Outcomes of endoscopic sclerotherapy for jejunal varices at the site of choledochojejunostomy (with video): Three case reports

BACKGROUND Hemorrhage associated with varices at the site of choledochojejunostomy is an unusual,difficult to treat,and often fatal manifestation of portal hypertension.So far,no treatment guidelines have been established.CASE SUMMARY We reported three patients with jejunal varices at the site of choledochojejun-ostomy managed by endoscopic sclerotherapy with lauromacrogol/α-butyl cyanoacrylate injection at our institution between June 2021 and August 2023.We reviewed all patient records,clinical presentation,endoscopic findings and treatment,outcomes and follow-up.Three patients who underwent pancre-aticoduodenectomy with a Whipple anastomosis were examined using conven-tional upper gastrointestinal endoscopy for suspected hemorrhage from the afferent jejunal loop.Varices with stigmata of recent hemorrhage or active he-morrhage were observed around the choledochojejunostomy site in all three patients.Endoscopic injection of lauromacrogol/α-butyl cyanoacrylate was carried out at jejunal varices for all three patients.The bleeding ceased and patency was observed for 26 and 2 months in two patients.In one patient with multiorgan failure and internal environment disturbance,rebleeding occurred 1 month after endoscopic sclerotherapy,and despite a second endoscopic sclero-therapy,repeated episodes of bleeding and multiorgan failure resulted in eventual death.CONCLUSION We conclude that endoscopic sclerotherapy with lauromacrogol/α-butyl cyanoac-rylate injection can be an easy,effective,safe and low-cost treatment option for jejunal varicose bleeding at the site of choledochojejunostomy.

Non-surgical treatment of diabetic foot ulcers on the dorsum of the foot with polydeoxyribonucleotide injection:Two case reports

BACKGROUND Diabetic foot ulcers are caused by a variety of factors,including peripheral neuropathy,peripheral arterial disease,impaired wound healing mechanisms,and repetitive trauma.Patients with diabetic foot ulcer on the dorsum of the foot are often treated surgically.However,the right non-surgical therapy must be chosen if surgical choices are contraindicated or if the patient prefers conservative treatment over surgery.CASE SUMMARY The purpose of this case report is to highlight the efficacy of polydeoxyribonucleotide(PDRN)injection as a non-surgical treatment option for diabetic foot ulcers on the dorsum of the foot,particularly in patients who choose against surgical intervention.This case report presents two cases of diabetic foot ulcers located on the dorsum of the foot that were successfully treated with PDRN injection as a non-surgical intervention.CONCLUSION If the patient declines surgery for diabetic ulcers with Wagner grade II or below,PDRN injection can be effective if necrotic tissue is removed and the wound bed kept clean.

Abnormal uterine bleeding successfully treated via ultrasoundguided microwave ablation of uterine myoma lesions: Three case reports

BACKGROUND Microwave endometrial ablation(MEA)is a minimally invasive treatment method for heavy menstrual bleeding.However,additional treatment is often required after recurrence of uterine myomas treated with MEA.Additionally,because this treatment ablates the endometrium,it is not indicated for patients planning to become pregnant.To overcome these issues,we devised a method for ultrasound-guided microwave ablation of uterine myoma feeder vessels.We report three patients successfully treated for heavy menstrual bleeding,secondary to uterine myoma,using our novel method.CASE SUMMARY All patients had a favorable postoperative course,were discharged within 4 h,and experienced no complications.Further,no postoperative recurrence of heavy menstrual bleeding was noted.Our method also reduced the myoma’s maximum diameter.CONCLUSION This method does not ablate the endometrium,suggesting its potential appli-cation in patients planning to become pregnant.

