Gastrointestinal (GI) bleeding represents one of the most frequently encountered clinical case scenarios in the emergency department. In the United States, the annual rate of hospitalization for any type of GI hemorrhage accounts for 300/100,000 population, with more than 1,000,000 hospitalizations each year and an approximately mortality rate of 5%. Upper GI bleeding (UGIB) is more common than lower GI bleeding (LGIB), yet there are many sites and multiple lesions from which bleeding could occur and the source could remain unidentified after upper endoscopy or colonoscopy evaluation. The uncertain etiology of GI hemorrhage is traditionally defined as obscure GI bleeding (OGIB) and constitutes a diagnostic challenge, so accurate investigations are crucial. Even if the mainstay of initial evaluation consists of upper endoscopy, colonoscopy or contrast X-ray studies, current guidelines suggest that video capsule endoscopy, push enteroscopy, angiography and radionuclide imaging are best suited, allowing an appropriate examination of the entire small bowel, which represents the most common source of OGIB. Hence, the aim of this review is to provide a multimodal investigation approach and to highlight the most adequate imaging technique according to the leading cause of OGIB.

Introduction. Morphea is a rare dermatological disease with no known cause, characterized by persistent inflammation, collagen deposition, fibrosis, and atrophy, as well as a considerable reduction in quality of life. Case presentation. An 89-year-old female patient, with a history of arterial hypertension, right mastectomy, and radiation therapy for breast cancer 10 years before, presented for the appearance of two erythematous plaques in the right submammary groove and right flank. The plaques are well-defined, with irregular margins, and have dimensions of 10/5 cm, and 13/8 cm respectively, were infiltrated, with areas of skin retraction and visible capillary network, itchy and painful. They were observed six months before presentation, as a single hyperpigmented lesion that gradually evolved into its current appearance and was treated as a subcutaneous hematoma, without resolution. Laboratory tests showed a nonspecific inflammatory syndrome and an increase in antinuclear antibodies. By corroborating the clinical and paraclinical data, the diagnosis of plaque morphea was made, and the systemic treatment with Penicillin G 2mil IU/12h, 311nm UVB phototherapy was initiated, with favorable evolution. At the subsequent hospitalization, after noticing the increase in the size of the plaques, with their extension to the left hemiabdomen, it was decided to start treatment with Methotrexate 7.5 mg/week, with a favorable evolution and the disappearance of fibrous bands. Conclusions. Although radiotherapy may be the trigger factor of morphea, the time until the onset of the disease (9 years) is consistent with the data presented in the literature (9.4 years).

Inflammatory bowel diseases (IBD) are chronic inflammatory diseases with increasing prevalence in elderly patients. Multiple comorbidities associated with polypharmacy are to be considered in such patients and impose some limitations in the diagnosis and treatment of IBD. This literature minireview has the purpose of highlighting the particularities of the diagnosis and treatment of IBD in elderly patients. Frailty and sarcopenia are key findings in the geriatric population and need careful consideration and proper therapeutic approach when constructing the diagnosis protocol and treatment regimen in elderly patients with IBD. Considering that the treatment options for IBD in elderly patients are quite extensive, adherence to treatment is expected to be attained. Diagnosing this pathology in the elderly patients’ group poses a great responsibility in weighing the risks and benefits of the procedures, as well as costs of hospitalization and comorbidities that can impede a timely diagnosis.

Kounis syndrome is a ubiquitous condition, representing a natural paradigm between coronary artery vasospasm, plaque rupture and anaphylactoid reactions. Kounis syndrome is underdiagnosed, as the inflammatory cells releases, in both allergic and non-allergic acute coronary syndrome, are the same. The syndrome is induced by various causes such as drugs, foods, environmental exposure, stents. There are three variants of Kounis syndrome: vasospastic allergic angina, allergic myocardial infarction, and stent thrombosis. All patients with systemic allergic manifestations correlated with clinical, laboratory and electrocardiography findings of acute myocardial infarction must be investigated for Kounis syndrome. The therapeutic management of Kounis syndrome represents a challenge, as it is necessary to treat both the cardiac and allergic events. After the acute event, a complete cardiological follow-up is mandatory, skin tests, verification of allergies to food, insect stings, drugs and environment agents. The awareness of etiology, epidemiology, pathogenesis, signs and symptoms is important for its diagnosis, treatment, prognosis and prevention.

Introduction. Prostate cancer is currently the second most frequent malignancy in males with nearly 1.4 million new cases every year. Hematuria, hemospermia, discomfort in the hypogastrium, urinary incontinence and incomplete evacuation of the bladder are some of the non-specific symptoms it associates. Acute kidney injury is a rapidly progressive form of renal dysfunction, most frequently associated with serum nitrogen by-product retention, electrolyte disturbances, a decreased total urinary output and numerous and diverse ethiologies. Case presentation. An 83-year-old male witsh severral preexisting cardiovascular and gastrointestinal disorders presented to the emergency department for hypogastric pain with no specific irradiation or apparent relation with meals or body posture. The blood tests revealed metabolic acidosis, leukocytosis, moderate anemia, and nitrogen by-products retention and Abdominal ultrasound confirmed an enlarged, prostate and a series of simple renal and hepatic cysts. antibiotic treatment and hydro-electrolytic rebalancing therapy were initiated but, as the clinical evolution was declining, the patient underwent a computed tomography (CT) scan that revealed ureterohydronephrosis, a large periaortic adenopathic block and a severe circumferential thickening of the colonic wall. After rulling out colorectal neoplasia the patient was transferred to the surgery department, where a bilateral double-J stent was placed, and a prostate biopsy was performed. The prostate biopsy result was that of a poorly differentiated acinar adenocarcinoma with a Gleason score of 9 (4 + 5) and the patient was discharged approximately four days after surgery and referred to the urology department for treatment. The peculiarity of this case is the concomitant presence of a parietal circumferential thickening located in the recto-sigmoid and a significant abdominal lymphadenopathy. Large abdominal adenopathy is some of the most atypical prostate cancer presentations. Conclusion. Acute kidney injury is a rapidly evolving syndrome that needs a complete evaluation and close follow-up for a correct diagnosis.