bluuebunny/crossref_metadata_2025 huggingface dataset:
2671 Sparing the Knife: A Case of Emphysematous Gastritis Managed Conservatively
Authors: Randhawa Tejinder , Attar Bashar M. , Omar Yazan Abu , Vohra Ishaan , Flores Estefania , Agrawal Rohit
Published: October 2019

INTRODUCTION:

Emphysematous gastritis (EG) is a rare and obscure disease that carries a high mortality rate, whilst posing a diagnostic challenge. EG is caused by gas forming bacteria invading the gastric wall through disruptions in the mucosal barrier. Diagnosis is made with abdominal computed tomography (CT) scan demonstrating gas in the gastric wall. Traditionally EG has been managed surgically with partial gastrectomy, however recent case based studies support the role of conservative medical management in treating this aggressive disease. Here we present a case of non-surgically managed emphysematous gastritis.

CASE DESCRIPTION/METHODS:

A 28-year-old male with a history of uncontrolled type 1 diabetes mellitus (Hemoglobin A1c: 14.70) presented with a three-day history of diarrhea, melena, and orthostatic dizziness. Earlier that week the patient had been diagnosed with diabetic and initiated on metoclopramide. Despite stopping metoclopramide, the patient's diarrhea continued. Upper and lower endoscopy was performed and was largely unremarkable. The patient was discharged on erythromycin. The patient returned to the ED the following morning after developing severe abdominal pain. The physical examination revealed a soft abdomen with diffuse tenderness to palpation. Abdominal CT scan demonstrated emphysematous gastritis. Treatment was initiated with aztreonam, clindamycin, vancomycin, levofloxacin, and caspofungin. Within twenty-four hours, the patient improved clinically and repeat abdominal CT scan demonstrated significant improvement in gastric wall emphysema. After five days of broad-spectrum antibiotics the patient had complete resolution of abdominal pain.

DISCUSSION:

EG is a rare condition caused by gastric wall invading bacteria. Recently there has been a drastic shift in the preferred management strategy for this deadly condition that carries a mortality rate as high as 60%. A retrospective review demonstrated that prior to the year 2000 62.5% of patients with EG underwent surgical management, after 2000 this percentage dropped to 22.2%. In deciding on appropriate regimens, it is important to have broad coverage for gram-negatives, anaerobes, and fungi. Despite the lethality of EG, our case contributes to the growing body of literature that suggests that with early diagnosis and initiation of broad spectrum antibiotics, patients can be spared operative management and have successful recovery.
2673 Acute Hemorrhagic Gastritis During Treatment With PD-1 Inhibitor Nivolumab for Stage IV Endometrial Cancer
Authors: Chong Michelle , Singh Simi
Published: October 2019

INTRODUCTION:

PD-1 inhibitors block immune checkpoints and activate the immune system. They show benefit in treating many advanced cancers, but are also associated with various immune-related adverse effects, including inflammatory diseases of the gastrointestinal (GI) tract. We present a rare side effect of hemorrhagic gastritis.

CASE DESCRIPTION/METHODS:

A 53-year-old woman with Lynch syndrome and metastatic endometrial cancer presented to our office after two weeks of epigastric abdominal pain associated with nausea and vomiting. Her primary care provider had prescribed pantoprazole and ondansetron and obtained an abdominal ultrasound, which was normal. She had been treated with nivolumab for stage IV endometrial cancer for the preceding three years, and had no evidence of disease after two years of treatment. Sucralfate was prescribed, and an upper endoscopy was scheduled. This showed white plaques in the esophagus and a severely hyperemic stomach with friable mucosa. Stomach biopsies revealed diffusely eroded gastric mucosa with marked acute and chronic inflammation, crypt abscesses, and increased intraepithelial lymphocytes with crypt degeneration and dropout. Esophageal biopsies showed mildly reactive squamous mucosa with scattered intraepithelial lymphocytes and rare eosinophils. Stains for fungal organisms, CMV, HSV, EBV, and H. pylori were negative. Nivolumab-induced acute hemorrhagic gastritis was suspected. After two weeks of prednisone 1 mg/kg daily, her symptoms did not improve. The dose was increased to 2 mg/kg and her symptoms significantly improved within one week. She was then slowly tapered off prednisone without recurrence of her symptoms at three month follow-up. She continues off nivolumab with no plans to resume further treatment by her oncologist.

DISCUSSION:

Immune checkpoint inhibitors are novel anti-cancer agents with increasingly widespread applications. They are associated with immune-mediated adverse effects, including inflammation of the GI tract. The diagnosis is made through pathologic and endoscopic features in the appropriate clinical context. Standard treatment is prednisone starting at 1 mg/kg, which can be increased to 2 mg/kg, and the immune checkpoint inhibitor should be discontinued. Infliximab may be considered if the disease does not respond to initial therapy. As immune checkpoint inhibitors become more common, it will be important to consider hemorrhagic gastritis in patients on such a medication who present with acute epigastric pain, nausea, and vomiting.
2682 The Evolution and Cure of Multifocal Gastric Cancer
Authors: Debesai Meron , Mikityanskiy Yevgeniy , Bernstein Michael
Published: October 2019

INTRODUCTION:

Gastric cancer incidence and mortality has continued to steadily decline but remains the second leading cause of cancer death worldwide. Predominantly, gastric cancers are known to arise from a single lesion whereas gastric cancer arising from multiple lesions is uncommon. We present a case of a 67 year-old female who was initially found with gastritis in the antrum that evolved into a multifocal gastric cancer within 1 year.

