bluuebunny/crossref_metadata_2025 huggingface dataset:
3039 Esophageal Ulcers: A Presenting Symptom of Acute HIV Infection
Authors: George Rollin , Ketwaroo Gyanprakash Avinash , Verstovsek Gordana
Published: October 2019

INTRODUCTION:

Dysphagia and odynophagia are commonly encountered in patients who are immunocompromised from chronic Human Immunodeficiency Virus (HIV) infection. Acute HIV infection can also cause odynophagia due to abrupt onset of oropharyngeal mucosal disease. We describe the eventual diagnosis of acute HIV infection in a patient presenting with dysphagia and odynophagia following endoscopic finding of esophageal ulceration.

CASE DESCRIPTION/METHODS:

A 43-year-old man presented with one week of epigastric pain, dysphagia, and odynophagia in the setting of recent fever (TMax 102.8F) and chills. He had intermittently taken a PPI following an emergency room visit the previous week. Oropharyngeal exam was negative for ulcers or thrush and abdominal exam was benign. Initial labs were normal aside from mild leukopenia (WBC 3,100/uL) with a low absolute neutrophil count. He underwent EGD showing several deep distal esophageal ulcers. Pathology showed acute esophagitis with mild to severe neutrophilic infiltrate and neutrophilic microabscesses. Staining of the ulcer biopsy specimens was negative for cytomegalovirus (CMV), herpes simplex virus (HSV) and fungal elements. The unknown etiology of his esophageal ulcers prompted testing for HIV. HIV immunoassay was positive however antibody differentiation was indeterminate. A subsequent HIV viral load was positive indicating acute HIV-1 infection. He was placed on anti-retroviral therapy soon after. A repeat EGD was performed three months later, demonstrating complete resolution of the previously seen ulcers.

DISCUSSION:

Presenting signs and symptoms of acute symptomatic HIV infection are nonspecific and the diagnosis is often missed or delayed. Esophageal ulceration may be underrecognized as an acute manifestation of illness. In one study of 16 men presenting with odynophagia who were eventually found to have acute HIV infection (HIV serology negative at presentation), all 16 were found to have esophageal ulceration during index endoscopy. Identification of viral particles resembling HIV-1 within ulcer biopsies with electron microscopy and isolation of HIV-1 from an ulcer biopsy specimen raise the possibility of direct viral infection of esophageal cells. With this in mind, endoscopists and gastroenterology providers should have a high index of suspicion for acute HIV infection in patients with odynophagia secondary to esophageal ulcer of unknown etiology.
3042 It's Appendagitis, Not Appendicitis!
Authors: Khan Zarak H. , Korpole Pranay R. , Jarodiya Vijay , Singh Tejveer , Wolok Ryan
Published: October 2019

INTRODUCTION:

Epiploic appendages are small peritoneal fat pouches located around the colon. There are no specific etiologic factors leading to EA. Because this disorder involves the sigmoid colon, descending colon, and cecum, symptoms often imitate diverticulitis and appendicitis. Although they are found spread all over the serosal surface of the colon, they are much more abundant and larger on the sigmoid and transverse colon walls. Two retrospective studies reported that men (70%) were affected more than women with an age range of 26 to 75 years.

CASE DESCRIPTION/METHODS:

66-year-old gentleman with past medical history of hypertension, type 2 diabetes mellitus and hyperlipidemia presented to the outpatient clinic with 1 day history of right lower quadrant pain. Pain was gradual in onset, 6/10 in intensity, throbbing in quality, non-radiating and associated with some nausea and four episodes of non-bloody vomiting. He denied fever, chills, back pain, bloating, hematochezia, constipation, diarrhea or heartburn. Lab work that was done was complete blood count, comprehensive metabolic panel, lipase, and urinalysis which showed a white blood cell count of 11,100 with 9,210 neutrophils but was otherwise unremarkable. CT scan of the abdomen and pelvis demonstrated epiploic appendagitis involving the sigmoid colon. Patient was advised to continue diet and over-the-counter painkillers as analgesia. Patient's symptoms resolved in the next 2 days and he was back to baseline.

DISCUSSION:

Epiploic appendagitis has been reported in 2-7% of patients with a presumed clinical diagnosis of acute diverticulitis and 0.3-1% of those suspected of having acute appendicitis. Owing to the nonspecific nature of presenting symptoms, physical signs, and laboratory findings, it is extremely difficult to make the correct diagnosis before radiological investigations. Therefore the vast majority of cases are detected incidentally on CT scans while ruling out other intra-abdominal pathologies. CT scan is the gold standard of diagnosis. Our case report is meant to shed light on the diagnosis and management of the condition. It requires only conservative management. Therefore physicians should keep in mind to avoid unnecessary hospitalizations, antibiotic use and surgical interventions. Nevertheless, more common and serious pathological conditions that necessitate urgent surgical or medical interventions should always be ruled out.
3044 Malignant Non-Hodgkin Lymphoma Presenting Only in the Sigmoid Colon as Suspicious Mass
Authors: Pacha Faris , Skrove Jamie L. , Mohan Karthik
Published: October 2019

INTRODUCTION:

Non-Hodgkin Lymphoma (NHL) is defined as a myriad of malignant neoplasms derived from B, T, Mature B, Mature T, and NK cells. The clinical presentation of NHL varies depending of the type and the areas of involvement. Most typical can be classified into aggressive and indolent. Aggressive present acutely with a rapidly growing mass and systemic B symptoms. These include diffuse large B cell lymphoma, Burkitt lymphoma, precursor B and T lymphoblastic leukemia,/lymphoma, and Adult T cell leukemia-lymphoma. Indolent lymphomas are more insidious in nature and are slower in growth. They demonstrate slow growing hepatomegaly, splenomegaly, or cytopenias. Examples of lymphomas that typically have indolent presentations include follicular lymphoma, chronic lymphocytic leukemia/small lymphocytic lymphoma, and splenic marginal zone lymphoma. Gastrointestinal Lymphoma presents with anorexia, weight loss, nausea and vomiting. Some patients can present with GI hemorrhage and early satiety along with the mentioned symptoms listed above.

