is rare and accounts for less than 20% of adult intussusception. More than 50% of adult intussusception is caused by mass-like lesions. In such cases, this could be an early presentation of malignant intestinal lesions. Abdominal CT is mandatory in all adult patients; when combined with ultrasound, it has 95.5% accuracy of pre-operative diagnosis. Here we report a case of a 42-year-old female who presented with a two-month history of intermittent abdominal pain; a CT abdomen revealed colo-colonic intussusception which was initially missed on prior imaging. We discuss the importance of considering intussusception as a rare differential of abdominal pain, the need for early diagnosis, and the role of colonoscopy and non-surgical management in adults.

In young adults, spontaneous craniocervical arterial dissections (sCAD), which involve the major arteries of the head and neck, are associated with an increased risk of stroke. sCAD occurs in the absence of major trauma as seen in traumatic craniocervical artery dissection. It may affect unilateral or bilateral carotid or vertebral arteries. Cases of spontaneous bilateral carotid and vertebral artery dissections occurring simultaneously are extremely rare. We present a case of a 49-year-old female with no history of arteriopathy who presented with aphasia and right upper extremity weakness and was found to have dissections in bilateral extracranial and intracranial carotid arteries, as well as the bilateral vertebral arteries. She had symptomatic improvement with antithrombotic therapy and aggressive outpatient rehabilitation.

Sphingobacterium spritivorum (SS) is a ubiquitous gram-negative organism and an uncommon cause of infection in humans. To our knowledge, there are no reported cases of this bacterium causing spontaneous bacterial peritonitis (SBP) in patients with cirrhosis. In this report, we discuss a case of a male patient in his late 60s who presented with severe sepsis from methicillin-resistant staphylococcus aureus (MRSA) , in whom SS was subsequently identified via ascitic fluid culture. This unusual organism is known to have an innate resistance to multiple antibiotics and can cause life-threatening sepsis in cases of delayed or missed diagnosis. Clinicians should not be weighed down by anchoring bias and look for alternative, uncommon gram-negative organisms in cases of progressive sepsis in patients with ascites.

Figure 1. Image 1: EUS demonstrating a 10 cm lobulated hypo-echoic mass in continuity with the posterior wall of the mid and distal rectum extending into the anal sphincter. Image 2: EUS demonstrating a large sub-epithelial lesion in the posterior wall of the distal rectum extending up to the dentate line.

Discussion: Villous adenomas, normally a benign condition, can present with a life-threatening electrolyte derangements and volume depletion which makes the ability to diagnose and adequately treat MWS critical. Patients typically have multiple admissions with watery or mucous diarrhea, nausea, and vomiting. Labs significant for hyponatremia, hypokalemia, AKI, and leukocytosis. The tumors are large and often past the splenic flexure and low in the rectum, therefore flexible sigmoidoscopy can be reliably used rather than colonoscopy, which often delays diagnosis due to patients' inability to prep. Treatment includes aggressive fluid and electrolyte repletion until tumor can be surgically resected. Few case reports suggest using indomethacin or octreotide as a bridge to surgery or as medical management for patients who are not surgical candidates. However, patients who are managed medically have a mortality rate up to ;61-100%. Surgical management to definitively resolve symptoms, although minimally invasive options are being explored. A high index of suspicion and a systematic approach is critical to diagnose and provide life-saving treatment for MWS patients.Tumor biopsy demonstrating positive to immunohistochemical stain for SOX-10, a common marker for malignant melanoma. C) Tumor biopsy with immunohistochemical stain for Melan-A positivity.