CASE DESCRIPTION/METHODS:

The patient was a 67 year-old female who was first seen in Hepatology clinic for chronic hepatitis C with early fibrosis. After successful treatment, she underwent upper endoscopy for non-specific gastric symptoms. EGD showed gastritis in the antrum and biopsy revealed intestinal metaplasia and H-Pylori was negative so repeat endoscopy was recommended in a year. Upon returning for repeat endoscopy, evaluation revealed a small antral erosion and a raised area of erythematous mucosa in the fundus. Unexpectedly, biopsies revealed extensive intestinal metaplasia and high-grade dysplasia in both lesions. The patient was immediately referred to an academic center for upper endoscopic ultrasound and mucosal resection. Both studies were unremarkable, so the patient returned to our facility and underwent upper chromo-endoscopy. By this time, the antral erosion had markedly increased in size and became an ulcer with circumferential induration and staining centrally with methylene blue. There was also methylene blue uptake in two other erosions within the fundus. Repeat biopsy of the ulcers now showed nascent well-differentiated adenocarcinoma associated with high-grade dysplasia. Whole body computerized tomography showed no evidence of metastasis so patient underwent total gastrectomy. Surgical pathology revealed multiple foci of intestinal type gastric adenocarcinoma in the background of high-grade dysplasia and intestinal metaplasia. All lymph nodes and margins were negative.

DISCUSSION:

There have been less than 50 cases of multifocal gastric cancer reported in the literature with even fewer cured by total gastrectomy. Upper gastrointestinal endoscopy remains the gold standard for diagnosing gastric lesions. Generally, surveillance isn’t recommended for findings of intestinal metaplasia. However, our case serves to highlight the importance of diligent endoscopic surveillance and tissue sampling, even if findings convey low suspicion. Our patient was successfully cured of multifocal gastric cancer, a disease that usually carries a very poor prognosis.
2683 Gastric Metastasis From Renal Cell Carcinoma: A Case Report
Authors: Nasir Umair M. , Ahmed Ahmed , Panchal Dayna , Rodgers Brandon , Patel Kalpesh , Lenza Christopher
Published: October 2019

INTRODUCTION:

Renal cell carcinoma (RCC) is the most common renal malignancy in adults and possesses extensive metastatic potential. At the time of diagnosis, over 30% of cases have metastatic lesions and a 10% risk of developing metastatic disease after 5 years. The most commonly involved sites for metastasis include regional lymph nodes and distant organs such as the lungs, liver, and brain. In very rare cases, it can spread to gastrointestinal tract.

CASE DESCRIPTION/METHODS:

The patient is a 74 year old male found to have a 5 cm right kidney mass while undergoing workup for uncontrolled HTN. Histology and workup after radical resection confirmed clear cell carcinoma limited to the right kidney. Follow up CT a year after diagnosis revealed bilateral adrenal gland nodules. Biopsy of which was consistent with metastatic renal cell carcinoma at which point chemotherapy was started. Restaging two years thereafter and multiple follow up surveillance CT scans revealed no evidence of disease progression. Nine years after the original diagnosis, patient was admitted for hypotension and anemia. EGD done in evaluation of anemia, revealed multiple gastric submucosal polyps, biopsy of which revealed metastatic renal cell carcinoma. Immunostaining with PAX-8 and renal tumor markers were positive further proving RCC as the primary carcinoma. At this point the patient was restarted on chemotherapy and discharged with close follow up.

DISCUSSION:

Within the gastrointestinal tract, metastasis of RCC to the stomach is the rarest, at a rate of <0.2%. The process by which tumor cells migrate from the primary site to distant organs and the predilection to metastasize to specific organ systems is not well understood. In the rare instance that RCC metastasizes to the stomach, it most frequently presents as a polypoid submucosal protruding mass leading to gastrointestinal bleeding and symptomatic to anemia . The optimal treatment for RCC remains controversial and the utility of resection on mortality remains unclear. In our patient, the period from radical resection to detection of metastatic gastric lesions was over nine years. At the time of resection, the lesion was confined to the left kidney only as per staging imaging obtained. This raises many questions: how can metastatic lesions present after the resection of a tumor with no invasion of the kidney capsule? How can these new lesions appear almost a decade later? And finally, how effective is resection of primary RCC tumor in regards to preventing metastasis?
2684 Gastric Sarcoidosis
Authors: Naseer Usman , Mansoor Muhammad Sohail , Wazir Ali , Arslan Mustafa Erdem , Chung Jae , Ells Peter F. , Fitzpatrick Michael
Published: October 2019

INTRODUCTION:

Sarcoidosis is a systemic inflammatory disease of unclear etiology. It can involve almost any organ in the body, with pulmonary involvement being the most common. Gastrointestinal (GI) involvement is rare (0.1- 0.9% of all cases) with symptomatic gastric sarcoid, even more rare (with a handful of cases reported in the literature). We present a case of a patient who developed symptomatic gastric sarcoidosis.

