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A santorinicele is a rare anomaly defined as focal cystic dilation of the terminal portion of the dorsal pancreatic duct at the minor papilla. Importantly this anomaly has been suggested as a possible cause of relative stenosis of the minor papilla. This anomaly has been associated with pancreatic divisum and recurrent acute pancreatitis. Magnetic resonance imaging/magnetic resonance cholangiopancreatography and endoscopic ultrasound (EUS) are the main diagnostic modalities. Endoscopic minor papilla sphincterotomy has been shown to improve pain and quality of life in patients with this anomaly presenting with recurrent pancreatitis. We present a case of a single episode of pancreatitis who underwent EUS for evaluation of possible pancreatic mass leading to a diagnosis of santorinicele and complete pancreatic divisum. We attempt to describe this anomaly, diagnostic approach, and management options.

Although much knowledge has been gained regarding the medical and surgical management of inflammatory bowel disease (IBD), a paucity of information is available on the psychosexual issues related to IBD. The aim of this study was to evaluate the sexual health of patients with IBD who were taking immunomodulators and/or biologic agents vs patients with IBD who were not on that medication regimen.All study participants completed a validated sexual health questionnaire, the Female Sexual Function Index or the International Index of Erectile Function, to assess their subjective perception of the effect of IBD on the different domains of sexual function during the prior 1-month time period.No statistically significant differences in any baseline demographic variables were found for either sex between the group taking immunomodulators/biologic agents and the nontreatment group. Among females and males, individual question responses, domain scores, and total scores showed no statistically significant differences between the 2 treatment groups.Our data suggest that the use of immunomodulators or biologic agents does not affect female or male sexual health. However, treatment of patients with IBD must be individualized based on the aggressive nature of the disease, treatment goals, and the tolerability of various medications.

In immunocompromised patients, histoplasmosis may present as disseminated disease. We present a 52-year-old Caucasian male with symptoms of dyspepsia, postprandial epigastric pain, nausea, and nonbloody diarrhea. Upper and lower gastrointestinal endoscopies were suspicious for inflammatory bowel disease (IBD); however, biopsies were consistent with histoplasmosis, specifically in the duodenum.

Background Studies have demonstrated that the use of sedation (regardless of type) increases polyp detection rates during colonoscopy. Compared to conscious sedation (CS), propofol sedation (PS) has led to detection of more advanced polyps, yet no apparent difference was found in the overall adenoma detection rate (ADR) in patients undergoing colonoscopy for various reasons. We aimed to assess whether there was a significant difference in the ADR in patients specifically undergoing screening colonoscopies using PS versus CS. Methods This is a retrospective analysis of 699 consecutive patients who underwent inpatient screening colonoscopies at one academic inpatient center. The decision to perform endoscopy using PS versus CS was determined on an individual basis by each provider, taking into account various patient parameters. Results No significant difference was noted between ADR or location of detected adenomas between the CS and PS groups. When accounting for each variable, only total endoscopy time of less than 20 min resulted in a statistically significant ADR difference between the two sedation groups (CS: 15.6% vs PS: 21.3%, P = 0.038). Conclusion ADR in screening colonoscopies is not increased by the use of PS compared to CS. While the use of propofol-based anesthesia is clearly associated with increased patient satisfaction and pain levels, the ADR is not enhanced, and its widespread use in screening colonoscopy sedation should still be investigated.

In immunocompromised patients, histoplasmosis may present as disseminated disease. We present a 52-year-old Caucasian male with symptoms of dyspepsia, postprandial epigastric pain, nausea, and nonbloody diarrhea. Upper and lower gastrointestinal endoscopies were suspicious for inflammatory bowel disease (IBD); however, biopsies were consistent with histoplasmosis, specifically in the duodenum.

Question: A 55-year-old African American man with a medical history of chronic pancreatitis, pancreatic mass, alcohol abuse, hypertriglyceridemia, gastroesophageal reflux disease, and essential hypertension presented to the emergency department with severe abdominal pain radiating to his back that was associated with diaphoresis and weight loss. The initial workup demonstrated acute pancreatitis. Prior radiologic studies were reviewed to better characterize the pancreatic mass. More recent computed tomography and MRI scans demonstrated an enlarging, cystic and septated mass within the pancreatic head with marked dilatation of the patient’s pancreatic, and intrahepatic and extrahepatic biliary ducts (MRI; Figure A). Additionally, there was evidence of peripancreatic fat infiltration and multiple enlarged peripancreatic lymph nodes. Ultrasonography had also shown that the mass was displacing the patient’s duodenum.