Gastric metastasis of small cell lung carcinoma:Three case reports and review of literature

BACKGROUND Small cell lung carcinoma(SCLC)is highly susceptible to metastasis in the early stages of the disease.However,the stomach is an uncommon site of metastasis in SCLC,and only a few cases of this type of metastasis have been reported.Therefore,SCLC gastric metastases have not been systematically characterized and are easily missed and misdiagnosed.CASE SUMMARY We report three cases of gastric metastasis from SCLC in this article.The first patient presented primarily with cough,hemoptysis,and epigastric fullness.The other two patients presented primarily with abdominal discomfort,epigastric distension,and pain.All patients underwent gastroscopy and imaging examinations.Meanwhile,the immunohistochemical results of the lesions in three patients were suggestive of small cell carcinoma.Finally,the three patients were diagnosed with gastric metastasis of SCLC through a comprehensive analysis.The three patients did not receive appropriate treatment and died within a short time.CONCLUSION Here,we focused on summarizing the characteristics of gastric metastasis of SCLC to enhance clinicians'understanding of this disease.

Imaging characteristics and treatment strategies for carotid artery occlusion caused by skull base fracture:Three case reports

BACKGROUND Traumatic internal carotid artery(ICA)occlusion is a rare complication of skull base fractures,characterized by high mortality and disability rates,and poor prognosis.Therefore,timely discovery and correct management are crucial for saving the lives of such patients and improving their prognosis.This article retrospectively analyzed the imaging and clinical data of three patients,to explore the imaging characteristics and treatment strategies for carotid artery occlusion,combined with severe skull base fractures.CASE SUMMARY This case included three patients,all male,aged 21,63,and 16 years.They underwent plain film skull computed tomography(CT)examination at the onset of their illnesses,which revealed fractures at the bases of their skulls.Ultimately,these cases were definitively diagnosed through CT angiography(CTA)examinations.The first patient did not receive surgical treatment,only anticoagulation therapy,and recovered smoothly with no residual limb dysfunction(Case 1).The other two patients both developed intracranial hypertension and underwent decompressive craniectomy.One of these patients had high intracranial pressure and significant brain swelling postoperatively,leading the family to choose to take him home(Case 2).The other patient also underwent decompressive craniectomy and recovered well postoperatively with only mild limb motor dysfunction(Case 3).We retrieved literature from PubMed on skull base fractures causing ICA occlusion to determine the imaging characteristics and treatment strategies for this type of disease.CONCLUSION For patients with cranial trauma combined with skull base fractures,it is essential to complete a CTA examination as soon as possible,to screen for blunt cerebrovascular injury.

Secondary diabetes due to different etiologies:Four case reports

BACKGROUND As research on diabetes continues to advance,more complex classifications of this disease have emerged,revealing the existence of special types of diabetes,and many of these patients are prone to misdiagnosis and underdiagnosis,leading to treatment delays and increased health care costs.The purpose of this study was to identify four causes of secondary diabetes.CASE SUMMARY Secondary diabetes can be caused by various factors,some of which are often overlooked.These factors include genetic defects,autoimmune disorders,and diabetes induced by tumours.This paper describes four types of secondary diabetes caused by Williams–Beuren syndrome,Prader–Willi syndrome,pituitary adenoma,and IgG4-related diseases.These cases deviate significantly from the typical progression of the disease due to their low incidence and rarity,often leading to their neglect in clinical practice.In comparison to regular diabetes patients,the four individuals described here exhibited distinct characteristics.Standard hypoglycaemic treatments failed to effectively control the disease.Subsequently,a series of examinations and follow-up history confirmed the diagnosis and underlying cause of diabetes.Upon addressing the primary condition,such as excising a pituitary adenoma,providing glucocorticoid supplementation,and implementing symptomatic treatments,all patients experienced a considerable decrease in blood glucose levels,which were subsequently maintained within a stable range.Furthermore,other accompanying symptoms improved.CONCLUSION Rare diseases causing secondary diabetes are often not considered in the diag-nosis of diabetes.Therefore,it is crucial to conduct genetic tests,antibody detection and other appropriate diagnostic measures when necessary to facilitate early diagnosis and intervention through proactive and efficient management of the underlying condition,ultimately improving patient outcomes.