CASE DESCRIPTION/METHODS:

A 48-year old African American male was seen in the GI clinic for a 5-year history of diffuse intermittent abdominal pain. The patient had a known diagnosis of severe sarcoidosis diagnosed 10 years ago. He had multiple organs effected including lungs (Restrictive disease on PFTs), liver (bridging fibrosis with hyalinized nodular sclerosis on the biopsy) and skin involvement (resulting in chronic pruritus treated with Plaquenil). The patient also had a history of H.pylori with multiple small clean-based ulcers in the gastric corpus and erythematous duodenopathy diagnosed on esophagogastroduodenoscopy (EGD) 11 years ago. Following that he completed the triple antibiotic regimen. The patient for the last four months reported severe periumbilical pain with several ED visits. He underwent 3 colonoscopies over the course of the last 5 years, which were unremarkable. EGD was repeated, which showed multiple nonbleeding duodenal ulcers with gastric biopsy showing non-caseating granulomas. His H.Pylori stain was negative on this occasion. At this time a diagnosis of gastric sarcoidosis was made. The patient was placed on a proton pump inhibitor with an escalation in the dose of his systemic steroids resulting in resolution of his symptoms.

DISCUSSION:

Most cases of gastric sarcoidosis are initially asymptomatic. The most commonly reported symptom is epigastric pain. Other symptoms include nausea, vomiting, hematemesis, melena, and weight loss. Due to the non-specific nature of these reported symptoms, making the diagnosis purely on clinical history is difficult, and a high index of suspicion is needed to make the diagnosis. Endoscopically it can present with ulceration or a diffuse linitis plastica like the involvement of stomach. Pathology is key to diagnosis and shows non- caseating granulomas. Asymptomatic patients do not require treatment though for symptomatic patients recommended treatment is a combination of proton pump inhibitors with systemic steroids. Marvin A. Chinitz et al. reported symptom improvement in 66% of gastric sarcoid patients with systemic steroids.
2685 Gastric Volvulus: A Forgotten Cause of Hematemesis
Authors: Remouns Julian , Alexandre Cassidy , Mansoor Muhammad Sohail , Parsa Nour , Baharith Harith
Published: October 2019

INTRODUCTION:

Gastric Volvulus, a pathologic torsion of the stomach, is a diagnosis that is often difficult given the rarity of the condition and nonspecific symptoms on initial presentation. Borchardt’s triad (sudden constant abdominal pain, retching with little vomitus and inability to completely pass a nasogastric tube) has been reported in many documented cases. Imaging studies often lack specificity. Here we present a rare case of hematemesis due to gastric volvulus.

CASE DESCRIPTION/METHODS:

An 85-year-old female with PE on apixaban, paroxysmal Afib presented with recent episodes of hematemesis. She initially had few episodes of non-bilious non-bloody emesis with nausea attributed to viral gastroenteritis with self-improvement. On the day prior to admission, she underwent a nuclear stress test after which nausea recurred followed by abdominal pain and coffee-ground emesis. She denied angina, SOB, fevers, chills, constipation, melena or hematochezia. In addition to apixaban, she took aspirin for CAD. She had no prior history of GI bleeding or abdominal surgeries. She was mildly tachycardic and hypertensive, but abdominal exam was unremarkable. CMP revealed hypokalemia of 2.6 mEq/L. CBC and lactic acid were normal. Abdominal ultrasound of RUQ revealed cholelithiasis without evidence of acute cholecystitis. Abdominal X-ray showed no abnormalities. Differential included PUD, gastritis and AVM so an EGD was performed. EGD revealed red blood in the entirety of the esophagus, diffuse severe mucosal changes characterized by black eschar in the middle and lower thirds of the esophagus and gastric fundus, a large paraesophageal hernia, gastric volvulus and mild gastritis in the body and antrum. Patient was subsequently treated with conservative medical management as she declined surgical intervention.

DISCUSSION:

Our patient presented with nonspecific signs and symptoms of gastric volvulus. Due to the rarity of the condition and the patient’s increased risk factors for other diagnoses on the differential, gastric volvulus was not expected. It was through endoscopy that we discovered not only the volvulus itself, but also a large paraesophageal herniation, which are known to have high associations with organoaxial volvulus-twisting about the longitudinal axis. Gastric volvulus is a surgical emergency due to a high morbidity and mortality. This case is an example of the insidious effects of gastric volvulus and demonstrates that clinical suspicion is hindered without familiarity of this condition.
2689 Gastric Volvulus: A Difficult Situation of Diagnosis and Management
Authors: Palamaru Andreea Luiza , Toader Elena
Published: October 2019

INTRODUCTION:

Gastric volvulus is a rare entity defined as an abnormal rotation of the stomach around its short or long axis leading to variable degrees of gastric inlet and outlet obstruction. Organoaxial and mesentericoaxial volvulus are distinguished according to the direction of rotation. A rotation of more than 180 degrees can cause strangulation, necrosis and finally perforation.

CASE DESCRIPTION/METHODS:

We present the case of a 43-year-old female that complained of severe abdominal pain, nausea and vomiting for 2 days after eating a large meal. She did not have any flatus or bowel movements in the last 48 hours. On admission in our clinic, biological findings included an inflammatory syndrome, an anaemic syndrome and hypokalaemia. The radiology images highlighted a high air-fluid level in the chest and the ultrasound examination showed a significant stomach fluid distension. The upper digestive endoscopy revealed multiple ulcerated lesions and stasis fluid at the gastric angle, a point from which exploration could no longer be continued. Computed tomography (CT) of the abdomen and pelvis showed a dilatation of the stomach and the displacement of the antrum above the gastroesophageal junction; the stomach appeared upside-down with the antrum and pylorus superior to the fundus and proximal body. Based on clinical manifestations, biological results, radiograph images, ultrasounds, upper endoscopy and CT scan, the patient was diagnosed with high occlusion via congenital organo-axial volvulus. Initial management was nasogastric decompression to decrease the intragastric pressure. The patient was transferred to the Surgery Department, where he underwent a laparotomy which confirmed an organoaxial volvulus at the level of the antrum and body of the stomach. Gastropexy was implemented and the stomach fixed to the posterior abdominal wall to prevent recurrence. Postoperative recovery was uneventful and the patient returned to his rehabilitation facility on the fourth post-operative day.

