Message in a bottle: decoding medication injury patterns in the gastrointestinal tract

Abdominal Abscess as a Rare Manifestation of Gout

Gout is a common inflammatory arthritis in adults. Elevated levels of uric acid lead to the formation of monosodium urate crystals and their deposition in joints, and rarely, other parts of the body. The tissues most frequently involved are synovium, bone, cartilage, skin, tendon, ligament, and kidney. Here, we report an unusual presentation of gout manifesting as an abdominal abscess. A 60-year-old man with a history of opioid abuse, hypertension, and knee gouty arthritis presented to the emergency department with severe right knee pain. During hospitalization, he complained of pain in the left lower abdominal quadrant and developed coffee-ground emesis. Computed tomography showed pneumoperitoneum. The patient underwent laparotomy and was found to have gastric perforation and a large abdominal abscess. Drainage of the abscess revealed necrotic and hemorrhagic fragments of omentum. Microscopic examination showed adipose tissue with fat necrosis, acute inflammation, and fungal hyphae. Eosinophilic, amorphous deposits of polarizable needle-shaped crystals were observed in all sections, indicating the presence of monosodium urate crystals. The combined characteristics suggested intra-abdominal gout with concurrent fungal infection resulting from gastric perforation. This presentation is very rare. Only one occurrence of intra-abdominal gout mimicking a pelvic abscess has been reported in the literature.

Sodium Polystyrene Sulfonate-Induced Massive Bowel Necrosis With Distant Extraintestinal Crystal Deposition: A Case Report and Review of the Literature

Sodium polystyrene sulfonate (SPS), a cation-exchange resin, has been a mainstay in long-term hyperkalemia management but is associated with significant gastrointestinal complications, particularly when used with sorbitol. The deposition of SPS crystals within the intestinal mucosa has been suggested to precipitate ischemia, necrosis, and ulcerations, ultimately leading to bowel perforation. This case report details a striking instance of massive bowel perforation subsequent to SPS administration, with accompanying findings of disseminated crystals in distant organs and tissues upon autopsy. Additionally, we provide a comprehensive review of the existing literature on this rare yet significant drug-induced side effect.

"Stranger things" in the gut: uncommon items in gastrointestinal specimens

Organic (such as parasites or vegetable remnants) and inorganic substances may be encountered during routine pathology diagnostic work up of endoscopic gastrointestinal biopsy samples and major resections, causing possible diagnostic conundrums for the young and not so young pathologists. The main aim of this review is the description of the most frequent oddities one can encounter as foreign bodies, in gastrointestinal pathology, on the basis of the current literature and personal experience. The types of encountered substances are divided into four principal categories: parasites (helminths such as Enterobius vermicularis, Strongyloides, Schistosoma, and Anisakis, and protozoa such as Entamoeba, Giardia and some intestinal coccidia); drugs and pharmaceutical fillers (found as deposits and as bystanders, innocent or not); seeds (possibly confused with worms) and plant remnants; pollutants (secondary to post-resection or post-biopsy contamination of the sample). An ample library of images is provided in order to consent easy referencing for diagnostic routine.

New Kids on the Block

CONTEXT.—

With the increasing development and use of iatrogenic agents, pathologists are encountering more novel foreign materials in retrieved gastrointestinal specimens. These colorful and unusual-appearing foreign materials can pose a diagnostic dilemma to those unaware of their morphology, especially if the relevant clinical history is lacking.

OBJECTIVE.—

To discuss the histopathologic features, clinical scenarios and significance, and differential diagnosis of relatively recently described, yet quickly expanding, family of iatrogenic agents that can present as foreign materials in gastrointestinal specimens-pharmaceutical fillers (crospovidone and microcrystalline cellulose), submucosal lifting agents (Eleview and ORISE), lanthanum carbonate, hydrophilic polymers, OsmoPrep, yttrium 90 microspheres (SIR-Sphere and TheraSphere), and resins (sodium polystyrene sulfonate, sevelamer, and bile acid sequestrants).

DATA SOURCES.—

We collate the findings of published literature, including recently published research papers, and authors' personal experiences from clinical sign-out and consult cases.

CONCLUSIONS.—

Correct identification of these iatrogenic agents is important because the presence of some novel agents can explain the histopathologic findings seen in the background specimen, and specific novel agents can serve as diagnostic clues to prompt the pathologist to consider other important and related diagnoses. Awareness of even biologically inert agents is important for accurate diagnosis and to avoid unnecessary and expensive diagnostic studies.

