Mycophenolate Mofetil (MMF) is routinely used immunosuppressant in solid organ transplantation is commonly associated with several gastrointestinal (GI) side effects. Here we present a case of giant gastric ulcer of 5 cm from MMF use post cardiac transplant. Case Description A 56-year-old male with history of severe ischemic cardiomyopathy post heart transplant was on immunosuppression with MMF, tacrolimus and prednisone for 5 months. He presented with severe epigastric pain and intermittent episodes of melena for 1 month. His pain radiated to back that is worsened with eating. Associated with loss of appetite, vomiting and 16-pound weight loss in 3 months. He never smoked, drank alcohol or used over the counter pain medications. He was profoundly anemic requiring blood transfusions. EGD performed demonstrated very large clean-based ulcer of 5 cm diameter in the body, smaller ulcer of 8 mm diameter in pre-pyloric region and 5-10 small aphthous ulcers in the gastric body and fundus. Gastric biopsies taken from the ulcer were negative for Helicobacter pylori, cytomegalovirus and malignancy. Flexible sigmoidoscopy revealed non-bleeding inflamed internal hemorrhoids. Consequently, MMF was discontinued and switched to azathioprine. He was treated with twice daily proton pump inhibitor therapy with resolution of abdominal pain, improved appetite and weight gain. Discussion MMF is well known for common GI side-effects such as nausea, diarrhea, vomiting, ulcers, abdominal pain and rarely gastrointestinal bleeding. Few studies reported 3 to 8% incidence of ulcer perforation and GI bleeding within 6 months. Risk of gastroduodenal erosions is nearly 1.83 times for MMF, with the highest lesions associated with MMFtacrolimus-corticosteroid combination treatment as seen in our patient. Hypothesis is that GI tract is vulnerable because of dependence of enterocytes on de novo synthesis of purines, which is disrupted by MMF. Typically, upper GI mucosal injuries of mucosal irritation leading to esophagitis, gastritis and/or ulcers are seen. Endoscopy is both diagnostic and therapeutic if bleeding gastric ulcers are noted. Minor complications improve with reduction of drug dose or use of enteric coated preparation if feasible. Discontinuation of the drug is main stay in the management of MMF related ulcer disease. Simple medical treatment with either H2-receptor antagonists, proton-pump inhibitors, coating agents, prostaglandins or combination has proven effective in most cases. Considering excellent results with medical management of ulcer, role of surgery is limited.

Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) is a rare but potentially life-threatening cutaneous hypersensitivity reaction characterized by extensive mucocutaneous eruption, fever, hematologic abnormalities, and extensive organ involvement. Here, we present a case of a young woman with DRESS syndrome following exposure to vancomycin with renal, cutaneous, and gastrointestinal involvement. To the best of our knowledge, this is the first case description in the literature of DRESS of the gastrointestinal tract with autoimmune enteropathy.

Figure 1. (A) Coronal and (B) axial arterial phase MRI through the abdomen demonstrating heterogenously enhancing bi-lobed mass with non-enhancing central scar. (C) Axial portal venous phase MRI demonstrating portal venous washout with non-enhancing central scars in a bilobed mass. 2: (A) Gross specimen demonstrating tumor. (B) Histology demonstrating macrotrabecular variant HCC.

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INTRODUCTION: Mesenteric venous thrombosis (MVT) is an uncommon cause of acute to sub-acute abdominal pain. Early recognition and treatment have survival implications. CASE DESCRIPTION/METHODS: A 42 year-old male with past medical history of hypertension and obstructive sleep apnea presented with 3 weeks of worsening abdominal pain, nausea and vomiting. Physical exam revealed diffusely tender abdomen with mild guarding, no rebound tenderness and normoactive bowel sounds. Pertinent labs on admission included an elevated white count of 13.5 K/mm3 and lactate of 2 mmol/L. A non-contrast CT abdomen demonstrated small bowel loops with abnormal wall thickening and associated inflammatory changes. He was started on broad spectrum antibiotics for enteritis, however he had worsening abdominal pain and an abdominal x-ray revealed small bowel obstruction. Patient was made NPO and conservatively managed with IV fluids. His hospital course was complicated by fever of 100.8 F and leukocytosis of 26.3 K/mm3 Infectious work up was unremarkable and a CT abdomen with contrast revealed thrombosis of main portal, superior mesenteric and splenic vein. Hypercoagulable workup resulted in decreased Protein S activity (1779X) and Factor II heterozygosity (prothrombin G20210A mutation). DISCUSSION: MVT accounts for 6%–9% of all the cases of acute mesenteric ischemia. Most common presenting symptom is abdominal pain which occurs in 91–100% of the cases followed by nausea, vomiting and melena. Associated portal venous thrombosis can be seen if the disease originates in the major veins instead of the small vena rectae. Young patients without known risk factors for venous thromboembolic (VTE) and thrombosis in unusual sites such as portal, mesenteric and cerebral veins should be evaluated for thrombophilias. Approximately 20-40% of patients have previous history of deep vein thrombosis or may have a pre-existing hereditary hypercoagulable state such as protein C deficiency, protein S deficiency, anti thrombin III deficiency, factor V Leiden deficiency, or antiphospholipid syndrome. In general, outcomes in MVT are better when compared to arterial thrombosis with mortality of 44% as compared to 66–89% respectively. Studies have shown that early use of heparin has been associated with improved survival. Early recognition of MVT and treatment with anti coagulation has led to non-surgical treatment and improved outcomes.