bluuebunny/crossref_metadata_2025 huggingface dataset:
1343 A Rare Case of Lemmel Syndrome
Authors: Kumar Anila , Gollapudi Lakshmi Asritha , Lebovics Edward , Georgostathis Dimitrios
Published: October 2019

INTRODUCTION:

Lemmel syndrome is a rare condition in which a periampullary duodenal diverticulum compresses the distal common bile duct (CBD) resulting in obstructive jaundice in the absence of choledocholithiasis or tumor. We present a rare case of Lemmel syndrome in an elderly patient below.

CASE DESCRIPTION/METHODS:

An 83-year-old woman with a past medical history of Crohn's disease and pancreatic cysts was transferred to our facility for management of biliary obstruction. She had noted a four-month history of progressive early satiety, post-prandial right upper quadrant abdominal pain, post-prandial emesis, poor oral intake, and significant weight loss. On presentation, labs were significant for WBC of 11.6 k/mm3, AST of 242 U/L, ALT of 1677 U/L, alkaline phosphatase of 1347 U/L, total bilirubin of 3.4 mg/dL, and lipase of 260 U/L. She underwent ERCP and was found to have a large periampullary diverticulum containing the major papilla. Cholangiogram revealed a tortuous bile duct and severe intra- and extrahepatic biliary dilation. A sphincterotomy was performed and multiple balloon sweeps were done with no stone extraction. A 10 F × 8 cm fully covered metal biliary stent (FCSEMS) was placed in the bile duct and she had improvement in her appetite, abdominal pain, and liver function tests. On follow up ERCP, the bile duct maintained a straightened position.

DISCUSSION:

Lemmel syndrome is characterized by obstructive jaundice caused by periampullary duodenal diverticulum (PAD) compressing the intra-pancreatic part of the CBD with resultant upstream dilatation of the extra- and intra-hepatic bile ducts. PAD is a pseudo-diverticula consisting of an extraluminal out-pouching of duodenal mucosa and lacks a muscularis layer. PAD develops within a 2-3 cm radius from the ampulla of Vater. Periampullary duodenal diverticuli are mostly asymptomatic and majority are diagnosed incidentally. When inflamed, they can cause pancreaticobiliary complications such as obstructive jaundice, cholangitis, pancreatitis, and stone formation. They are diagnosed on imaging such as CT scan, MRCP, and barium studies, which can show lateral compression of the distal CBD by the diverticulum. ERCP with sphincterotomy and biliary stent placement has shown to reduce the risk of morbidity and mortality, although diverticulectomy remains standard of care for PAD. Lemmel syndrome is rare but should be considered in the differential diagnosis for obstructive jaundice in patients with a periampullary duodenal diverticulum.
1352 Doxycycline-Induced Acute Pancreatitis: A Likely Source Rarely Seen
Authors: Hoffman Paul , Civil Wilco
Published: October 2019

INTRODUCTION:

The diagnosis of drug-induced acute pancreatitis compared to the others causes of acute pancreatitis is estimated between 1.4 and 2%.1 Despite this association, the clinical evidence on doxycycline-induced acute pancreatitis is sparse as proving the association with a particular drug may not always be straightforward.2 In this case, we report an episode of an acute pancreatitis (AP) where well-known etiologies were ruled out and the patient was deemed to have doxycycline induced acute pancreatitis (DIAP).

CASE DESCRIPTION/METHODS:

A 71-year-old female with significant past medical history of cholecystectomy, hyperlipidemia and bullous pemphigoid presented to Regional Medical Center Bayonet Point with one-day history of epigastric pain with nausea and non-bilious emesis while eating. She denied prior history of AP or recent alcohol use. Review of systems was otherwise unremarkable. Patient did admit to using doxycycline twice daily starting a month prior to treat her bullous pemphigoid. Her only other home medication that has an association with drug induced acute pancreatic was simvastatin, which has not been changed or adjusted for several years. On physical examination, vital signs were within normal limits. Abdominal examination was positive for epigastric tenderness, otherwise unremarkable. Laboratory studies revealed: white blood cell count of 28,100 mm3; (neutrophils 92.9%); blood urea nitrogen 25 mg/dL; serum creatinine 1.33 mg/dL; sodium 138 meq/L; and serum lipase 6204 IU/L. Abdominal and pelvis tomography revealed peri-pancreatic fat stranding and fluid suggestive of acute pancreatitis. The patient was immediately started on intravenous normal saline. A magnetic retrograde cholangio-pancreatography was obtained to rule out choledocholithiasis, which revealed no extrahepatic biliary dilation, choledocholithiasis or choledochal filling. After an exhaustive work up, we determined the patient had DIAP. Doxycycline was immediately discontinued. The following day her symptoms improved. The patient recovered and was discharged.