CASE DESCRIPTION/METHODS:

Patient is a 52 year old Hispanic woman presented outpatient for several days of diarrhea and bright red blood in the bowl. Outpatient imaging with contrast showed a soft tissue density in the left lower quadrant demonstrating inflammatory changes. Patient had no family history of CRC, other CA's or hereditary disorders. Labs demonstrated microcytic anemia and Hgb of nine. The patient received a flexible sigmoidoscopy and “25 cm from the anal verge demonstrated a large abscess appearing mass in the sigmoid colon attributable to diverticulitis.” Antibiotics were administered followed by a colonoscopy in three months. Colonoscopy demonstrated “Abscess formation 25 cm from anal verge larger than previously noted on flexible sigmoidoscopy and multiple biopsies taken and sent to pathology.” Pathology revealed “monotonous atypical infiltrate with ulceration and necrosis highly suspicious for a malignant non-Hodkin Lymphoma.” The patient was then referred to oncology and oncological surgery.

DISCUSSION:

This case was chosen because cases in NHL are majority male (5 to1), found on the right side of the colon (70-75% in the cecum vs 1.2-5% in the Sigmoid colon), and have B-symptoms. In our patient she had no B-symptoms and the primary presentation was in the sigmoid colon. Also, the NHL to be intramural accounts for less than 4% of all extranodal NHL. Primary site for NHL in the colon accounts for less than 1% of all acute NHL.
3049 Mantle Cell Lymphoma in Routine Screening Colonoscopy
Authors: Vuong Stephanie , Sotiriadis John
Published: October 2019

INTRODUCTION:

The incidence of colorectal cancer has been on the rise in young and middle aged adults in the United States. While adenocarcinoma remains the most common type of colorectal cancer, lymphoma, particularly mantle cell lymphoma (MCL) is a rare type of lymphoma that can occur in those between the ages of 35-85. We present a case of MCL seen during routine colonoscopy.

CASE DESCRIPTION/METHODS:

A 51 year old male with recent diagnosis of MCL by oncology was referred to gastroenterology for a screening colonoscopy. During the procedure innumerable large polypoid lesions were visualized in the cecum and ascending colon with similar findings scattered throughout the colon. Biopsies taken from the ascending colon revealed dense atypical lymphoid proliferation with immunohistochemistry confirming MCL.

DISCUSSION:

MCL comprises about 7% of non-Hodgkin lymphomas. Extranodal manifestations of MCL occurs in 25% of those that are newly diagnosed, with GI involvement estimated to be 15-60%. At the time of diagnosis, most patients present in the advanced stages of MCL. It is associated with poor long term survival and high relapse rates. However, recent advances in potential new therapies for MCL have shown promise. Our case is unusual in that the typical signs of intestinal malaise (abdominal pain, diarrhea, anorexia, and hematochezia) and/or systemic B symptoms were not present. With remission rates being dismal, and treatment strategies based on patient fitness and symptoms, early detection is imperative. It is important to be cognizant to the complaints patients have as it may warrant earlier colonoscopy and therefore diagnosis of colorectal cancer.
3050 Case of Vanishing Colonic Mass
Authors: Davis Nathan , Goyal Abhinav , Govil Yogesh , Zavala Stacey
Published: October 2019

INTRODUCTION:

We present a case of left sided colonic mass as a finding of colonic ischemia.

CASE DESCRIPTION/METHODS:

A 58 year old female with a past medical history of multiple sclerosis (MS) requiring tracheostomy and gastrostomy tube, non-verbal at baseline, seizure disorder, and constipation presented to the emergency room for one day of maroon stools as reported by her caretaker. On arrival, the patient was on hemodynamically stable. Physical examination revealed a slightly distended, but non-tender and non-tense abdomen with intact PEG tube site. Maroon stool was present on rectal exam. Her labs revealed a hemoglobin of 10.1 g/dL, platelets 301 × 103/mcL, BUN 14 mg/dL, Creatinine 0.3 mg/dL, and lactic acid 0.87 mmol/L. Computed tomography of the abdomen showed distal colonic distension up to 7.9 cm, a large stool burden resulting in fecal impaction throughout the distal colon and an area of focal narrowing in the sigmoid colon. The patient was admitted and given four liters of polyethylene glycol, one bottle of magnesium citrate solution, and tap water enema for bowel preparation. She continued to have maroon stools with a decrease in hemoglobin from 11.1 g/dL to 9.1 g/dL. A diagnostic colonoscopy was then performed which could only be completed to the hepatic flexure due to redundant colon. Upon withdrawal, a 6 cm partially obstructing mass was noted in descending colon which was biopsied the colon proximal and distal to it was tattooed with carbon black. Pathology showed acute inflammatory cellular debris, fibrin and blood. Given the inconclusive biopsies, a flexible sigmoidoscopy was done two days after the colonoscopy. The previously seen mass was not visualized. The site had an ulcerated lesion with granular, erythematous mucosa. Biopsies were obtained from edges as well as center of this lesion. Histology revealed ulcerated colonic mucosa, granulomatous tissue, fibrin and acute inflammatory cellular debris raising the possibility of ischemia. The patient remained stable without further bleeding and was safely discharged to her nursing facility.