DISCUSSION:

We present this case because it is an uncommon life-threatening disease. Given its rarity and unusual presentation, the clinical index of suspicion is always low. Diagnosis of gastric volvulus is challenging due to the non-specificity of the symptoms and rarity of the condition. Early diagnosis and treatment will reduce the risk of developing chronic gastric volvulus to acute gastric volvulus.
2691 Quadruple Therapy: A Cure for Gastric High Grade B-Cell Lymphoma?
Authors: Jessamy Kegan , Ozden Nuri , Antoine Marsha , Tambe Vikrant
Published: October 2019

INTRODUCTION:

H. pylori contributes to approximately 75 % of stomach cancers internationally. Gastric MALT lymphoma is a rare disease with an incidence of 0.38 per 100,000 people in the United States of America (USA). The majority of gastric MALT lymphoma cases are cured with H pylori eradication therapy while chemotherapy is the mainstay of treatment for gastric diffuse large B-cell lymphoma (DLBCL). Gastric high grade DLBCL is rare and there is limited data in which treatment with H pylori eradication can attain complete remission. We present a case of a woman with DLBCL and was treated for H pylori and attained complete remission.

CASE DESCRIPTION/METHODS:

A 59 year old woman presented to our clinic for evaluation of epigastric pain for 2 months. A trial of Prior proton pump inhibitor (PPI) treatment did not improve her pain. Abdominal CT imaging was significant only for diverticulosis. Esophagogastroduodenoscopy (EGD) showed a 25 mm non-bleeding cratered gastric ulcer with pigmented material at the incisura of the stomach. Incisiural biopsies revealed high grade B cell lymphoma and antral/body biopsies showed H pylori. PET CT imaging showed diffuse fluorodeoxyglucose uptake along the lesser curvature of the stomach corresponding to the known area of lymphoma. There was no evidence of metastatic disease. The patient declined chemotherapy due to fear of associated side effects. Instead, she was given H pylori quadruple therapy with a 14 day course of Pantoprazole, Bismuth subsalicylate, Metronidazole, and Tetracycline. Repeat EGD with endoscopic ultrasound at 1 and 4 months later were unremarkable and biopsies at the site of the healed ulcer were negative for neoplasia. To date, she remains asymptomatic.

DISCUSSION:

To date, there is no established standard management strategy for primary gastric lymphoma. Major guidelines recommend chemotherapy as the initial treatment for DLBCL. The efficacy of HP eradication for gastric pure DLBCL has mostly remained unknown, with limited data available. Despite histological remission, lymphoma recurrence is possible. Given the limited data available, long term, careful follow-up should be done for all patients if they are treated with antibiotics for DLBCL.
2692 Dunbar Syndrome: A Rare Cause of Abdominal Pain
Authors: Ali Farhan , Steimle Cassandra , Reddy Dayakar , Kelts Andrew , Jeng Jennifer , Kochik Michael , Golikov Edwin , Raborn Eric
Published: October 2019

INTRODUCTION:

Dunbar Syndrome, also known as median arcuate ligament syndrome (MALS), is a rare condition with a reported incidence of 2 per 100,000. It is characterized by an extrinsic compression of the celiac trunk, and should be considered when evaluating patients with abdominal pain of unknown etiology.

CASE DESCRIPTION/METHODS:

A 78 year old female presented with a complaint of epigastric discomfort that was post-prandial in nature, with associated weakness and early satiety. Her symptoms had been persistent for one year. Workup prior to her presentation included a normal nuclear medicine (NM) gastric emptying scan and normal NM hepatobiliary scan with CCK. A detailed history revealed that her pain was particularly worse after eating and was associated with early satiety. Laboratory results on admission were unremarkable. Contrast-enhanced CT scan of the abdomen and pelvis showed external compression and indentation of the superior aspect of the proximal celiac axis with post-stenotic dilation. Further diagnostic evaluation utilized end-inspiratory phase CT angiography of the abdomen, which showed an approximately 1 cm length segment of proximal celiac arterial narrowing, measuring 70% maximally at its origin. She was diagnosed with MALS after review of the CTA reconstructive images which showed moderate external compression of the celiac artery.

DISCUSSION:

MALS predominantly affects women between the ages of 30 and 50 and is marked by the hallmark feature of postprandial abdominal pain. Other signs and symptoms may include nausea, vomiting, and consequent weight loss from an inability to tolerate oral intake. Symptoms are thought to have both a vascular (mesenteric ischemia) as well as neurogenic component (somatic pain thought to originate from the splanchnic plexus). CT angiography and conventional angiography are considered to be gold standard imaging modalities for Dunbar syndrome. They demonstrate focal stenosis that has a characteristic hooked appearance due to the indentation of the celiac trunk on its superior surface. Imaging for an accurate diagnosis should ideally be performed during the end-inspiratory phase, as indentation of the celiac trunk may be seen normally during expiration. Additional imaging features may include post-stenotic dilation, prominent collateral vessels, and thickening of the median arcuate ligament. Treatment includes endovascular transluminal angioplasty and stent placement, as well as laparoscopic division of the arcuate ligament and resection of the celiac plexus.
2695 Pedunculated Polyp at the Pyloric Channel Causing Intermittent Gastric Outlet Obstruction
Authors: Rezaie Aida , Ahmed Shifat , Mann Saba , Abidali Hussein
Published: October 2019

INTRODUCTION:

Gastric outlet obstruction (GOO) is the intrinsic or extrinsic obstruction of the pyloric channel or duodenum. The most common cause remains to be peptic ulcer disease which results in inflammation, edema or fibrosis. GOO typically presents with epigastric abdominal pain and postprandial vomiting. While the incidence of GOO is unclear, it has declined since the identification of Helicobacter pylori, H2-receptor antagonists and endoscopic therapy. We present a case of a benign polyp obstructing the pyloric channel.