DISCUSSION:

Tetracyclines have long been designated as causative agents in AP. Unfortunately, there have only been a few case reports of DIAP.3–5 Interestingly, several report a female patient as in this case. What makes our case unique is that doxycycline as the sole source of drug induced acute pancreatitis has rarely been reported.6–9 Further research is required to identify the mechanism of DIAP, true incidence, and additional risk factors.
1362 A Rare Case of Obstructive Jaundice and Acute Pancreatitis
Authors: Bofill Aliana , Rodriguez Esteban , Martin-Ortiz Jose
Published: October 2019

INTRODUCTION:

Gallstones is the most common cause of both biliary pancreatitis and obstructive jaundice. Rarely, periampullary diverticula (PAD) and choledochal cysts can present with the same symptomatology. PAD is usually asymptomatic, but complications can occur in about 5% of cases. Among these, Lemmel's syndrome defined as obstructive jaundice in absence of choledocholithiasis or neoplasm and pancreatitis have been rarely reported. Choledochal cysts are abnormal dilatations of the biliary tree with type III (choledochocele) being the least common subtype, representing <5% of reported cysts. Pancreatitis is the most common clinical complication and is normally the inciting event that leads to identification of the choledochocele. We present a case of recurrent pancreatitis and obstructive jaundice secondary to Lemmel's syndrome and choledochocele.

CASE DESCRIPTION/METHODS:

Case of a 60-year-old male with history on uncomplicated pancreatitis, who presented with nausea, vomiting, epigastric pain and fever of 2 days of duration. Physical examination with diffuse abdominal tenderness. Laboratories with leukocytosis, alkaline phosphatase 202 U/L, total bilirubin 8.3 mg/L, lipase 700 U/L and amylase 1089 U/L. Abdominopelvic CT showed acute pancreatitis, no cholelithiasis or biliary tree dilation. Magnetic resonance cholangiopancreatography showed duodenal diverticulum and choledochocele. Endoscopic retrograde cholangiopancreatography revealed a large diverticuli next to the ampulla with debris and sacular appearance of the intraduodenal portion of the common bile duct (CBD) as seen in choledochocele. The pancreatic duct was normal. A pre-cut sphincterotomy was performed. There was normalization of laboratories for which he was discharge home.

DISCUSSION:

Lemmel's syndrome is caused by a periampullary duodenal diverticula causing extrinsic compression of the CBD and preventing secretion of the bile. In choledochocele, there is a dilatation of the intramural portion of the distal CBD within the duodenal wall. Both diagnoses should be included in the differential of benign biliary obstruction or pancreatitis when PAD or cyst are present in imaging. In both cases, symptomatic patients can be approach with sphincterotomy. As in our case, the patient had no further episode of pancreatitis or obstructive jaundice after successful sphincterotomy. Maintaining a high index of suspicion is required to establish an accurate diagnosis since they can mimic other cystic or solid lesions around the pancreas head.
1369 Not Feeling so Groovy: A Case of Groove Pancreatitis
Authors: Lamb Bernie , Bhat Ishfaq
Published: October 2019

INTRODUCTION:

Groove pancreatitis is a rare form of chronic segmental pancreatitis that affects the anatomical area between the pancreatic head, duodenum, and common bile duct. Definitive etiology is unknown, however, it predominantly affects males 40 to 50 years of age with a significant alcohol use history. Groove pancreatitis is an important diagnosis to consider in the evaluation of pancreatic head lesions.