DISCUSSION:

We believe the initial mass like lesion was rather a large clot which subsequently got sloughed off permitting visualization of underlying mucosa. This is a very rare finding. A few case reports and case series have described cases of colonic ischemia presenting as masses but mostly in the right colon. We present the first case of this finding in the left colon. This case provides an important differential diagnosis for colonic mass.
3052 Colonic Polyp Found on Capsule Endoscopy After a Normal Colonoscopy: A Case Report and Literature Review
Authors: Nagirimadugu Ankita , Herman Michael , Bsrat Makda , Weisberg Ilan
Published: October 2019

INTRODUCTION:

Video capsule endoscopy (VCE) is a vital diagnostic tool in detecting occult gastrointestinal bleeding but has limited use in detecting colonic polyps due to low sensitivity and specificity. We present a case of a missed colonic polyp by colonoscopy that was detected with capsule endoscopy.

CASE DESCRIPTION/METHODS:

A 50-year-old man with an extensive cardiac history on systemic anticoagulation presented with symptomatic anemia, intermittent melena, and labs consistent with blood loss anemia. He underwent an endoscopy and colonoscopy in July 2018 and a push enteroscopy in February 2019 due to persistent symptoms, which were all normal and did not identify the etiology of obscure GI blood loss. Given the unresolved symptomatic anemia, the patient underwent VCE that did not identify any etiologies of small bowel bleeding, however, it did show a medium to large sized sessile polyp in the colon that not appreciated on colonoscopy eight months earlier.

DISCUSSION:

A head to head comparison of colonoscopy and VCE has shown that VCE's sensitivity and specificity for detecting adenomas 6 mm or larger are 64% and 84%, respectively. In fair or poorly prepped colons, VCE sensitivity and specificity for detecting adenomas 6 mm or larger dropped to 44% and 81%, making VCE an inferior choice for colon polyp detection. While colonoscopy remains the gold standard for colorectal cancer surveillance, the potential for missed polyps exists. In a recent tandem study with same-day consecutive colonoscopies, the adenoma miss rate was 24.1%. However, advanced adenomas and carcinoma miss rate was lower and significantly dropped to 1.2% and 0%, respectively. Right-sided, sessile, small adenomas were more likely to be missed than left-sided, pedunculated, large adenomas. Additionally, findings greater than two polyps were also associated with an increased missed rate. Current proposed methods for increasing adenoma detection rate include increased withdrawal time, multiple observers, and enhanced imaging modalities such as narrow band imaging. In this case, VCE identified a polyp not seen on colonoscopy from eight months prior. Although VCE currently does not meet the standards of a colorectal cancer screening, VCE's minimally invasive nature, lack of sedation and patient preference warrants continued work to define its role in the cancer-screening algorithm.
3057 Unusual Presentation of MRSA Colitis Complicated With Acute Appendicitis
Authors: Estifan Elias , Nanavati Sushant , Kumar Vinod , Komal Fnu , Vora Aarohi , Agnelli Michael
Published: October 2019

INTRODUCTION:

Clostridium difficile colitis has been the most aware bacterial enterocolitis for years and other bacteria been relegated such as Staphylococcus colitis. Staphylococcus enterocolitis following antibiotics had been one of the most frequent complications in surgical patients in 1950s and 1960s and now reappear with more resistance such as Methicillin-Resistant Staphylococcus Aureus (MRSA) colitis which brings a new challenge.

CASE DESCRIPTION/METHODS:

A 32-year-old Hispanic female with a history of Type I Diabetes Mellitus presenting with altered sensorium and a 2-day history of watery, non-bloody diarrhea, intractable emesis and diffuse crampy abdominal pain. About a month before the presentation, the patient had a soft-tissue laceration on left foot requiring a 7-day course of Cephalexin and Clindamycin that healed appropriately. On physical exam, she was tachycardic with HR of 110 bpm and tachypneic with RR of 28, somnolent but arousable with GCS >12. The abdomen was soft, tender diffusely to palpation without rebound or guarding. On the biochemical analysis, her blood glucose was 968 mg/dL with anion-gap metabolic acidosis (AG 46). In the ICU, she initiated on IV fluids, insulin and IV antibiotics for suspicion of colitis. C. diff testing was negative, but stool cultures grew MRSA for which she was started on Vancomycin and TMP-SMX. Due to continued abdominal pain on antibiotics, CT-Abdomen with Contrast showed acute appendicitis with inflammatory debris and without perforation or abscess (Figure 1) requiring laparoscopic appendectomy.

DISCUSSION:

Although Staphylococcal species are known to cause of antibiotic-associated colitis, MRSA colitis cases are unique and can pose a challenge in treatment if not ruled out and managed. When patients present with watery diarrhea, it is common to order C. diff testing, and stool culture is delayed or performed in an inappropriate time manner resulting in inconclusive cultures. Our case presented with DKA, which complicates the etiology of abdominal pain on admission for the clinician masking MRSA colitis associated with a rare complication of appendicitis double challenge and difficult to diagnose as most DKA patients present with abdominal pain. Oral Vancomycin is the treatment of choice, but our patient required coverage with TMP-SMX that proves to be effective double coverage. There were no case reports previously presenting with DKA or complication of acute appendicitis, which provides a learning opportunity in varied presentations.
3058 An Unusual Case of Ischemic Colitis
Authors: Bofill Aliana , Medina Rafael , Estremera Rodolfo , Martin Jose
Published: October 2019

INTRODUCTION:

48-year-old obese (BMI: 40) female, G0P0A0 LMP 1 year ago, with hypertension and hypercholesterolemia who presented with sudden left lower abdominal cramping pain associated with bloody diarrhea of one day duration. Denied associated systemic symptoms. She was using aspirin, simvastatin, metoprolol and had a progestin-only intrauterine device (IUD) placed 2 years ago. Physical examination with tenderness at the left lower quadrant. Digital rectal examination unremarkable. Laboratories with leukocytosis, lactatemia and positive fecal leukocytes. Abdominopelvic CT with IV contrast revealed left-sided peri-colonic and colonic inflammatory changes.

