INTRODUCTION: Breast cancer with metastasis involving the esophagus is a rare phenomenon. Most cases involve metastasis to the mediastinum resulting in esophageal compression. Less commonly these cases will metastasize directly to the mucosa or submucosa of the esophagus. Here we present a rare case of breast cancer metastasizing to the mucosal layer of the esophagus in addition to the mediastinum, resulting in esophageal compression. CASE DESCRIPTION/METHODS: Patient is a 73 year old female with a medical history of left breast cancer with known metastasis to the lung, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), hypothyroidism, and osteoporosis who presented to the emergency department complaining of worsening dysphagia for the past 3 months. She began having dysphagia to solids that slowly progressed to include liquids. Notable workup included a complete blood count with a hemoglobin of 10.9 gm/dL. The gastroenterology service was then consulted and performed an upper esophagagastroduodenoscopy which showed severe narrowing in the mid to lower esophagus with unhealthy appearing mucosa with contact oozing and desquamation. Multiple biopsies were taken from this area which returned showing metastatic carcinoma, consistent with breast primary. Immunohistochemical stains showed the neoplastic cells were positive for ER, and negative for p63, supporting the diagnosis. The patient then underwent PET scan which showed hypermetabolic posterior mediastinal lymphadenopathy causing extrinsic esophageal compression. During her admission the patient was able to tolerate pureed diet and was discharged to follow with oncology where she would undergo further treatment with Fulvestrant and Palbociclib. DISCUSSION: Breast metastases of mucosal and submucosal layers of the esophagus are extremely rare as esophageal involvement is usually secondary to mediastinal carcinosis. Diagnosis of breast cancer metastasizing to the esophagus is difficult as esophageal involvement can occur without clinical symptoms in a considerable number of patients with breast cancer. The most common clinical manifestations include dysphagia, accompanied by weight loss, anorexia and vocal dysfunction. Chemotherapy and hormonal therapy are the initial treatment of choice given that they significantly affect survival. Endoscopic placement of a stent should be reserved to those patients who do not have a significant improvement of dysphagia after treatment, or in cases of trachea-esophageal fistulas.

INTRODUCTION: Solitary rectal ulcer syndrome (SRUS) is an uncommon rectal disorder that may result in severe rectal bleeding. The term solitary rectal ulcer syndrome is a misnomer. Endoscopic findings in patients with SRUS can range from mucosal erythema alone to single or multiple ulcers and polypoid mass lesions. Here, we present a rare case of severe hematochezia occurring secondary to a solitary rectal ulcer. CASE DESCRIPTION/METHODS: The patient is a 37 year-old male with a medical history of alcohol abuse who presented to our emergency department complaining of three episodes of hematochezia accompanied by dizziness and lightheadedness that began the night prior. Notable workup in the emergency department included a complete blood count (CBC) showing a hemoglobin of 12.5 gm/dL. A fecal occult blood test was also done which returned positive. This was followed by a repeat CBC showing an acute drop in the hemoglobin to 9.8 gm/dL. The gastroenterology service was then consulted and performed a colonoscopy. This was done and showed a large cratered ulcer about two centimeters in size and a non-bleeding visible vessel noted approximately five centimeters from the anal verge (Figure 1). These were treated with BiCAP cautery and the three hemostatic clips. Biopsies were not taken given the high risk of bleeding and emergent nature of the procedure. After the procedure the patient remained hemodynamically stable with no further drops in hemoglobin. He was then discharged with follow up appointments for repeat colonoscopy. DISCUSSION: SRUS is an oftentimes-misdiagnosed condition. The prevalence of SRUS is not clear, but has an estimated incidence of 1 in 100,000 people per year. Its diagnosis can usually be accomplished through a combination of symptomatology, endoscopy, sigmoidoscopy, and the histologic finding of fibromuscular obliteration of the lamina propria. The pathogenesis if SRUS is not well known, but various factors contribute to its development. This includes straining, self-induced trauma, paradoxical contraction of puborectalis muscle and rectal prolapse, and intussusception. Treatment of SRUS is based on the symptoms and severity. Asymptomatic patient treatment options include dietary modification, patient education, and behavioral modification. Endoscopic treatment can be applied to control bleeding and allows the clinician to obtain a biopsy specimen. Surgical treatment is recommended for those who have full thickness and rectal prolapse.

Intestinal spirochetosis is characterized by spirochetes on the luminal surface of colorectal mucosa with a higher prevalence in homosexual men and HIV-infected patients. Previous studies found an association with diverticular disease and intestinal bowel disease with diarrhea as a common presenting symptom seen in our patient. The Brachypiracea family are the most common organisms associated with intestinal colonization with co-infection with other enteric pathogens including Helicobacter pylori being common. Endoscopic mucosal appearance can be variable ranging from normal to mucosal erosions with diagnosis made with biopsy showing a diffuse fringe along the border of the intercryptal epithelial layer (Figure ) and metronidazole being an effective treatment. When an immunocompromised patient with high risk behaviors presents with chronic diarrhea, intestinal spirochetes should be considered on the differential diagnosis.[2183] Figure 1. A, B: Hematoxylin and Eason Stain (H&E) showing intestinal spirochetes at 20x magnification and 40x respectively showing intestinal spirochetes (red arrow).Figure C: Silver Steiner stain showing intestinal spirochetes (red arrow).

No abstract

No abstract