Blastic plasmacytoid dendritic cell neoplasm:Two case reports

BACKGROUND Blastic plasmacytoid dendritic cell tumor(BPDCN)is a rare and highly invasive lymphohematopoietic tumor that originates from plasmacytoid dendritic cells.BPDCN has an extremely poor prognosis.Skin lesions are usually the first manifestation of BPDCN,although the tumor may also invade the bone marrow,lymph nodes,peripheral blood,and other parts of the body,leading to several other manifestations,requiring further differentiation through skin biopsy and immunohistochemistry.CASE SUMMARY In the present paper,the cases of 2 patients diagnosed with BPDCN are discussed.The immunohistochemistry analysis of these 2 patients revealed positivity for CD4,CD56,and CD123.Currently,no standard chemotherapy regimen is available for BPDCN.Therefore,intensive therapy for acute lymphoblastic leukemia was applied as the treatment method for these 2 cases.CONCLUSION Although allogeneic bone marrow transplantation could be further effective in prolonging the median survival the ultimate prognosis was unfavorable.Future treatment modalities tailored for elderly patients will help prolong survival.

Misdiagnosis of hemangioma of left triangular ligament of the liver as gastric submucosal stromal tumor:Two case reports

BACKGROUND Extragastric lesions are typically not misdiagnosed as gastric submucosal tumor(SMT).However,we encountered two rare cases where extrinsic lesions were misdiagnosed as gastric SMTs.CASE SUMMARY We describe two cases of gastric SMT-like protrusions initially misdiagnosed as gastric SMTs by the abdominal contrast-enhanced computed tomography(CT)and endoscopic ultrasound(EUS).Based on the CT and EUS findings,the patients underwent gastroscopy;however,no tumor was identified after incising the gastric wall.Subsequent surgical exploration revealed no gastric lesions in both patients,but a mass was found in the left triangular ligament of the liver.The patients underwent laparoscopic tumor resection,and the postoperative diagnosis was hepatic hemangiomas.CONCLUSION During EUS procedures,scanning across different layers and at varying degrees of gastric cavity distension,coupled with meticulous image analysis,has the potential to mitigate the likelihood of such misdiagnoses.

Monodermal teratoma:Three case reports and review of literature

BACKGROUND The incidence of monodermal teratomas of the reproductive system is low,and most doctors lack adequate understanding,which can easily lead to missed diagnoses and/or misdiagnosis.Therefore,it is important to fully understand the clinical characteristics,diagnosis,differential diagnosis,and treatment of monodermal teratomas of the reproductive system.CASE SUMMARY Case 1:A 14-year-old boy was admitted to the hospital with a right testicular mass for 1 wk and underwent surgical resection.He was finally diagnosed with right testicular monodermal teratoma with no special postoperative discomfort.Case 2:A 40-year-old woman was admitted to the hospital for uterine abnormalities indicated by ultrasound 20 d prior and underwent laparoscopic surgery.She was finally diagnosed with a left ovarian monodermal teratoma with a satisfactory postoperative quality of life.Case 3:A 49-year-old woman was admitted to the hospital with a pelvic mass that was discovered on B-ultrasound a week prior and underwent laparoscopic resection of the left adnexa.She was finally diagnosed with left ovarian monodermal teratoma,and her postoperative quality of life was satisfactory.CONCLUSION Monodermal teratoma is a rare tumor whose clinical manifestations are primarily benign.Simple surgical resection of the tumor is effective.

Low-molecular-weight heparin and preeclampsia—does the sword cut both ways?Three case reports and review of literature

BACKGROUND Low-molecular-weight heparins(LMWH)are the most commonly used anticoagulants during pregnancy.It is considered to be the drug of choice due to its safety in not crossing placenta.Considering the beneficial effect in the improvement of microcirculation,prophylactic application of LMWH in patients with preeclampsia became a trend.However,the bleeding risk related with LMWH in preeclampsia patients has seldomly been evaluated.This current study aimed to identify the potential risks regarding LMWH application in patients with preeclampsia.CASE SUMMARY Herein we present a case series of three pregnant women diagnosed with preeclampsia on LMWH therapy during pregnancy.All the cases experienced catastrophic hemorrhagic events.After reviewing the twenty-one meta-analyses,the bleeding risk related with LMWH seems ignorable.Only one study analyzed the bleeding risk of LMWH and found a significantly higher risk of developing PPH in women receiving LMWH.Other studies reported minor bleeding risks,none of these were serious enough to stop LMWH treatment.Possibilities of bleeding either from uterus or from intrabdominal organs in preeclampsia patients on LMWH therapy should not be ignored.Intensive management of blood pressure even after delivery and homeostasis suture in surgery are crucial.CONCLUSION Consideration should be given to the balance between benefits and risks of LMWH in patients with preeclampsia.