CASE DESCRIPTION/METHODS:

A 35-year-old male with past medical history significant for chronic pancreatitis and alcohol use disorder presented with complaint of acute-onset epigastric abdominal pain with associated nausea and vomiting. He reported that his last use of alcohol was three weeks prior to presentation. Laboratory studies were significant for elevated lipase at 1,591 IU/L and normal liver enzymes. CT abdomen and pelvis demonstrated an enlarged peripancreatic fluid collection between the uncinate process and horizontal portion of the duodenum. The horizontal portion of the duodenum was narrowed secondary to mass effect from the peripancreatic fluid collection. MRI with MRCP revealed fluid collections interposed between the pancreatic head and third portion of the duodenum. EGD with endoscopic ultrasound was performed and showed induration and edema of the second portion of the duodenum and anechoic cysts present in the duodenal wall. Biopsies were obtained during EUS via FNA and were negative for pancreatic adenocarcinoma. Together, these findings were consistent with a diagnosis of groove pancreatitis. The patient clinically improved with conservative medical management: fluid resuscitation, analgesia, antiemetics, and pancreatic enzyme supplementation.

DISCUSSION:

Groove pancreatitis is characterized by fibrosis in the “groove” area between the pancreatic head, duodenum, and common bile duct. Characteristic findings include cystic lesions in the duodenal wall and duodenal stenosis. It poses a challenge to clinicians, as its presentation may be similar to that of pancreatic adenocarcinoma. It is important for clinicians to be aware of this disease entity and consider it in evaluation of pancreatic head lesions.
1381 Bile Reinfusion in Obstructive Jaundice
Authors: Khurana Shruti , Larson Scott
Published: October 2019

INTRODUCTION:

Bile acid and salts depletion from percutaneous transhepatic cholangiodrainage (PTCD) in obstructive jaundice can lead to fat malabsorption causing malnutrition and fat-soluble vitamin deficiencies, dehydration, acute kidney injury (AKI) and electrolyte abnormalities. Bile reinfusion (BR) is a method of enteral feeding of biliary drain secretions for restoration of bile salts in the gut. We describe a case of oral BR in a patient with PTCD for choledocholithiasis.

CASE DESCRIPTION/METHODS:

A 64 year-old Caucasian woman with history of gastric adenocarcinoma requiring subtotal gastrectomy and roux-en-y gastric reconstruction presented with nausea, vomiting, and epigastric pain. Imaging showed a stone in the mid common bile duct (CBD) measuring 0.7 × 0.6 cm causing mild biliary dilation. An endoscopic retrograde cholangiopancreatography (ERCP) was attempted with unsuccessful cannulation due to abnormal anatomy from prior surgeries. Hence, an open CBD exploration was performed for stone extraction and a 14 French percutaneous T-tube was placed for PTCD. Post-operatively, she developed large volume output (∼1-2 L/day) from the T-tube, loose stools and AKI with rise in creatinine from 1.12 to 2.96 mg/dL. She was started on BR 4 times/day by mouth (mixed with juice in 1:1 ratio). Over the next few weeks, she had resolution of diarrhea with a slow renal recovery.

DISCUSSION:

BR has shown variable success as reported in a few case reports and small studies mainly focusing on patients with pancreatitis with enteric fistulae, and obstructive cholangiocarcinoma.
1,2
Tripathy et al. demonstrated that it is a cost-effective method for hastened renal recovery, a common complication in patients with obstructive jaundice.
3
In conclusion, BR should be considered in patients with PTCD as an alternate to exogenous bile salt administration for improved enterohepatic equilibrium.
1390 Impacted Fully Covered Self-Expanding Metal Biliary Stent Within an Uncovered Metal Stent by Exuberant Granulation Tissue Growth Successfully Removed After Treatment With Argon Plasma Coagulation (APC)
Authors: Fayyaz Mohammad
Published: October 2019

INTRODUCTION:

We describe the case of an impacted, fully covered, self-expanding metal biliary stent within an uncovered metal stent because of exuberant granulation tissue growth at the ampullary orifice. The stent was successfully removed after treatment of granulation tissue with Argon Plasma Coagulation (APC).

CASE DESCRIPTION/METHODS:

A 95-year-old lady underwent placement of an uncovered self-expanding metal stent for a tight stricture of the distal bile duct by another gastroenterologist several years ago. The stricture was initially felt to be a malignant stricture but subsequently turned out to be a benign stricture. However, the biliary tree was frequently obstructed with excessive tissue ingrowth and recurrent stone formation requiring placement of a fully-covered self expanding metal stent within the uncovered metal stent, exchanged every nine months. During one of the ERCPs for stent exchange, the covered metal stent could not be removed because of exuberant growth of granulation tissue around the ampullary orifice covering the edges of the stent. The stent was left in place, the stones were extracted with a stone-extraction balloon and the granulation tissue was treated with APC. The plan was to bring the patient back for an ERCP and stent exchange after resolution of the granulation tissue. The patient ended up being hospitalized with stent occlusion and cholangitis after three months. At that time an ERCP was performed and the granulation tissue was noted to have completely resolved. The stent was occluded with stones and debris. The stent was removed without difficulty and a new stent was placed. The same exact situation recurred two years later. The granulation tissue was treated again with APC and stent was cleaned out with a stone-extraction balloon. The patient was brought back in three months for an ERCP and easy stent removal.

