A 49-year-old man presented with abdominal pain and rectal bleeding for two days associated with a 50-pound unintentional weight loss. History was notable for hypertension, chronic kidney disease, obesity, gout, and acute cholecystitis status post cholecystectomy. Computed tomography (CT) of the abdomen and pelvis showed rectal wall thickening. Colonoscopy showed proctitis with superficial ulcerations. In the setting of renal insufficiency, malabsorption, and low-voltage QRS complexes on electrocardiogram (ECG), amyloidosis was considered in the differential diagnosis. Rectal and renal biopsies with subsequent retrospective staining of gallbladder tissue confirmed amyloid deposition. Gastrointestinal involvement of amyloidosis is relatively uncommon. Particularly, amyloid deposition in the gallbladder and rectum is very rare. The development of AA amyloidosis in our patient may have been related to gout, obesity, and the presence of a heterozygous complex variant for the MEFV (familial Mediterranean fever) gene. Awareness of this atypical presentation of amyloidosis is important, as additional staining of biopsy samples is necessary, and diagnosis allows for directed treatment.

Background Eptifibatide is used in acute coronary syndromes to reversibly block platelet aggregation by inhibiting the platelet glycoprotein IIb/IIIa receptor. A serious adverse effect of eptifibatide is a profound drop in platelet count, termed eptifibatide-induced thrombocytopenia (EIT). Objective To provide insight into the types of complications and management of EIT. Methods Cases of EIT submitted to the Food and Drug Administration adverse event reporting system were evaluated. Data analyses included management of EIT, complications of thrombocytopenia, initial platelets, and platelet nadir following eptifibatide. Results 103 cases of EIT were reported from January 2010 to 2019; 57 cases met the Naranjo scale and were included. Only 37 of those cases contained information on how EIT was managed. Eptifibatide administration was withheld in all 37 of those cases. Platelet transfusions were administered in 20 cases (54%). Two cases were managed with steroids (5.4%), and 1 case used intravenous immunoglobulin G to reverse EIT (2%). The median initial platelet count prior to administration of eptifibatide was 207 000 cells/mm3 (SD = 69 000; n = 27), and median platelet nadir was 9000 cells/mm3 (SD = 19 000; n = 35) The majority of complications of EIT included bleeding events (16/28, 57%). Delayed procedures, prolonged stay, allergic reactions, and thrombosis were each reported in 3 patients (10.75%). Conclusion and Relevance Most cases of EIT were managed by withholding eptifibatide with platelet transfusion if necessary. The majority of complications included bleeding. However, significant procedure delays, prolonged hospital stay, thrombosis, and allergic reactions were also reported.

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INTRODUCTION: Ileitis is often seen in Crohn's disease and infection. Less often, it is associated with other conditions, including vasculitides, neoplasia, ischemia and medication-related complications. Ileitis typically presents with right lower quadrant abdominal pain and diarrhea; in some cases, it causes a small bowel obstruction (SBO). There are very few case reports of 5-fluorouracil associated ileitis and it is not well-described in literature. CASE DESCRIPTION/METHODS: A 66-year-old male with stage IV gastroesophageal junction adenocarcinoma was started on radiation therapy to the upper esophagus along with continuous infusion of fluorouracil (5FU). On day four of 5-FU, the patient developed severe mucositis causing dysphagia and odynophagia, requiring hospitalization and PEG-tube placement. With initiation of tube feeds, patient developed nausea, vomiting and watery nonbloody diarrhea. CT abdomen/pelvis showed SBO, with thickening of the distal small bowel thickening suggestive of terminal ileitis (Figure 1). Despite cessation of tube feeds, he continued to have diarrhea. C. difficile PCR, enteric pathogen panel, GI pathogen panel, and Yersinia culture were negative. He remained afebrile and without leukocytosis. Colonoscopy revealed inflammation of the terminal ileum characterized by erythema and ulceration (Figure 2). Biopsies of the terminal ileum showed chronic active inflammation (Figure 3). The terminal ileitis was attributed to treatment with 5-FU. With supportive care, the patient's diarrhea resolved and he was discharged home. 5-FU was held and patient received radiation therapy alone. Repeat colonoscopy 2 months later showed endoscopically normal mucosa. Biopsies showed nonspecific chronic inactive ileitis. DISCUSSION: We report a case of diarrhea and SBO associated with terminal ileitis, which was likely related to 5-fluorouracil therapy. Histology showed chronic inflammation with crypt architectural distortion, which are similar to the findings associated with radiation induced enteritis. However, this patient received only radiation therapy to the upper esophagus, none to the abdomen or lower abdomen. Infectious etiologies of ileitis were ruled out, and the ileitis resolved with discontinuation of 5-FU. Terminal ileitis may be an important diagnostic consideration in patients receiving 5-FU. We suggest that colonoscopies performed for diarrhea associated with 5-FU should include intubation into the terminal ileum when possible.