Esophageal melanosis:Two case reports and review of literature

Esophageal melanosis(EM)is a rare condition characterized by melanin pigmentation in the esophageal mucosa.It is not well understood and has been documented in less than 100 cases worldwide.CASE SUMMARY We report two cases of African American patients who complained of significant weight loss(over 20 pounds in approximately six months)and abdominal pain during their first visit.The first case involves a 54-year female with a history of hepatic steatosis and polysubstance abuse,who also experiences nausea and vomiting.The second case is a 59-year-old male with hypertension and gastroesophageal reflux disease(GERD),who was diagnosed with esophageal squamous cell carcinoma.Both cases show benign melanocytes in the basal layer on the esophagus biopsy and are diagnosed as EM.CONCLUSION It is important to note that EM has been associated with malignancies such as carcinoma and melanoma.Therefore,accurate diagnosis and appropriate management are crucial.Patients with EM,especially those with concurrent risk factors(e.g.,GERD,smoking),should be carefully monitored for any signs of malignancy.

Colo-colonic intussusception as a rare complication of colonoscopy with polypectomy: Two case reports

BACKGROUND Colonoscopy is the most frequently used diagnostic and therapeutic tool for the treatment of colorectal diseases.Although the complication rate is low,it can be potentially serious.Intussusception is a rare and severe complication often associated with polypectomy.Only a handful of post-colonoscopy intussusception cases have been reported,making this study a valuable addition to the medical literature.CASE SUMMARY Case 1:A 61-year-old man underwent colonoscopy with polypectomy for chronic abdominal pain.The patient experienced abdominal pain 11 hours later but was still discharged after pain management.He was readmitted due to recurring pain.Computed tomography(CT)showed colo-colonic intussusception.Initial conservative management and attempts at endoscopic reduction failed;therefore,laparoscopic right hemicolectomy was performed.Histopathological examination revealed tubular adenomas in the polyps and inflammation in the resected specimens.Case 2:A 59-year-old woman underwent colonoscopy with polypectomy for a polyp in the transverse colon.She experienced upper abdominal pain,fever,nausea,and vomiting 9 hours after the procedure.Emergency CT and blood tests revealed a colo-colonic intussusception near the hepatic flexure and an elevated white blood cell count.Initial attempts at endoscopic reduction failed and conservative treatment showed no improvement.She underwent successful laparoscopic reduction and recovered uneventfully.Histopathological examination of the resected polyp revealed hyperplasia.CONCLUSION Post-colonoscopy intussusception in adults is rare,and polypectomy may contribute to its occurrence.Early diagnosis is crucial,with prompt CT examination serving as key.After excluding malignancies,conservative management and reduction of intussusception should be considered before surgical bowel resection.

Delayed postpancreatectomy hemorrhage as the role of endovascular approach:Four case reports

BACKGROUND Pancreatic resection is still associated with high morbidity rates and delayed postpancreatectomy hemorrhage(PPH)is the most feared complication as it may lead to hemorrhagic shock or serious septic complications.Today,endovascular approach represent safe and efficient method for minimally invasive management of extraluminal PPH.CASE SUMMARY We describe four patients whose postoperative recovery after pancreatic resection was complicated by postoperative pancreatic fistula(POPF)and visceral artery hemorrhage.In all cases endovascular approach was utilized and it resulted in satisfactory outcomes.We discuss modern diagnostic and therapeutic approach in this clinical scenario.CONCLUSION PPH is relatively uncommon,but it is a leading cause of surgical mortality after pancreatic surgery.Careful monitoring and meticulous follow-up are required for all patients post-operatively,especially in the case of confirmed POPF,which is the most significant risk factor for the development of a PPH.Angiography as a diagnostic and therapeutic method may be an optimal first-line treatment for the management of delayed PPHs.In our experience,endovascular treatment for hemorrhagic complications of pancreatic resections has shown satisfactory results.