CASE DESCRIPTION/METHODS:

39 year-old female with a history of pulmonary embolism on Eliquis, Diabetes mellitus type 2 who presents for several months of epigastric pain, nausea and intractable vomiting. Prior to arrival, she had endoscopic evaluation at an outside hospital showing evidence of 1.5 cm gastric polyp in the pyloric channel. At the time, the polyp was not excised due to the patient being on anticoagulation. On admission, she underwent CT angiography showing no evidence of clot. She subsequently underwent repeat endoscopic evaluation demonstrating a 15 mm non-bleeding, pedunculated polyp at the pyloric channel obstructing the pyloric opening. The polyp was resected with hot snare. Biopsy showed a hyperplastic gastric polyp negative for malignancy. To prevent bleeding post-intervention, two hemostatic clips were placed. The patients abdominal pain, nausea and vomiting nearly resolved one day after her procedure.

DISCUSSION:

While the incidence of GOO has declined, it should continue to be considered in patient’s presenting with recurrent epigastric abdominal pain. Recent reviews estimate that, contrary to earlier years, 50 to 80% of cases have been attributable to malignancy such as pancreatic adenocarcinoma and distal gastric cancer. CT scan may show gastric distension or retained material within the gastric lumen. However, identifying the obstruction with upper endoscopy establishes the diagnosis. Treatment should be aimed at the underlying cause.
2697 Gastrointestinal Stromal Tumor Mimicking a Small Lymphocytic Lymphoma
Authors: Garcia-Rodriguez Victor , Coronel Emmanuel
Published: October 2019

INTRODUCTION:

Gastrointestinal stromal tumors (GIST) have been associated with synchronous or metachronous secondary malignancies in up to 43% cases. The occurrence between GIST and hematological malignancies is approximately 7%. Here, we present a case of a GIST mimicking Small Lymphocytic Lymphoma (SLL).

CASE DESCRIPTION/METHODS:

A 70-year-old male presented with a one-month history of bilateral axillary lymphadenopathy. Physical exam revealed a conglomerate of lymph nodes of both axillary regions. CT of the chest-abdomen-pelvis showed diffuse axillary, mesenteric, retroperitoneal and inguinal lymphadenopathy. In addition, it showed a 40 mm mass in the lesser curvature of the stomach (Figure 1). FNA of the axillary region showed findings consistent with SLL. Upper endoscopy showed a large subepithelial mass in the stomach (Figure 2). Biopsies were taken with cold forceps showing reactive white blood cells, this was suspected to be lymphoma. The patient was diagnosed with Stage IV SLL and started on Ibrutinib. Three months after therapy was started, CT revealed significantly improved on adenopathy but an increase in the size of the gastric mass. A repeat upper endoscopy with endoscopic ultrasound (EUS) showed a hypoechoic, heterogeneous round mass with well-defined borders, originating from muscularis propria layer (Figure 3). Fine needle biopsy (FNB) was performed and showed clusters of neoplastic cells, positive for CD117 and DOG1, negative for CK7, CK20, and CDX2, consistent with a GIST.

DISCUSSION:

Little is known about the coexistence of GIST and other metachronous tumors of different anatomic location. Several theories have been proposed to explain this link. These theories include pro-oncogenic changes in the tissue microenvironment, carcinogenic effect by chemotherapy and desmoid-type fibromatosis after trauma or surgery. When located in the stomach, GISTs most commonly present as subepithelial lesions. Since mucosal biopsies have a false negative rate of almost 50%, additional evaluation with EUS and EUS guided tissue acquisition is of essential importance. Obtaining core samples by FNB is useful for tissue architecture evaluation and immunohistochemistry assessment of the sample. In this particular case, EUS was not performed initially; instead, mucosal biopsies were obtained leading to a false negative result. This case highlights the rare association between GISTs and other malignancies, as well as, the importance of EUS for the evaluation and accurate diagnosis of different subepithelial lesions.
2702 Tumor Lysis Syndrome in a Patient With Gastric Adenocarcinoma
Authors: Lingamaneni Prasanth , Desai Parth M. , Mathew Madhu , Moturi Krishna Rekha , Gupta Shweta
Published: October 2019

INTRODUCTION:

Tumor lysis syndrome (TLS), considered a hematologic emergency, is uncommonly seen with solid tumors. TLS is most often seen in the context of aggressive lymphomas, where cell turnover is high. We present a case of tumor lysis syndrome in a patient with gastric adenocarcinoma, as a complication of FOLFOX (5-fluorouracil, leucovorin, oxaliplatin) chemotherapy.