CASE DESCRIPTION/METHODS:

Gastroenterology service consulted due to non-specific colitis and there was concern for ischemic colitis as CT revealed inflammation in a watershed area. Colonoscopy showed edematous mucosa from the splenic flexure to the sigmoid colon associated with multiple large longitudinal ulcers. Biopsies revealed mucosal hemorrhage and neutrophil infiltration, suggestive of ischemic injury. Etiology of ischemia not clear given no obvious risk factors. Cardiovascular, myeloproliferative and prothrombotic workups were negative. The last piece of the puzzle rested on the IUD which was removed by the OBGYN service. A few days later, a follow up CT showed marked inflammation improvement.

DISCUSSION:

Ischemic colitis is generally considered a disease of the elderly. The most common causes include low-flow states due to cardiac dysfunction and hypovolemia. However, in younger patients, hypercoagulable states and drugs are the most common etiologies. In our patient, it was hard to initially find a reasonable cause of ischemia but, after excluding all etiologies, patient's IUD was the most likely cause of bowel ischemia. Combination contraceptives are a well-known risk factor for venous thromboembolism (VTE). However, few data have been published regarding whether the risk of VTE increases with progestin-only contraceptives (1). Mechanism is unclear, although it is hypothesized that protein concentrations influenced by hormones affect coagulation homeostasis (2). This risk appears to increase if additional VTE risk factors are present such in our patient with an elevated BMI (3). This rare case proves the importance of acquiring a detailed medical history including the use of contraceptives. Moreover, awareness of this diagnosis is essential so that early recognition can lead to individualized treatment decision and better patient's outcome.
3060 Octreotide Use in Chronic Diarrhea Post Capecitabine Treatment
Authors: Stewart Sarah , Hobson Erin , Penland-Ismatov Sherry , Demott Chad
Published: October 2019

INTRODUCTION:

Diarrhea is a known common side effect of chemotherapy, and is commonly associated with Capecitabine which was developed to increase systemic tolerability with tumor-specific conversion to 5-FU. Early onset diarrhea and mild to moderate diarrhea have been noted to occur in colorectal cancer patients on Capecitabine. Chemotherapy induced diarrhea (CID) can be life-threatening in severe cases due to resulting electrolyte imbalances, metabolic acidosis, and renal failure. Loperamide is the first line treatment for CID with octreotide being second-line treatment when patients fail to respond to loperamide within 48 hours. However, in cases of severe CID it is recommended that octreotide be initiated as first line therapy.

CASE DESCRIPTION/METHODS:

A 70 year old male with a history of poorly differentiated mucinous adenocarcinoma of the colon status post capecitabine presented to the ED with complaints of diarrhea. The patient initially presented to the oncology office with reported diarrhea, which was untreated at that time as diarrhea was suspected to be self limiting since he had stopped chemotherapy two days prior. When diarrhea did not abate he was admitted for diarrhea with dehydration. During admission octreotide was initiated since diarrhea did not abate on Imodium and loperamide. One week into admission, the patient developed metabolic acidosis (bicarb 8.6) and minimal resolution of diarrhea while on octreotide. Due to continued soft to loose frequent stools, the patient's octreotide dose was increased to 200 mcg every 8 hours and patient was placed back on scheduled loperamide. He was discharged on 30 mg long acting subcutaneous octreotide and as needed loperamide. He subsequently received 2 additional doses due to continued diarrhea before representing to the ED three months later for worsening diarrhea.

DISCUSSION:

This case demonstrates the complications that can arise from delayed octreotide treatment in diarrhea status post capecitabine treatment for colon cancer. 5-FU based chemotherapy has been known to result in potentially life-threatening mucosal toxicity. Literature review has shown that octreotide has improved overall response when compared to loperamide in resolution of CID diarrhea. This patient's poor inpatient response to anti-diarrheal agents highlights the importance of early CID management.
3064 A Case of a Rectal Xanthoma: A Sessile Polyp in an Uncommon Place
Authors: Urazov Konstantin , Singh Vikram , Mehra Shilpa
Published: October 2019

INTRODUCTION:

Xanthomas are benign collections of lipid bearing histiocytes that form a localized mass. While they are usually found in the soft tissue, they may also be found in the gastrointestinal (GI) tract. Within the GI tract, they are most commonly located in the stomach, and rarely within the rectosigmoid colon. These polyps are found within the mucosa and while usually asymptomatic, can rarely cause obstructive symptoms or pain if large enough. This case presents a rare finding of a rectal xanthoma.

CASE DESCRIPTION/METHODS:

A 55-year-old woman without any significant PMH presented for an initial screening colonoscopy. Physical exam and basic laboratory evaluation were unremarkable. Colonoscopy showed pan-diverticulosis, internal hemorrhoids, and a rectal polyp. The polyp was 4 mm, sessile, and yellow-white in color. It was removed with cold biopsy forceps. Pathology identified the polyp as a xanthoma. Given the benign nature of the polyp, patient was instructed to undergo screening colonoscopy in 10 years.