Gradient inflammation in the pancreatic stump after pancreaticoduodenectomy:Two case reports and review of literature

BACKGROUND Postoperative pancreatic fistula(POPF)contributes significantly to morbidity and mortality after pancreaticoduodenectomy(PD).However,the underlying mechanisms remain unclear.This study explored this pathology in the pancreatic stumps and elucidated the mechanisms of POPF following PD.CASE SUMMARY Pathological analysis and 16S rRNA gene sequencing were performed on specimens obtained from two patients who underwent complete pancreatectomy for grade C POPF after PD.Gradient inflammation is present in the pancreatic stump.The apoptosis was lower than that in the normal pancreas.Moreover,neu-trophildominated inflammatory cells are concentrated in the ductal system.No-tably,neutrophils migrated through the ductal wall in acinar duct metaplasia-formed ducts.Additionally,evidence indicates that gut microbes migrate from the digestive tract.Gradient inflammation occurs in pancreatic stumps after PD.CONCLUSION The mechanisms underlying POPF include high biochemical activity in the pancreas,mechanical injury,and digestive reflux.To prevent POPF and address pancreatic inflammation and reflux,breaking the link with anastomotic dehi-scence is practical.

Moyamoya syndrome may result from psoriasis: Four case reports

BACKGROUND Moyamoya syndrome(MMS)is a group of diseases that involves more than one underlying disease and is accompanied by moyamoya vascular phenomena.Psoriasis is a chronic immune skin disease closely linked to high blood pressure and heart disease.However,psoriasis-related MMS has not been reported.CASE SUMMARY We collected data on patients with stroke due to MMS between January 2017 and December 2019 and identified four cases of psoriasis.Case histories,imaging,and hematological data were collected.The average age of the initial stroke onset was 58.25±11.52 years;three cases of hemorrhagic and one case of ischemic stroke were included.The average duration from psoriasis confirmation to the initial MMS-mediated stroke onset was 17±3.56 years.All MMS-related stenoses involved the bilateral cerebral arteries:Suzuki grade III in one case,grade IV in two cases,and grade V in one case.Abnormally elevated plasma interleukin-6 levels were observed in four patients.Two patients had abnormally elevated immunoglobulin E levels,and two had thrombocytosis.All four patients received medication instead of surgery.With an average follow-up time of 2 years,two causing transient ischemic attacks occurred in two patients,and no hemorrhagic events occurred.CONCLUSION Psoriasis may be a potential risk factor for MMS.Patients with psoriasis should be screened for MMS when they present with neurological symptoms.

Recipient artery dissection during extracranial-intracranial bypass surgery:Two case reports

BACKGROUND Superficial temporal artery to middle cerebral artery(STA-MCA)bypass is a valuable treatment for preventing ischemia and hemorrhage in occlusive cerebrovascular disease.Anastomosis site dissection is rarely reported among the various bypass-related complications.CASE SUMMARY In this case report,we describe two patients,who were 63-and 59-years-old with middle cerebral artery occlusion treated by STA-MCA bypass.During bypass surgery,the recipient M4 artery intima was dissected.We sacrificed the dissecting portion,and no complications occurred during the follow-up period.Postoperative brain imaging revealed improved brain perfusion.We report rare cases of recipient artery dissection located in the extracranial to intracranial bypass site,and we suggest atherosclerotic changes in the recipient artery and insufficient puncture as the causes.CONCLUSION Appropriate recipient artery selection is critical,and if dissection occurs,it is essential to sacrifice the dissecting portion quickly.

Colonic schistosomiasis mimicking cancer,polyp,and inflammatory bowel disease:Five case reports and review of literature

BACKGROUND Schistosomiasis,officially named as a neglected tropical disease by The World Health Organization,is a serious parasitic disease caused by trematode flukes of the genus Schistosoma.It is a common infectious disease,endemic in more than 78 countries.The disease can involve various organs and poses far-reaching public health challenges.CASE SUMMARY Here,we present a series of five patients with variable presentations:an asymptomatic patient who was diagnosed with colonic schistosomiasis upon screening colonoscopy;2 patients with clinical suspicion of colonic cancer;and 2 patients with a clinical diagnosis of inflammatory bowel disease.All patients were subsequently confirmed to have colonic schistosomiasis after colonoscopy and histopathologic examination.The clinical manifestations,colonoscopy features and histologic findings of the patients are described.Most of the patients showed significant clinical improvement following administration of oral praziquantel.CONCLUSION Intestinal schistosomiasis can present with features mimicking other gastrointestinal conditions.This disease should be a diagnostic consideration in patients who live in or have traveled to endemic areas.