CASE DESCRIPTION/METHODS:

48-year-old male with metastatic gastric adenocarcinoma (Figure 1), who received his first cycle of FOLFOX 4 days prior, presented to the emergency department with slurred speech and altered mental status. Vitals at presentation were normal. Systemic examination was remarkable for agitation and disorientation to time, place and person. He had no focal neurologic deficits and rest of the exam was unremarkable. CT scan of the head and EEG were unrevealing. Laboratory analysis was significant for an elevated creatinine, phosphorus and uric acid (Table 1 day 5). The pattern of electrolyte abnormalities and their development after recent chemotherapy was consistent with a diagnosis of chemotherapy-induced laboratory and clinical TLS. Patient was managed with aggressive IV fluids and rasburicase, following which, the electrolyte abnormalities resolved, and he improved clinically back to baseline.

DISCUSSION:

Tumor lysis syndrome occurs when tumor cells release their contents into the bloodstream, either spontaneously or in response to therapy, leading to hyperuricemia, hyperkalemia, hyperphosphatemia, and hypocalcemia. Complications include renal insufficiency, cardiac arrhythmias, seizures and death. Rapidly proliferating tumors like high-grade lymphomas and acute leukemias are predisposed to TLS. TLS occurs infrequently with solid tumors. TLS-associated mortality rate, with solid tumors, is around 35%; higher than that with hematologic malignancies. This is likely explained because prophylactic measures are implemented more often in hematological malignancies and less often in solid tumors. Our patient fulfilled the Cairo-Bishop criteria for grade II TLS. To our knowledge, there have been only nine cases of TLS secondary to gastric adenocarcinoma published in the literature. We present the first case of FOLFOX-induced TLS in a patient with gastric adenocarcinoma. This case highlights the importance of early recognition of TLS in patients with gastric cancer. Initiation of early treatment can reduce the high morbidity and mortality associated with this condition.
2711 A Rare Cause of Hematemesis: Metastatic Prostate Cancer to the Stomach
Authors: Then Eric O. , Lopez Michell , Ofosu Andrew , Chaudhri Ali , Culliford Andrea , Gaduputi Vinaya
Published: October 2019

INTRODUCTION:

Prostate cancer is a malignancy that constitutes the third most common type of cancer in males. Present day its mortality rate is decreasing with better screening in the form of prostate specific antigen (PSA). The most common site of metastasis is the bone. Rarely will this form of malignancy metastasize to the gastrointestinal tract. Here we present a rare case of advanced prostate cancer with gastric metastasis.

CASE DESCRIPTION/METHODS:

Patient is an 81 year old male with a medical history of hypertension and prostate cancer (on anti-androgen therapy) who presented to our emergency department with altered mental status, aphasia, and left sided hemiparesis. Given his poor neurologic status and inability to maintain oxygenation the patient was intubated. Notable imaging included a computed tomography (CT) scan of the brain showing findings consistent with acute infarct of the left middle cerebral artery. Notable laboratory workup included a hemoglobin 7.8 gm/dL. Physical exam was notable for a cachectic male with left sided weakness in the left upper extremity and left lower extremity. He was then admitted to the intensive care unit (ICU) where he was noted to have an acute drop in hemoglobin to 5.0 gm/dL with coffee ground emesis. An esophagogastroduodenoscopy (EGD) was then performed which showed a large infiltrative, ulcerated, friable mass lesion with contact oozing in the gastric body along the greater curvature which was biopsied. The pathology results of the biopsy specimen returned with positive staining to prostate specific antigen (PSA) consistent with metastatic prostatic adenocarcinoma in the gastric mucosa. During his hospital course at our facility, the patient's condition worsened and his family decided to withdraw care. The patient then underwent palliative extubation and expired peacefully.

DISCUSSION:

There are multiple primary malignancies that have the potential for metastasis to the stomach. Of these, the most common cancers include those of the lung, breast, kidney, esophagus and finally, cancers of the head and neck. Rarely will prostate cancer present with gastric metastasis. Symptoms of metastatic lesions to the stomach mimic those of primary gastric cancers and include abdominal pain, nausea, vomiting and hematemesis. Treatment of metastatic prostate cancer is best managed with androgen deprivation therapy. If this fails, alternate treatment options include chemotherapy or immunotherapy with androgen receptor antagonists or androgen synthesis inhibitors.
2712 Pyloric Crohn's Disease: A Rare Presentation of Gastric Outlet Obstruction
Authors: Then Eric O. , Are Vijay S. , Ofosu Andrew , Chaudhri Ali , Culliford Andrea , Gaduputi Vinaya
Published: October 2019

INTRODUCTION:

Crohn’s disease is an inflammatory bowel disease that may present anywhere along the gastrointestinal tract, spanning from the esophagus to the large intestine. The majority of cases of Crohn’s disease are located in the colon and small intestine, constituting approximately 70% of cases. Rarely will Crohns disease present in the stomach. Here we present a rare case of gastric outlet obstruction secondary to Crohn’s disease of the stomach.

CASE DESCRIPTION/METHODS:

Patient is a 53 year old female with a medical history of Crohn’s disease who presented to the emergency department complaining of epigastric abdominal pain, nausea and yellow vomiting for three days. Notable laboratory workup included a complete blood count and comprehensive metabolic panel within normal limits. Notable imaging included a computed tomography of the abdomen with contrast which showed a dilated stomach suggestive of gastric outlet obstruction. This was followed by a barium swallow which showed a dilated stomach, delayed gastric emptying, and inflammatory changes in the pyloric channel. An upper esophagogastroduodenoscopy was then done which showed diffuse edematous, ulcerated mucosa in the antrum with pyloric narrowing. Biopsies were taken of this area which showed extensive surface erosion and fresh granulation tissue with transmural chronic inflammation. The option for repeat EGD with balloon dilation or surgical intervention were discussed with the patient, but she opted for conservative measures. This consisted of total parenteral nutrition and treatment with intravenous high dose steroids (Solumedrol 60 mg IV). During her course the patient slowly improved was able to tolerate oral intake. She was then discharged with oral steroids and follow up appointments.