SIMI 2015 A 27-year-old man, with no pertinent past medical history, presented with a 3-week history of severe nausea, vomiting, diarrhea, and abdominal pain. The pain was nonspecific and described as bloating. Associated symptoms included subjective fever and flatulence. The patient worked as a truck driver, traveling often, who had recently transported a shipment of river mulch. His mother was recently diagnosed with colon cancer and grandmother with lymphoma. The patient was afebrile, normotensive, and mildly tachycardiac on arrival. No cough, chest pain, alcohol use, weight change, sick contacts, or bleeding was reported. Physical examination revealed diffuse abdominal tenderness without peritoneal signs. Complete blood count showed a leukocytosis at 17.4 9 10 3 /lL. Folate, B12, and

Several studies have described celiac disease patients presenting with esophageal symptoms. We present the case of a 33-year-old Caucasian woman who presented with three months of strictly dysphagia to solids. She reported no weight loss, abdominal pain, or diarrhea and reported no heartburn symptoms. Labs revealed a tissue transglutaminase IgA of >100 units. Biopsies revealed moderate to severe villous blunting and increased intraepithelial lymphocytosis consistent with Marsh 3 celiac disease in the 2nd and 3rd portions of the duodenum. To the best of our knowledge, this case represents the first reported case of dysphagia as initial and sole presentation of celiac disease completely resolved by gluten-free diet.

Background Barrett's oesophagus is the primary risk factor for oesophageal adenocarcinoma; erosive oesophagitis is considered an intermediate step with Barrett's oesophagus development potential upon healing. Barrett's oesophagus occurs in 9–19% following erosive oesophagitis but minimal data exists in African Americans. The study aim was to determine if ethnicity is associated with Barrett's oesophagus formation following erosive oesophagitis. Methods Retrospective review of endoscopies from September 2007 to December 2012 was performed. Inclusion criteria were erosive oesophagitis on index endoscopy, repeat endoscopy ≥6 weeks later and non-Hispanic white or African American ethnicity. Barrett's oesophagus frequency following erosive oesophagitis by ethnicity was compared. Results A total of 14,303 patients underwent endoscopy during the study period; 1636 had erosive oesophagitis. Repeat endoscopy was performed on 125 non-Hispanic white or African American patients ≥6 weeks from the index procedure. Barrett's oesophagus occurred in 8% of non-Hispanic whites while no African American developed it on repeat endoscopy following erosive oesophagitis (p = 0.029). No significant difference was seen between ethnic groups in any clinical parameter assessed. Conclusions African American ethnicity appears to result in decreased Barrett's oesophagus formation following erosive oesophagitis. Further investigation to demonstrate factors resulting in decreased Barrett's oesophagus formation among African Americans should be performed.

53-year-old Caucasian woman presented withcomplaints of abdominal pain, constipation,pyrosis, and occasional red blood in her stool for 6months’ duration. The abdominal pain was burning innature, worse with eating, and radiated from her chest toher back. Physical examination was unremarkable anddid not show any pigmentation of the skin or the eyes.Hemoglobin and hematocrit levels on admission were14.3 g/dL and 43.1%, respectively. Colonoscopy showedinternal hemorrhoids and a bi-lobed rectal polypmeasuring 1.5 cm, which was snared and retrieved(Figures A and B). Immunohistochemical analysis wasstrongly positive for S-100, melan A, HMB-45, and nega-tive for chromogranin, which is most consistent with thediagnosis of malignant melanoma (Figure C).After the skin and retina, anorectal malignant mela-noma is the third most common location of melanoma.Anorectal melanomas make up less than 3% of all mel-anomas, and less than 1% of all malignant tumors of theanorectum are melanoma.

Question: A 74-year-old Caucasian woman with a history of persistent hemorrhoids presented with painless intermittent hematochezia per rectum of 6 months’ duration. A thorough physical and digital rectal examination were unremarkable. Laboratory analysis on admission included hemoglobin of 9.9 g/dL and hematocrit of 30.3%. Previous colonoscopy 5 years before admission showed a tubular adenoma. She became symptomatically anemic and underwent a colonoscopy, showing a large rectal fungating mass extending between 10 and 15 cm in length, occupying >50% of the colon circumference (colonoscopy; Figure A, B). Biopsy and subsequent immunohistochemical (IHC) analysis of the rectal mass was completed (IHC analysis; Figure C). What is the most likely diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.