Challenges in Diagnosing Medication Resins in Surgical Pathology Specimens: A Crystal-Clear Review Guide

CONTEXT

- Medication resins, including Kayexalate, sevelamer, and bile acid sequestrants, can be encountered in gastrointestinal tract specimens. Their classic histologic appearances have been well documented, but pathologist recognition of the resins is 75%, patient history is not always available, and atypical morphologic findings are sometimes present.

OBJECTIVE

- To offer a succinct overview of resins in the gastrointestinal tract, including typical and atypical appearances, in order to serve as a quick reference guide.

DATA SOURCES

- The study comprises published literature, survey data, and our personal experiences.

CONCLUSIONS

- Classic morphology is the benchmark for identifying these resins, but color, location, and fish scale pattern can deviate from the norm, making proper identification a challenge. Patient history should be sought whenever possible, and ancillary staining is an option when necessary. Additionally, the presence of resins should prompt the pathologist to search for potentially related diagnoses (namely, causes of diarrhea in patients on bile acid sequestrants and diagnoses associated with renal failure in patients on Kayexalate or sevelamer).

Medication-associated gastrointestinal tract injury

Medication-associated gastrointestinal (GI) tract injury has been known for centuries for some medications. The more recently introduced biologicals are a class of drugs that constantly increases, and as such, the spectrum of GI tract side effects is steadily growing. This review covers not only long-known GI tract side effects of drugs but also those more recently described. A comprehensive but concise list of medications used in daily practice and associated with GI tract injury is presented.

Peculiar histiocytic lesions with massive lanthanum deposition in dialysis patients treated with lanthanum carbonate

Pathologic lesions caused by lanthanum carbonate (LC), a recently developed phosphate-binding agent, have not been recorded. A peculiar gastroduodenal histiocytic lesion associated with a mucosal lanthanum overload was reported. Our routine gastrointestinal biopsy series included 6 cases with heavy lanthanum burden in the gastroduodenal mucosa. In addition to routine histopathologic examinations, a series of immunohistochemical analysis and electron microscopic examinations associated with x-ray diffraction and elemental analysis were performed. Six cases, 3 of male and 3 of female individuals with ages from 59 to 69 years, were all patients of end-stage renal diseases managed under dialysis and treated with LC for >21 months. Endoscopic examinations demonstrated gastric erosions in 3, gastric polyps in 2, and duodenal ulcer in 1. In the mucosal layer, there were numerous non-Langerhans cell histiocytes, stained with CD68 but not S100 protein, engulfing a large amount of mineral-like materials. An electron microscopic and elemental analysis revealed a similar distribution of lanthanum and phosphorus in the histiocytes. Long-standing LC administration can cause massive mucosal accumulation of lanthanum in the tissue histiocytes associated with several forms of gastroduodenal lesions. A long-standing outcome is not clear at present; hence, careful follow-up studies of these patients may be needed.

Exposure to non-steroid anti-inflammatory drugs (NSAIDs) and suppressing hydrogen sulfide synthesis leads to altered structure and impaired function of the oesophagus and oesophagogastric junction

INTRODUCTION

The non-steroid anti-inflammatory drugs (NSAIDs) are among the drugs that can commonly cause injury in the esophagus, such as non-reflux oesophagitis, with important clinical consequences. This injury may be 'silent' and therefore often overlooked. Recently, we established that hydrogen sulfide (H2S) is a critical mediator of esophageal mucosal protection and repair. The aim of the study was to determine the effect of naproxen, the most commonly used NSAIDs, on the oesophagus and oesophagogastric junction and its relation with suppression or stimulation of endogenous H2S synthesis during naproxen-induced oesophageal injury.

METHODS

Rats were treated with vehicle (control) or naproxen, with or without being subjected to water immersion restricted stress (Takagi et al. Chem Pharm Bul 12:465-472, 1964). Subgroups of rats were pre-treated with an inhibitor of H2S synthesis cystathionine γ-lyase (CSE) or cystathionine β-synthase (CBS), or with the Sodium sulphide (NaHS), which spontaneously generates H2S in solution. Damage of the oesophageal mucosa and oesophagogastric junction was estimated and scored using a histological damage index.

RESULTS

Treatment with naproxen increased the thickness of the corneal and epithelial layers of the oesophagus, as well as producing disorganization of the muscle plate and irregular submucosal oedema. Both injury factors, stress and suppression of H2S synthesis resulted in the development of severe esophagitis and damage to the oesophagogastric junction. The damage was exacerbated by inhibitors of H2S biosynthesis, and attenuated by treatment with NaHS.

CONCLUSIONS

Inhibition of endogenous H2S synthesis provides a novel experimental model that can be useful in preclinical studies NSAID-related non-reflux oesophagitis. H2S contributes significantly to mucosal defence in the oesophagus.