DISCUSSION:

During endoscopy, xanthomas are often overlooked as a differential diagnosis for a polypoid lesion, especially when found in an unlikely location. The exact incidence of rectal xanthomas is unknown and mostly limited to case reports alone. They can be seen in any age group, but tend to be more frequent with age. Colorectal xanthomas can present as flat, sessile, or pedunculated lesions. They are usually solitary and yellow-white in color. Xanthomas are typically confined to the lamina propria mucosa with pathology showing the characteristic foamy histiocytes in this location. Unlike cutaneous and tendinous xanthomas that often have a relation to hyperlipidemia, gastrointestinal xanthomas are usually not associated with an underlying disease (though this remains under investigation). The etiology of gastrointestinal xanthomas are poorly understood but it is believed that they arise in areas of damage, especially when they are found in the stomach. As xanthomas are benign and typically do not cause symptoms, there is no treatment necessary. Xanthomas continue to remain an important and rare finding within the GI tract that may eventually be found to have associations with certain systemic conditions.
3067 Colon Mass From an Unusual Etiology
Authors: Aurand William , Wayde Melinda , Back Gregory
Published: October 2019

INTRODUCTION:

There is a high level of suspicion for colon cancer in an adult patient with hematochezia and endoscopic evidence of a mass. However, it is important to biopsy the mass for definitive diagnosis as other etiologies may be responsible. This case reports on the surprising finding of an ulcerated colon mass found to be due to CMV infection.

CASE DESCRIPTION/METHODS:

A 71-year-old female with past medical history significant for end stage renal disease, hypertension, diabetes mellitus type 2, atrial fibrillation, and peripheral vascular disease was admitted for chest pain and generalized weakness. Gastroenterology was consulted after the patient complained of rectal bleeding in the setting of anemia. A colonoscopy was performed, which showed an ulcerated-appearing 5 × 4 cm mass extending into the ileocecal valve with biopsies taken with concern for malignancy. However, the biopsies showed evidence of a sessile-serrated adenoma that was negative for malignancy and positive for CMV. Ganciclovir was started for treatment of the CMV, and a colonoscopy was scheduled to be done after completion of the antiviral course.

DISCUSSION:

CMV is a member of the Herpesviridae family and has a high prevalence, with 50-80% of adults in the United States being seropositive at 40 years of age or older. It often reactivates in people who are immunosuppressed, with the GI tract being a common area for reactivation. CMV in the colon has a variable presentation, though it usually presents with signs of colitis. Definitive diagnosis of CMV requires biopsy. Treatment is with antiviral medications, such as ganciclovir. This case shows that while a colonic mass in an adult patient presenting with hematochezia places colon cancer high in the differential diagnosis, it is important to consider other etiologies.
3070 A Rare Case of 5-Fluorouracil-Induced Ulcerative Colitis
Authors: Akanbi Olalekan , Perry Courtney , Barrett Terrence
Published: October 2019

INTRODUCTION:

5-Fluorouracil (5-FU), an antimetabolite used in the management of advanced gastrointestinal cancers, is often complicated by the development of colitis with several reported cases. However, there has been no report of new onset ulcerative colitis (UC) following 5-FU-based chemotherapy. We report a case of 5-FU-induced UC in a patient with no previous personal or family history of inflammatory bowel disease (IBD).

CASE DESCRIPTION/METHODS:

A 60-year-old Caucasian female presented to the emergency department with 1-month history of diarrhea, abdominal pain, nausea and vomiting. Her past medical history is notable for hypertension, gastroesophageal reflux disease and recently diagnosed stage III invasive cecal adenocarcinoma for which she had right-sided hemicolectomy 3 months prior. She also received 3 cycles of adjuvant chemotherapy (folinic acid, fluorouracil and oxaliplatin) with the last cycle being five weeks ago. She had no previous history of colitis or IBD and had been asymptomatic prior to receiving chemotherapy. She was afebrile, mildly tachycardic with moderate tenderness in bilateral lower abdominal quadrants. Apart from anemia, her labs including stool studies and dihydropyrimidine dehydrogenase test were normal. She had little response to conservative management with fluids, antidiarrheals and antibiotics. Colonoscopy showed diffuse severe mucosa inflammation and ulceration with histology suggestive of an emerging IBD and negative for CMV. Fecal calprotectin was significantly elevated. Following minimal improvement with mesalamine and confirmation of UC by serology, she was started on steroids, azathioprine and infliximab with subsequent abatement of symptoms.

DISCUSSION:

Colitis is a significant gastrointestinal complication of chemotherapy. The four most common chemotherapy-induced colitis subtypes in the literature are neutropenic enterocolitis, pseudomembranous colitis, ischemic colitis and anti-CTLA4 antibody enterocolitis. 5-FU is a potent cause of colitis and majority of cases resolve with cessation of chemotherapy and supportive treatment. UC may be considered as a complication of 5-FU especially in the presence of corroborative laboratory, imaging and endoscopic features as well as poor response to conventional management. In addition to withdrawal of chemotherapy, treatment should be initiated per standard management of UC. Benefits and risks of biologic therapy should be thoroughly assessed. This case illustrates the rare potential for UC following 5-FU-based chemotherapy.
3071 A Rare Case of Colonic Mucosal Schwann Cell Hammartoma That Mimics a Regular Polyp
Authors: Shahbazi Shandiz , Higley Cory , Choden Tenzin , Pang Maoyin
Published: October 2019

INTRODUCTION:

Mucosal Schwann cell hammartomas are considered benign and were rarely reported as an incidental finding during colonoscopies. There is a lack of data on outcomes and surveillance guidelines due to the rarity of these unusual polyps. Here we report a case of colonic mucosal Schwann cell hammartoma incidentally found in a patient with intermittent diarrhea to enhance recognition of this rare lesion.