DISCUSSION:

Crohn’s disease of the stomach is rare occurrence. The first case of gastric crohns disease was reported in 1949. Since then current data suggests that a mere 0.5 to 4% of all Crohns disease cases present with gastric involvement. Diagnosis of gastric crohns disease can be accomplished through biopsy. This would show classic transmural inflammation, which was consistent with the biopsy findings in our patient. Symptoms of gastric Crohn’s disease are varied and can include symptoms of gastric outlet obstruction if the pylorus is involved. This includes nausea, post-prandial vomiting, abdominal pain and bloating. These cases have been successfully treated with endoscopic balloon dilation, Adalimumab, and surgical resection in more severe cases.
2713 Ulcerated Gastric Leiomyoma: A Rare Cause of Gastric Outlet Obstruction
Authors: Then Eric O. , Deda Xheni , Ofosu Andrew , Maddika Srikanth , Chaudhri Ali , Gaduputi Vinaya
Published: October 2019

INTRODUCTION:

True leiomyomas are rare tumors that can be found anywhere along the gastrointestinal tract, more commonly in the esophagus, stomach and colon. These tumors are usually asymptomatic but may present with abdominal pain and gastrointestinal bleeding. Here, we present a rare case of a gastric leiomyoma resulting in gastric outlet obstruction.

CASE DESCRIPTION/METHODS:

The patient is a 52-year-old male with a past medical history of Asthma, Heroin abuse, and Peptic ulcer disease who presented to the emergency department complaining of epigastric abdominal pain accompanied by non-bloody vomiting. Notable laboratory workup included a Hemoglobin of 10.3 gm/dL. Notable imaging included a computed tomography (CT) scan of the abdomen without contrast which showed large volume gastric debris suggestive of gastric outlet obstruction. This was followed by small bowel series which showed loculated barium within the stomach with no barium seen within the pylorus. Gastroenterology service was then consulted to perform an upper esophagogastroduodenoscopy. This was done and showed severe luminal distortion of the pylorus making intubation of the duodenum difficult. This was accompanied by a large, unhealed 3 cm deep cratered ulcer just beneath the incisura. Biopsies were taken which returned showing histology consistent with gastric leiomyoma. This diagnosis was supported by diffuse positive staining with SMA and desmin and negative staining with c-kit and DOG1 immunostaining. During his admission a nasogastric tube was unable to be placed due to the level of obstruction in the pylorus. He was then started on total parenteral nutrition to meet her dietary needs. The patient was then discharged home on TPN but was lost to follow up thereafter.

DISCUSSION:

Gastric leiomyomas represent approximately 2.5% of all gastric neoplasms and are mostly encountered in patients aged 50-70 years with no gender predilection. Most gastric leiomyomas are slow-growing and asymptomatic; therefore, they are usually found incidentally on EGD, surgical exploration, or at autopsy. Rarely will gastric leiomyomas result in gastric outlet obstruction. The gold standard for diagnosis is biopsy which will show spindle cells that display smooth muscle differentiation and stain positively to desmin and actin. Submucosal leiomyomas less than 3 cm may be followed up by periodic EGD or endoscopic ultrasound. Lesions greated than 3 cm however may require surgical or endoscopic excision to rule out malignancy.
2714 Famotidine-Induced Hypomagnesemia Leading to Hypocalcemia
Authors: Essrani Rajesh , Mehmood Asif , Kirshan Ravi Shri Jai
Published: October 2019

INTRODUCTION:

Famotidine is a long-acting histamine H2 receptor antagonist that is indicated for the treatment of gastroesophageal reflux disease (GERD), peptic ulcer disease and Zollinger- Ellison syndrome. It is considered to have an excellent safety profile with only a few side effects like constipation, diarrhea, and headache. We present a case of famotidine induced hypomagnesemia and functional hypoparathyroidism causing hypocalcemia.

CASE DESCRIPTION/METHODS:

A 55-year-old female with a past medical history of GERD was admitted to hospital due to increased lethargy, confusion, and muscle cramps for last 15 days. These muscle cramps affected functions of her hands and legs, causing multiple falls. She was taking famotidine 20 mg twice a day for the last two years. Her vital signs were stable. On exam, alert and oriented 2x, dry skin, positive Chvostek’s and Trousseau's sign. Initial blood work showed sodium 141 mmol/L, BUN 13 mg/dL, creatinine 0.7 mg/dL, calcium 5.7 mg/dL, magnesium 0.55 mg/dL, phosphorus 3.4 mg/dL. She was treated with multiple doses of intravenous (IV) 2 g magnesium sulfate and 1 g of calcium gluconate. Further work showed low PTH but normal PTHrP, vitamin D (25) and vitamin D (1,25). Her calcium and magnesium level normalized with IV therapy, so she was discharged home on oral electrolyte supplements. She followed up with her family doctor with a repeat blood work and noted to have very low calcium and magnesium so admitted to hospital. Extensive workup including 24 hours urine calcium and magnesium was unimpressive. She was treated with IV therapy and discharged to follow up with nephrology in the clinic with a repeat blood work. Her famotidine was discontinued on discharge. Her calcium and magnesium level remained normal, and few weeks later, oral electrolyte supplements were discontinued.

