A 35-year-old woman presented to the gastroenterology clinic for evaluation of dull abdominal pain. The abdominal pain started insidiously 2 years previous, was intermittent in nature, and located in the epigastric and left lower quadrant. The patient also complained of concomitant diarrhea, flatulence, and bloating. She denied melena, hematochezia, nausea, vomiting, fevers, chills, or weight loss. She had an upper endoscopy and colonoscopy 2 years earlier with no significant findings. She had a medical history notable for type 1 diabetes mellitus and a previous benign bladder tumor with unknown pathology that was surgically resected. She was born and raised in the United States and had lived in multiple cities within the United States. Her only travel outside of the United States had been during her childhood on vacation to the Bahamas, the Cayman Islands, and Mexico. She denied any wading or swimming in any freshwater source outside of the United States. She denied any cigarette smoking, alcohol use, or illicit drug use.\nHer abdominal examination revealed no distention, no scars, normal bowel sounds, no tenderness, no organomegaly, and normal tympani. The rest of her physical examination was unremarkable. Her laboratory testing was within normal limits. Abdominal ultrasound was performed at a later time due to abdominal pain showed a 9-mm indeterminate hepatic lesion. Abdominal magnetic resonance with and without contrast showed multiple hyperenhancing liver lesions. The hepatic lesions were biopsied. It revealed non-necrotizing granulomas composed of multinucleated giant cells and cuffs of lymphocytes; moderate hepatic steatosis was present.\nUpper endoscopy was performed to reveal a 40-mm pedunculated polyp with no bleeding in the second part of the duodenum; this was resected (Figure ). The esophagus and stomach were normal. Colonoscopy revealed a 6-mm sessile polyp in the sigmoid colon; this was resected. Pathology from the duodenal polyp revealed adenomatous changes arising in a hamartomatous polyp (Peutz-Jeghers type); there was also the presence of parasite organisms present in the crypts of the polyp consistent with schistosomiasis with tissue eosinophilia (Figure ). Pathology of the colon polyp revealed hyperplastic changes. The patient was diagnosed with a hamartomatous duodenal polyp due to Schistosoma mansoni. The patient was referred to infectious disease. She was prescribed praziquantel 20 mg/kg/dose 3 times per day for 1 day. The patient followed up with gastroenterology after treatment with praziquantel. Her diarrhea had resolved, but she continued to have intermittent left lower quadrant abdominal pain, attributed to irritable bowel syndrome. Repeat endoscopy showed no evidence of duodenal hamartomatous polyp.
A 67-year-old woman from the Philippines with a medical history of psoriatic arthritis, hypertension, osteoporosis, and resected left-sided invasive ductal carcinoma of the breast presented with complaints of chronic lower abdominal discomfort associated with constipation alternating with diarrhea for a year, along with decreased appetite and 20 lbs. weight loss. She denied fever, bright red blood per rectum, or melena. She migrated to the United States from the Philippines in 1998. She never had a colonoscopy in the past. Her family history was negative for cancer. Vital signs and physical examination were unremarkable. Laboratory tests were noncontributory other than normocytic anemia with hemoglobin of 11.6 g per deciliter, no eosinophilia.\nSubsequent colonoscopy revealed a malignant appearing obstructing mass in the distal sigmoid, around 20 cm from the entry site (Figure ). Biopsies from the mass revealed fragments of adenocarcinoma. Pelvic computed tomography (CT) revealed bladder wall thickening (Figure ). Thoracic and abdominal CT revealed no distant metastasis. She underwent successful anterior pelvic exenteration, sigmoid resection with primary anastomosis, and ileal conduit creation for sigmoid cancer invading the bladder. Surgical pathology showed invasive, moderately differentiated adenocarcinoma in the sigmoid colon and numerous Schistosoma eggs in the colon, ovaries, posterior cul de sac, and pelvic wall (Figure ). Along with surgical treatment, the patient was treated with praziquantel (60 mg/kg/d in 2 divided doses). Stool microscopic examination after 4 weeks of treatment was negative for ova and parasites.