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Cholesterol crystal embolism can be spontaneous or iatrogenic, and it can involve any organ of the gastrointestinal tract, presenting with common gastrointestinal symptoms such as bleeding, perforation, obstruction, and inflammation. It is therefore considered the "great masquerader," requiring a high level of suspicion because the condition is associated with increased morbidity and mortality. We present a 69-year-old man who presented with gastrointestinal bleeding and azotemia. He was found to have cholesterol crystal embolization in the kidney and a duodenal leiomyoma, the latter being an uncommon site to embolize.

Pneumobilia, or air within the biliary tree, is a poor prognostic indicator in a patient without prior biliary sphincterotomy. Differential diagnosis includes infection with gas-forming organisms, choledochoenteric fistula in the setting of gallstones or penetrating ulcer disease, malignant invasion from a primary liver or biliary tract tumor, or metastatic disease. Treatment depends on etiology and patient factors, but often requires surgical intervention. We report a patient with gastrointestinal bleeding in whom pneumobilia was incidentally noted on abdominal plain film. Computed tomography and endoscopy revealed the biliary-enteric fistula to be caused by metastatic colon adenocarcinoma invading the biliary tree.

Graft-versus-host disease (GVHD) in recipients of autologous stem cell transplantation (SCT) is less common compared to recipients of allogeneic SCT, but its existence has been well documented. Similarly, the diarrheal component of the disease is highlighted when discussing its gastrointestinal (GI) manifestations, with less emphasis given to upper GI symptoms like nausea and vomiting. We present a case illustrating the upper GI tract signs and symptoms of GVHD after autologous SCT, and emphasize that prompt treatment can rapidly improve morbidity and prevent disease progression.

AIM: To define which segments of the gastrointestinal tract are most likely to yield angioectasias for ablative therapy. METHODS: A retrospective chart review was performed for patients treated in the Louisiana State University Health Sciences Center Gastroenterology clinics between the dates of July 1, 2007 and October 1, 2010. The selection of cases for review was initiated by use of our electronic medical record to identify all patients with a diagnosis of angioectasia, angiodysplasia, or arteriovenous malformation. Of these cases, chart reviews identified patients who had a complete evaluation of their gastrointestinal tract as defined by at least one upper endoscopy, colonoscopy and small bowel capsule endoscopy within the past three years. Patients without evidence of overt gastrointestinal bleeding or iron deficiency anemia associated with intestinal angioectasias were classified as asymptomatic and excluded from this analysis. Thirty-five patients with confirmed, bleeding intestinal angioectasias who had undergone complete endoscopic evaluation of the gastrointestinal tract were included in the final analysis. RESULTS: A total of 127 cases were reviewed. Sixty-six were excluded during subsequent screening due to lack of complete small bowel evaluation and/or lack of documentation of overt bleeding or iron deficiency anemia. The 61 remaining cases were carefully examined with independent review of endoscopic images as well as complete capsule endoscopy videos. This analysis excluded 26 additional cases due to insufficient records/images for review, incomplete capsule examination, poor capsule visualization or lack of confirmation of typical angioectasias by the principal investigator on independent review. Thirty-five cases met criteria for final analysis. All study patients were age 50 years or older and 13 patients (37.1%) had chronic kidney disease stage 3 or higher. Twenty of 35 patients were taking aspirin (81 mg or 325 mg), clopidogrel, and/or warfarin, with 8/20 on combination therapy. The number and location of angioectasis was documented for each case. Lesions were then classified into the following segments of the gastrointestinal tract: esophagus, stomach, duodenum, jejunum, ileum, right colon and left colon. The location of lesions within the small bowel observed by capsule endoscopy was generally defined by percentage of total small bowel transit time with times of 0%-9%, 10%-39%, and 40%-100% corresponding to the duodenum, jejunum and ileum, respectively. Independent review of complete capsule studies allowed for deviation from this guideline if capsule passage was delayed in one or more segments. In addition, the location and number of angioectasias observed in the small bowel was further modified or confirmed by subsequent device-assisted enteroscopy (DAE) performed in the 83% of cases. In our study population, angioectasias were most commonly found in the jejunum (80%) followed by the duodenum (51%), stomach (22.8%), and right colon (11.4%). Only two patients were found to have angioectasias in the ileum (5.7%). Twenty-one patients (60%) had angioectasias in more than one location. CONCLUSION: Patients being considered for endoscopic ablation of symptomatic angioectasias should undergo push enteroscopy or anterograde DAE and re-inspection of the right colon.