DISCUSSION:

Fully covered self-expanding metal stents have been used successfully for a variety of malignant and benign conditions and are generally easily removable. Occasionally exuberant growth of granulation tissue at the biliary orifice can preclude stent removal. Attempts to remove the stent forcibly can result in stent disruption and can lead to serious complications. In these situations the best approach is to treat the granulation tissue with APC and bring the patient back after resolution of the granulation tissue for an easy stent exchange.
1391 Too Much of a Good Thing: HIV and Immune Reconstitution in a Patient With IGG4-Related Pancreatitis
Authors: Berger David M. , Glazman-Kuczaj Galina , Kanevsky Julie
Published: October 2019

INTRODUCTION:

Autoimmune pancreatitis accounts for 2% of cases of chronic pancreatitis. Autoimmune pancreatitis is differentiated into Type I (IgG4-related disease) and Type 2 (with normal IgG4 levels). Nearly 40% of patients with IgG4-related pancreatitis have involvement of salivary or lacrimal glands.

CASE DESCRIPTION/METHODS:

A 65 year-old-female with a history of HIV on anti-retroviral therapy (ART) (CD4 count of 588 cells/uL and undetectable viral load) and submandibular gland swelling presented with two weeks of epigastric discomfort and watery yellow diarrhea. The patient was noted to have elevated alkaline phosphatase to 802 U/L, aspartate aminotransferase to 284 U/L, alanine aminotransferase to 518, as well as total bilirubin of 2.8 mg/dL and direct bilirubin of 1.8 mg/dL. Amylase was 79 u/L and Lipase was 75 u/L. Four months prior to admission ART was changed from emtricitabine/tenofovir/raltegravir to bictegravir/emtricitabine/tenofovir; at that time CD4 count was 318 cells/uL. Liver tests were normal at that time. ART was held at the time of admission. Abdominal ultrasound demonstrated a diffusely enlarged, hypoechoic pancreas, consistent with pancreatitis. Magnetic resonance cholangiopancreatography showed abnormal morphology of the pancreas with loss of lobulation in the distal pancreatic body and tail, as well as irregularity of the pancreatic duct. Endoscopic ultrasound-guided biopsy with biliary stenting was performed. Prednisone was started empirically at 1 mg/kg/day for suspected IgG4 pancreatitis with rapid improvement in symptoms and liver tests. ART regimen was resumed simultaneously. Biopsy showed fibrosis with chronic inflammation, as well as the presence of IgG4 positive plasma cells. One month later, the patient's liver tests have returned to baseline.

DISCUSSION:

In this patient with a recent change in ART medications and newly elevated liver enzymes, drug-induced liver injury (DILI) can be considered initially. Imaging in this case showed diffuse edema and pancreatitis. Recent research suggests that patients with IgG4-related disease have over-activity of a specific class of cytotoxic CD4+ T cells driving the cytokine release that leads to its characteristic fibrosis. We suspect that this patient's flare of IgG4 pancreatitis may have been triggered by a recent change in her ART regimen. This allowed proliferation of all CD4+ T cell lines, leading to an response resembling the Immune Reconstitution Inflammatory Syndrome, resulting in the patient's clinical presentation.
1393 Calcified Gastroduodenal Artery Aneurysm Presenting as a Pancreatic Mass
Authors: Laharwal Mehak M. , Bhurwal Abhishek , Safarova Maya , Rahni David
Published: October 2019

INTRODUCTION:

Gastroduodenal artery (GDA) aneurysm is among the rarest visceral artery aneurysms (VAAs) with an estimated prevalence of 1.5%. Rarely does it present with an outpouching which can sometimes mimic pancreatic malignancy with vastly different outcomes. We report a case of incidental GDA aneurysm which was mimicking a pancreatic mass where EUS was valuable in diagnosis and management.