Reconstruction of cervical necrotizing fasciitis defect with the modified keystone flap technique:Two case reports

BACKGROUND Cervical necrotizing fasciitis(CNF)is a rare,aggressive form of deep neck space infection with significant morbidity and mortality rates.Serial surgical debridement acts as the cornerstone of CNF treatment;however,it often results in defects requiring complex reconstructions.CASE SUMMARY We report two cases in which the keystone flap(KF)was used for CNF defect coverage:Case 1,an 85-year-old patient with CNF in the anterior neck,and Case 2,a 54-year-old patient with CNF in the posterior neck.Both patients received empirical intravenous antibiotic therapy and underwent serial debridement,enabling adequate wound preparation and stabilization.The final defect size measured 5.5 cm×12 cm in Case 1 and 6 cm×11 cm in Case 2.For defect coverage,we employed an 8 cm×19 cm type II KF based on perforators from the superior thyroid artery in Case 1 and a 9 cm×18 cm type II KF based on perforators from the transverse cervical artery in Case 2.Both flaps showed complete survival.No postoperative complications occurred in both cases,and favorable outcomes were observed at 7-and 6-month follow-ups in case 1 and 2,respectively.CONCLUSION We effectively treated CNF-associated defects using the KF technique;KF is viable for covering CNF defects in carefully selected cases.

An unusual etiology of subarachnoid hemorrhage,basilar artery perforator aneurysms,in Macao:Three case reports and review of literature

BACKGROUND Subarachnoid hemorrhage is a severe neurological condition that requires prompt and appropriate treatment to prevent complications.Aneurysms are the most common cause of spontaneous subarachnoid hemorrhage.Conversely,basilar artery perforator aneurysms(BAPAs)are a rare etiology.There is no consensus on the optimal management of ruptured BAPAs in the acute setting.CASE SUMMARY We present a case series of 3 patients with ruptured BAPAs who were treated at our institution.Two patients had a modified Fisher grade of I,and one had a grade of IV on initial presentation.The aneurysms were detected by computed tomography angiography in two cases and conventional angiography in one case.The 3 patients underwent endovascular treatment with Guglielmi detachable coils.Post-treatment,the patients had good clinical outcomes,and follow-up brain computed tomography scans showed reduced subarachnoid hemorrhage without any new hemorrhage.However,one patient experienced a cerebral infarction 2 months later and eventually succumbed to the condition.The other 2 patients showed progressive recovery,and no aneurysm recurrence was observed at the 2-year follow-up.CONCLUSION Endovascular treatment may be a preferable approach for managing ruptured BAPAs compared with surgical intervention or conservative management.Early detection and prompt treatment is important to achieve favorable patient outcomes.

Omadacycline in the treatment of scrub typhus:Three case reports

BACKGROUND Scrub typhus is a naturally occurring acute infectious disease that is primarily transmitted through the bites of chiggers or larval mites infected by Orientia tsutsugamushi(O.tsutsugamushi).Omadacycline,a novel tetracycline,exhibits potent antibacterial efficacy against both typical bacteria and atypical pathogens.However,omadacycline application in the treatment of scrub typhus remains limited.CASE SUMMARY In the present work,we report several cases of scrub typhus,with the main clinical symptoms being fever,the formation of eschars or ulcers,local or systemic lymphadenopathy,headache,myalgia and rash.Blood samples were collected before omadacycline was administered,and O.tsutsugamushi infection was confirmed through targeted next-generation sequencing(tNGS).After two days of treatment,the patients’symptoms,including fever,were alleviated,with no adverse drug reactions.CONCLUSION tNGS is an effective method for diagnosing scrub typhus.Omadacycline can be considered an alternative option for antiinfective therapy in patients with O.tsutsugamushi infections.