CASE DESCRIPTION/METHODS:

A 70-year-old-male with history of venous thromboembolism in setting of Factor V Leiden mutation on rivaroxaban had presented to our gastroenterology clinic complaining of chronic intermittent diarrhea without pain, hematochezia, melena, upper GI symptoms, or weight loss. To further evaluate ongoing diarrhea, the patient had a colonoscopy that showed patchy erythematous mucosa of the sigmoid colon with a single polyp measuring 4 mm at the descending colon, which was removed with a cold snare. The polyp showed focal expansion of the lamina propria by a bland spindle cell proliferation (Schwann cells) with no evidence of atypia or mitotic figures. No ganglion cells were noted and by immunostaining the spindle cells were strongly immunoreactive for S100 (Figure 1). Neuron-specific enolase (NSE) and synaptophysin were negative supporting the absence of ganglion cells. The immunoprofile and morphology was consistent with a diagnosis of mucosal Schwann cell hamartoma. Random colon biopsies ruled out microscopic colitis. Follow up visits were suggestive that food intolerances were the likely cause of his intermittent diarrhea.

DISCUSSION:

Benign nerve sheath tumors are mostly seen in the stomach and are rare in the rest of the gastrointestinal tract. The differential diagnosis is wide including neurofibromas, perineuromas, ganglioneuromas, granular cell tumors, gastrointestinal stromal tumors, carcinoid, and leiomyoma. Although there are common histological features of neural tumors, the immunostaining pattern is necessary to differentiate them from one another. Due to its rare occurrence, the exact incidence and prevalence of mucosal Schwann cell hammartoma is unknown. This distinction is important as this lesion has no association with any inherited polyposis syndrome and has a benign clinical course.
3075 Initial Presentation of Advanced Colorectal Cancer in the Cecum Presenting With Mild Tenesmus
Authors: Pacha Faris , Skrove Jamie L. , Sobrado Javier
Published: October 2019

INTRODUCTION:

Colorectal cancer (CRC) is a lethal disease. 140,250 new cases of large bowel cancer are diagnosed annually in the USA including 97,220 colon and 43,030 rectal cancers. 50,630 Americans are expected to die of large bowel cancer each year. CRC is the third most common cause of cancer death in the USA in women, and the second leading cause of death in men. Common symptomology include change in bowel habits (74%), rectal bleeding with change in bowel habits (71%), iron deficiency anemia (21%). Appendicitis as the initial symptom of CRC is less than 1% for individuals over 40.

CASE DESCRIPTION/METHODS:

Patient is a 52 year old man who presents to our facility for general abdominal pain and tenesmus for three months. The patient has no family history of CRC nor colonoscopy. In the ED routine labs negative Imaging revealed acute appendicitis. Laparoscopic appendectomy was performed and the patient was discharged the following day. Patient returned two months later with complaints of tenesmus and abdominal pain. In the ED acute microcytic anemia was discovered. CT Abdomen and pelvis demonstrated diverticulosis without diverticulitis and FOBT positive. Colonoscopy performed and findings consisted of: large 6 cm cecal mass, biopsies taken, 8 mm polyp in transverse colon removed with cold snare, two 5-7 mm polyps in the ascending colon removed by cold snare, and 4 cm polyp removed via the hot snare in the descending colon. The patient then underwent colonic resection of the mass by general surgery.

DISCUSSION:

What is learned from this case is the importance of CRC screening and rare initial symptom of CRC of appendicitis in a male over the age of 40. The patient is 52 years old with without having CRC screening and acute appendicitis. Had the patient had his diagnostic colonoscopy at the age of 50 the cecal mass would have been discovered sooner and treatment could have been initiated. Another aspect of this case that makes it unusual was the patient did not have any of the more common symptoms of CRC. Our patient presented with general abdominal pain and tenesmus and the latter accounts for less than 1% of all symptomatology along with acute appendicitis. The patient did not have any of the “alarm” symptoms and if not for the appendicitis diagnosed in the hospital the patient “had no intentions” of doing CRC screening. The patient explains he had no family history of gastric or colon cancers, “So why bother?” The acute appendicitis from the cecal mass proved to be critical in the initiation of treatment.
3085 Delayed Diagnosis of Cecal Adenocarcinoma in a Premenopausal Female
Authors: Saliaj Merjona , Ahmad Jan Sayed Tauseef , Saeed Mariam , Khan Zinobia
Published: October 2019

INTRODUCTION:

Cecal adenocarcinomas can present with anemia and non-specific abdominal symptoms. It is a rare colon cancer associated with aggressive course and poor outcomes. In premenopausal women it can be masked by other gynecological pathologies, resulting in delayed diagnosis and poor outcomes.