DISCUSSION:

This is the first reported case of famotidine induced hypomagnesemia and functional hypoparathyroidism causing hypocalcemia. Famotidine might cause impaired absorption of magnesium, leading to hypomagnesemia and functional hypoparathyroidism. Patients being started on a H2 receptor antagonist for the long-term course should have a baseline serum calcium and magnesium level and periodic monitoring as well. The optimal timing for monitoring levels is unknown, but annual monitoring (sooner if the patient develops symptoms) may be reasonable. Long-term use of famotidine should be considered in the differential diagnosis for hypomagnesemia and hypocalcemia.
2715 A Hiatal Hernia Causing Atrial Fibrillation Through Direct Mechanical Irritation
Authors: Sourial Kirolus , Yaqoob Zaid , Chahin Anthony , Borgan Saif , Gonzaga Ernesto Robalino , Javaid Aamir
Published: October 2019

INTRODUCTION:

Hiatal hernia (HH) is anatomically classified into four types according to herniated structures. Giant HH refers to a herniation of >50% of the stomach. Atrial fibrillation (AF) is a common arrhythmia, frequently seen in association with cardiovascular diseases. We report a case of AF caused by a giant HH compressing the left atrium.

CASE DESCRIPTION/METHODS:

A 90+ year-old female with a past medical history of gastroesophageal reflux disease (GERD), was admitted for surgical evaluation of symptomatic HH. During hospital stay the patient developed AF with rapid ventricular response, became hypotensive and lightheaded. EKG (Figure 1) confirmed new onset AF with non-specific ST-T wave changes. Sinus rhythm conversion was achieved by amiodarone drip. Metabolic and endocrine causes of the AF were ruled out. Ischemic etiology of the AF was ruled out by a normal myocardial perfusion imaging study. Computed tomography Angiography of the chest (Figure 2) was only remarkable for persistent giant hiatal hernia. Echocardiogram (Figure 3) showed external material compressing against the heart and the left atrium. At that point, the patient and the surgical team have decided on conservative management for her HH due to her high surgical risk. Patient was discharged home in sinus rhythm on oral anticoagulant and beta blocking agent.

DISCUSSION:

Gastroesophageal reflux disease (GERD), HH and AF are often seen in association. AF in GERD patients is likely due to local cytokine release from esophageal injury or vagal overstimulation. Such association is supported by reduced AF recurrences by reflux suppression with PPI use or fundoplication. However, the underlying mechanism of AF in HH patients has not been fully understood. In our case, left atrial compression and impingement were seen, which indicates direct left atrial irritation causing atrial arrhythmia. Surgical reconstitution of HH to relieve the cardiac compression would be the definitive treatment. Unfortunately, our patient was not a candidate for such invasive thoracic surgery due to her age. A similar case scenario was previously reported, in which AF was suppressed after laparoscopic surgical repair of a giant paraesophageal hernia. More cases need to be studied to confirm the hypothesized etiology of AF in patients with giant HH.
2722 Thinking With the Gut: An Unfortunate Case of Metastatic Gastric Cancer
Authors: Hussaini Zeba , Amer Kamal , Asif Bilal , Tofani Christina
Published: October 2019

INTRODUCTION:

Metastatic brain tumors represent 20-40% of intracranial neoplasms [Table 1]. Although rare, the incidence of brain metastasis from the gastrointestinal (GI) tract has increased likely secondary to prolonged survival of patients with GI cancers. Symptoms of metastatic spread parallels space-occupying lesions in brain: confusion, headache, visual disturbances, nausea, vomiting, altered mental status, gait abnormalities, seizures, and decreased consciousness. Current literature estimates 0.63% of gastric adenocarcinoma (GA) cases metastasize to the brain1. Here, we present an unusual case of metastatic brain spread of GA.

CASE DESCRIPTION/METHODS:

59-year-old male with history of hypertension, tobacco use, GERD, and gastric cancer who presented with a one-week history of headaches, nausea and vomiting, and decreased visual acuity. His gastric cancer had previously been treated with neoadjuvant chemotherapy, radiation and partial esophagectomy with repeat screening via computed tomography (CT). A CT of his head showed vasogenic edema in the right frontal lobe, raising concern for metastatic disease versus primary CNS lesion [Figure 1]. A magnetic resonance imaging (MRI) brain showed an enhancing mass in the anterior-inferior right frontal lobe with metastatic disease as well as leptomeningeal carcinomatosis [Figure 2]. He underwent right frontal burr-hole for stereotactic biopsy of the right frontal tumor. Pathology was consistent with metastatic adenocarcinoma. He was started on IV steroids and began whole brain radiation therapy. He was not a surgical candidate and was unstable for chemotherapy. His family transitioned him to comfort care measures after which he shortly passed.

DISCUSSION:

Gastric cancer is the fourth most common cancer worldwide and the second most common cause of cancer-related death. Current literature estimates GA incidence rate to be 6.7/100,000 persons with a mortality rate of 3.4/100,000 persons in the United States. Risk factors include H. pylori, male sex, Asian/Pacific island ethnicity, obesity, smoking, and a diet rich in smoked, salted, pickled foods. Our patient demonstrated an unusual case of metastatic GA without evidence of visceral metastases. His case was further complicated as he had screening CT scans at six month intervals which had been within normal limits until his presentation. His case unfortunately demonstrates the ominous prognosis of patients with brain metastasis, prompting the need for increased surveillance and brain imaging.