Chronic liver disease in infancy is uncommon, diagnostically demanding, and rarely reported from sub-Saharan Africa, where advanced hepatologic evaluation is seldom accessible. We describe a one-year-old boy from rural Somaliland who presented with a two-week history of progressive abdominal distension, followed by jaundice, hematemesis and bloody diarrhea. Examination showed wasting, deep scleral icterus, tense ascites, caput medusae and splenomegaly. Investigations demonstrated severe anemia (hemoglobin 3.8 g/dL), thrombocytopenia (130 × 109/L), conjugated hyperbilirubinemia (total 2.45 mg/dL, direct 1.69 mg/dL), severe hypoalbuminemia (albumin 1.8 g/dL) and marked coagulopathy (INR 3.0). Grayscale ultrasonography showed an irregular hepatic surface, splenomegaly and large-volume ascites. Doppler ultrasonography, upper gastrointestinal endoscopy, liver biopsy, elastography, cytomegalovirus IgM and polymerase chain reaction testing, and metabolic and genetic studies were unavailable, and an isolated positive cytomegalovirus IgG was considered inconclusive. A clinical diagnosis of decompensated chronic liver disease with suspected portal hypertension was therefore made without an established etiology. Whole blood transfusion, intravenous albumin, vitamin K, sodium restriction and combined spironolactone and furosemide produced short-term improvement, with a 4 cm reduction in abdominal girth, a rise in hemoglobin to 8.3 g/dL and cessation of bleeding. This case shows that a defensible syndromic diagnosis and effective stabilization are achievable without advanced testing, and supports adoption of a defined minimum diagnostic dataset-fractionated bilirubin, gamma-glutamyl transferase, coagulation profile, albumin, hepatitis serology, diagnostic paracentesis and grayscale ultrasonography-for infants with suspected chronic liver disease in low-resource settings.

Anti-neutrophil cytoplasmic antibody-associated vasculitis (AAV) presenting with predominant gastrointestinal (GI) symptoms in the absence of overt respiratory or renal involvement is rare. We present a young man with recurrent ocular and oral symptoms who presented to us in the second week of moderately severe acute pancreatitis (AP) with upper GI bleeding and was diagnosed with probable AAV based on serology and biopsy findings after excluding alternative diagnoses. He responded well to immunosuppressive therapy with resolution of AP and GI bleed. This case highlights the necessity of a high index of suspicion for vasculitis in unexplained AP and/or GI bleed and actively pursuing it by serology and biopsy to improve outcomes.

Coffee-ground emesis in a patient with cirrhosis frequently triggers an emergency pathway for suspected variceal upper gastrointestinal bleeding (UGIB) and urgent endoscopy. However, diagnostic anchoring may delay recognition of alternative life-threatening conditions. A 68-year-old man with decompensated liver cirrhosis (Child-Pugh B), large-volume ascites, COPD GOLD grade 3 with chronic global respiratory failure developed shock and recurrent vomiting of coffee-ground material and fresh blood on a gastroenterology ward. Variceal bleeding was initially suspected. After transfer to ICU, he deteriorated with severe hypoxaemia and progressive ventilatory compromise. A markedly tense, distended abdomen prompted point-of-care ultrasound (POCUS), which demonstrated extensive pneumoperitoneum. Emergency percutaneous decompression via a standard paracentesis needle evacuated free intraperitoneal air under tension with rapid respiratory improvement. Urgent oesophagogastroduodenoscopy showed no evidence of upper gastrointestinal perforation or variceal bleeding. Computed tomography confirmed diffuse pneumoperitoneum and suggested pathology at the ileocaecal transition; surgery revealed perforation of the ascending colon with localized peritonitis. This case highlights the importance of whole-patient reassessment before emergency endoscopy, early use of POCUS when abdominal findings are discordant, and interdisciplinary crisis management. Needle decompression can be lifesaving as a bridge to definitive surgery in tension pneumoperitoneum.

A man in his 20s presented with progressive fatigue and melena, with a history of recurrent epistaxis since adolescence and a positive family history. Evaluation revealed severe iron-deficiency anaemia (haemoglobin 27 g/L) with persistently positive faecal occult blood. Upper gastrointestinal endoscopy demonstrated multiple bleeding telangiectasias in the stomach and duodenum. Cross-sectional imaging of abdomen, thorax and brain identified multisystem arteriovenous malformations involving the liver, lung and brain. Despite repeated argon plasma coagulation and thalidomide therapy, bleeding persisted with ongoing transfusion dependence. Treatment with intravenous bevacizumab and subcutaneous octreotide stabilised haemoglobin and resolved occult gastrointestinal bleeding. A clinical diagnosis of hereditary haemorrhagic telangiectasia was established using Curaçao criteria despite negative genetic testing. This case highlights the importance of recognising hereditary haemorrhagic telangiectasia in unexplained severe anaemia and supports the role of anti-angiogenic therapy in refractory gastrointestinal bleeding.

Iron deficiency anemia (IDA) is common in older adults, and gastrointestinal bleeding is an important cause that should be investigated. However, identifying the bleeding source can be challenging when upper and lower gastrointestinal endoscopy findings are negative. We report the case of a 90-year-old woman who presented with anorexia, general fatigue, and dizziness and was found to have severe IDA with a hemoglobin level of 3.9 g/dL. Upper and lower gastrointestinal endoscopy failed to identify the bleeding source. Although her anemia initially improved after blood transfusion and iron supplementation, it recurred, requiring readmission. Double-balloon enteroscopy (DBE) revealed a submucosal tumor with ulceration in the ileum, and surgical resection confirmed an ileal gastrointestinal stromal tumor (GIST). Retrospective review of contrast-enhanced computed tomography (CT) images also identified the corresponding small bowel lesion. This case highlights the importance of considering small bowel lesions in patients with recurrent IDA despite negative findings on upper and lower gastrointestinal endoscopy. It also highlights the value of retrospectively reviewing existing CT images, which may reveal overlooked lesions. Our findings suggest that additional evaluation of the small bowel should be considered in patients with recurrent IDA regardless of advanced age.