CASE DESCRIPTION/METHODS:

A 48 yo Hispanic female presented with acute onset nausea, vomiting and epigastric pain radiating to the right lower abdominal quadrant (RLQ). Her past medical history included active smoking, overactive bladder syndrome, sickle cell trait, hirsutism, uterine fibroids with chronic menorrhagia, constipation, and chronic iron deficiency anemia (IDA). In addition, she had multiple visits to the emergency room with similar symptoms. Prior work up was remarkable for microcytic hypochromic anemia with Hgb of 7.4, Hct of 24 and MCV of 62, severe iron IDA with ferritin 6, total iron 26, TIBC 358, iron saturation 7.3, normal LDH and reticulocyte count. Stool occult was negative. Her usual symptoms were attributed to either gynecological etiologies or her chronic constipation. During this admission her CT abdomen was consistent with acute appendicitis. However, laparoscopy revealed a right colon mass requiring hemicolectomy. Pathology report confirmed grade II cecal adenocarcinoma stage pT3, pN2a.

DISCUSSION:

IDA in men prompts extensive workup for colon cancer. In contrast in women it is normally attributed to gynecological/benign gastrointestinal (GI) conditions resulting in delayed diagnosis. Most of the times IDA can be the only manifestation of right sided colon cancer. In the last years, our patient had persistent abdominal discomfort which were attributed to either uterine fibroids or iron supplement induced constipation. Stool occult test was negative correlating with its low sensitivity, especially in small amounts of bleeding. Many pelvic ultrasounds were done but no advanced investigation was considered to evaluate her GI symptoms. Her anemia was always assumed to be secondary to menorrhagia, which confounded the clinical judgment and underestimated the diagnosis of colorectal cancer. This case illustrates the need for low threshold in screening for colorectal malignancies especially in premenopausal women in which anemia can be overlooked as caused mainly by gynecological conditions.
3092 A Clinically Confounding Presentation of Dysphagia With Multiple Valid Etiologies
Authors: Harriss Patrick B. , Roussel Jordan , Chiu Yiu-Ting , Pandit Sudha , Morris James D. , Jordan Paul
Published: October 2019

INTRODUCTION:

Dysphagia may result from a variety of different disease processes, including inflammation, infection, motility disorders, mechanical causes, or even functional. The etiology is less clear when a patient presents with multiple individual causes of dysphagia, each alone which may account for their symptoms. Our case report describes the coexistence of dysphagia due to several factors in a single patient, and a puzzling presentation warranting further evaluation to ultimately alleviate the underlying complaint.

CASE DESCRIPTION/METHODS:

We present a case of a 62-year-old female with a past medical history of hypertension that presented to her PCP with 6 months of weakness and limited oral intake. She endorsed issues swallowing and sensation of food stuck in her throat. Dysphagia to solids progressed to include liquids, and with nausea, vomiting, and 40 lbs unintended weight loss. The patient was admitted and failed bedside swallow study. Upper GI series and CT thorax showed hiatal and paraesophageal hernias. EGD revealed GE junction angulation from hernias, as well as esophagitis and gastritis. Manometry demonstrated weak swallows and sparse motility representative of a motility disorder. A gastric tube was placed for continued poor oral intake. She did not tolerate tube feeds, and gastric emptying study showed decreased emptying with marked GERD. EGD biopsies resulted and were consistent with eosinophilic esophagitis and H. pylori. She was prescribed triple therapy and started on PPI. She then had good symptom improvement and was discharged. At 6 week follow-up, the patient was able to tolerate oral intake and plans were initiated for gastric tube removal.

DISCUSSION:

Our patient exhibited numerous clinical findings that could account for her symptoms: esophageal herniations, eosinophilic esophagitis, H. pylori, an intrinsic motility disorder, and GERD. Though dysphagia has various etiologies, it is exceedingly rare for a single patient to display multiple simultaneous findings that might each individually explain their symptoms. Our case is unique in that the patient demonstrated sources from many different levels, yet given resolution with medication, likely originated from the primary eosinophilic esophagitis. Further investigation revealed the complexities of her case, and culminated in the eventual diagnosis, treatment, and symptomatic improvement. Our case also emphasizes the importance of thorough evaluation, as initial findings may be more complex than first realized.
3093 Epiphrenic Diverticula: An Added Source of Complexity in Achalasia Management
Authors: Holmes Ian , Ko Myung S. , Kouanda Abdul , Singh Aparajita , Kathpalia Priya
Published: October 2019

INTRODUCTION:

Epiphrenic esophageal diverticula are rare and almost always associated with an underlying esophageal motility disorder. Therapeutic options for epiphrenic diverticula are evolving as per oral endoscopic myotomy (POEM) is increasingly being used for treatment of achalasia. We present two cases of epiphrenic diverticula associated with achalasia at our institution and review the clinical presentation, pathophysiology, and current management of epiphrenic diverticula.

CASE DESCRIPTION/METHODS:

Case 1 A 77 year old female presented with dysphagia. An esophagram showed two diverticula with a distal narrowing. Upper endoscopy showed two epiphrenic diverticula and a narrowed gastroesophageal junction. Manometry showed an elevated median IRP of 22.5 mmHg and pan-esophageal pressurization with all swallows, consistent with type II achalasia. A CT scan of the chest did not show any evidence of malignancy. She is currently seeking a surgical opinion for consideration of myotomy. Case 2 A 66 year old male presented with dysphagia. An esophagram showed marked dysmotility with a 1.8 cm epiphrenic diverticulum. Upper endoscopy confirmed the presence of the diverticulum. Subsequent manometry showed a median IRP of 28.8 mmHg and spastic contractions in all swallows consistent with type III achalasia. Given his type III achalasia and the smaller size of the diverticulum, he was referred for consideration of POEM.

DISCUSSION:

Esophageal diverticula can be grouped into pharyngoesophageal, mid-esophageal, and epiphrenic diverticula. Epiphrenic diverticula are “false” diverticula, with herniation of the mucosa and submucosa only, that occur due to increases in intraluminal pressure. They are associated with major esophageal motility disorders. Management of epiphrenic diverticula requires addressing the underlying motility disorder, or else the diverticula may recur after diverticulectomy. Generally, laparoscopic or combined laparoscopic/thorascopic myotomy, diverticulectomy and anterior fundoplication is required. The overall mortality rate for surgical management of epiphrenic diverticula is around 5%, with morbidity rate as high as 20%. POEM without diverticulectomy has also been described for patients who either decline surgical intervention or are not surgical candidates. As POEM technique is refined for this indication, management of epiphrenic diverticula will require close collaboration between gastroenterologists, advanced endoscopists, and surgeons for selection of the optimal treatment for each patient.
3096 Esophageal Pancreatic Acinar Ectopia—Premalignant or Benign: A Case Report and Brief Literature Review
Authors: Gboluaje Temitayo , Ajose Taiwo , Simien Melvin
Published: October 2019

INTRODUCTION:

Esophageal Pancreatic Acinar Ectopia (EPAE) is a rare incidental endoscopy finding with reported prevalence ranging from 16% to 24% in asymptomatic patients and 3% in patients with Barrette Esophagitis, EPAE has been found in patients as young as 1 day old to incidental autopsy finding. We present a brief literature review and a case of EPAE in distal esophagus with severe dysphagia associated with active inflammation and focal metaplasia.

CASE DESCRIPTION/METHODS:

A 59 year old male with medical history of Degenerative Joint Disease (DJD), HTN, GERD, and chronic constipation presented to GI clinic with complaint of insidiously worsening dysphagia to solid food of 4 months duration. He also endorsed 30-pound weight loss and denied any other associated symptoms. He has significant family history of colon cancer. He is a current smoker with 10 pack years. His medications include Hydrochlorothiazide, Amlodipine, Lisinopril, Atorvastatin and Nexium. Physical exam revealed no significant findings in all systems, including gastrointestinal. Most recent labs including hematology and chemistry were within normal limits. An endoscopy was performed which revealed slightly irregular gastroesophageal (GE) junction, 5 × 3 cm pink rubbery mass at the GE junction which was biopsied, and an irregular gastric mucosa with biopsy obtained. The biopsy obtained from the GE junction revealed intestinal metaplasia and pancreatic acinar type tissue with no dysplasia while the biopsy from the stomach revealed numerous h-pylori, intestinal metaplasia with active chronic gastritis. At follow up appointment 2 weeks after the endoscopy, patient reported complete resolution of dysphagia and improvement in constipation.

DISCUSSION:

A review of the literature showed that Esophageal Pancreatic Acinar Ectopia (EPAE) is often an incidental finding, with prevalence in up to 24 percent of all adults and no associated symptoms in most. It has however been associated with symptoms like epigastric pain, hemoptysis, odynophagia, dysphagia, and pathologies like esophageal atresia, anaplastic carcinoma, pancreatitis, IPMN, and squamous cell carcinoma. EPAE has been documented in neonates making congenital etiology most plausible. Our case bolsters the knowledge that dysphagia, which is the most common presenting symptom in EPAE, is likely due to mass effect and our literature review revealed that most pathologies known to pancreatic tissue are possible in EPAE.
3108 Esophageal Phlebectasias: A Difficult Diagnosis to Swallow
Authors: Joshi Tejas V. , Miller Justin , Vellanki Shaitalya , Landreneau Stephen , Hutchings John
Published: October 2019

INTRODUCTION:

In an attempt to further investigate a three-year complaint of dysphagia as well as evaluate a three-month history of diarrhea, we performed an endoscopic evaluation which revealed a unique case of esophageal phlebectasias. Phlebectasias are non-neoplastic, non-tortuous, fusiform dilatations of veins, and their pathogenesis although not fully understood. Early diagnosis of phlebectasias both its management as well as the prevention of its complications such as rupture and bleeding.

CASE DESCRIPTION/METHODS:

A 59-year-old Caucasian male with history of hypertension, GERD, hyperlipidemia, gout, obesity (BMI 40), and hypothyroidism presented to the clinic complaining of a 3-month history of loose, watery, non-bloody diarrhea that occurs 3-6 times per day with occasional nocturnal stools that occur about twice a month and is associated with abdominal cramping preceding the bowel movement. He reported a long history of GERD improved with Omeprazole and a 3-year history of substernal dysphagia to solids without regurgitation, which improved with fluid wash. Vitals were normal and his physical examination was unremarkable. Endoscopic evaluation of his dysphagia revealed numerous medium sized venous outpouchings with a localized distribution found within the lower two-thirds of the esophagus. Endoscopic ultrasound confirmed venous lakes throughout the esophagus.

DISCUSSION:

Most cases of phlebectasias found in the GI tract are asymptomatic and incidentally discovered during either GI procedures or surgeries. Guidelines on treatment have yet to reach a consensus. Surgical management of phlebectasias has more often been opted for those lesions that rapidly evolve leading to risk of rupture and subsequent hemodynamic instability, or in lesions in which the venous dilation can lend itself to forming an intramural thrombus. Phlebectasias are one of multiple vascular anomalies which can exist in the GI tract, but most of them are predominantly located in the lower GI tract such as in the stomach, small intestine, and colon. Recognizing more cases of esophageal phlebectasias can prevent complications such as severe bleeds and even bowel wall infarction. Due to scarcity of published reports, there are currently no associations of dysphagia as a complication of esophageal phlebectasias. Nevertheless, this case demonstrates the seriousness of early recognition to prevent potentially fatal complications.