CASE DESCRIPTION/METHODS:

A 63-year-old male with a past medical history of heroin and cocaine abuse, presented to the emergency room with shortness of breath and hypoxia. CT angiography revealed acute bilateral pulmonary embolism along with a pancreatic mass. This finding prompted a triple phase CT scan revealing a round 2.8 × 2.6 cm lesion with peripheral thin calcifications identified as a partially thrombosed GDA aneurysm. Additionally, a 2 × 1.5 cm hypodense area was also noticed. However, it was unclear if this was an outpouching from the aneurysm or a separate pancreatic mass. To better delineate the structure, an endoscopic ultrasonography was then performed. The main pancreatic duct and the pancreatic parenchyma were normal with the exception of a calcified abnormality within the GDA. These calcifications were partly contiguous with the GDA aneurysm. No other structural pathology was reported. Pancreatic biopsies were negative for malignancy. Development of the calcified pseudoaneurysm of the GDA was attributed to cocaine abuse. Thereafter, he underwent successful embolization of the aneurysm due to the high risk of bleeding from the aneurysm. He was thereafter discharged with no further complications.

DISCUSSION:

The most common etiologies of the GDA aneurysms are pancreatitis and atherosclerosis. Unruptured GDAs may present as abdominal pain or obstructive jaundice or remain asymptomatic. Pancreaticoduodenal and GDA aneurysms may manifest with rupturing into stomach, bile or pancreatic ducts in 50-75% of the cases with mortality approaching 50%. Incidentally found GDA aneurysms, as demonstrated in this case, must be treated irrespective of the size and presence or absence of symptoms since the potential of rupture is unrelated to its size. Given the high mortality, it is imperative to diagnose these lesions early. EUS provides valuable information and is useful in diagnosis as is noticed in our case. Therefore, EUS should definitely be considered in cases where diagnosis of GDA aneurysm is considered.
1395 Nivolumab-Induced Hemorrhagic Pancreatitis
Authors: Rogers Wesley , Mehta Amit , Mukewar Saurabh , Niec Rachel , Issa Danny , Wan David
Published: October 2019

INTRODUCTION:

The checkpoint inhibitor nivolumab is an anti-PD-1 monoclonal antibody (mAb) that treats malignancy. Increased usage of checkpoint inhibitors has led to an increasing incidence of immune-related adverse events (irAEs) such as immune checkpoint inhibitor-induced pancreatic injury (ICIPI). We report a case of nivolumab-induced pancreatitis that progressed to fatal hemorrhagic pancreatitis.

CASE DESCRIPTION/METHODS:

A 61-year-old man diagnosed with small cell lung cancer with brain, adrenal, and osseous metastases presented with a one-day history of epigastric pain radiating to the back after starting a biweekly dose of nivolumab forty days prior. On admission, he had a lipase of 2700 U/L. His abdominal CT scan was consistent with acute interstitial pancreatitis. The patient was treated with hydromorphone as needed and Lactated Ringer's. He was continued on his home dexamethasone and discharged. Fourteen days after initial presentation, the patient reported increased abdominal cramping. MRCP findings were consistent with acute hemorrhagic pancreatitis with organizing complex peripancreatic fluid collections. He became febrile and hypoxic, and twenty-three days after initial presentation, chest CT scans showed acute respiratory distress syndrome or multifocal pneumonia. The patient decompensated and eventually died of cardiopulmonary failure secondary to hemorrhagic pancreatitis and worsening of his underlying malignancy.

DISCUSSION:

Nivolumab is a PD-1 mAb that works by enhancing the T-cell response to malignancies. Checkpoint inhibitors are known to cause irAEs including ICIPI due to their increased immune activation. However, reports of nivolumab-related pancreatitis are rare, with a reported rate of <1%. While anti-PD-1 mAbs often cause asymptomatic pancreatic enzyme elevations, nivolumab-related pancreatitis may also progress to serious complications, such as pseudocyst or chronic pancreatitis. The mainstay of treatment for irAEs is a combination of immunosuppression with glucocorticoids and/or a removal of the checkpoint inhibitor, depending on the severity of the irAE. Expert opinion currently guides steroid and checkpoint inhibitor management based on the intensity of the reaction: at lower severity the drug can either be stopped temporarily or not at all. This case adds to the growing presentations of nivolumab-induced pancreatitis. Though the incidence of pancreatitis as a result of checkpoint inhibition remains low, the progression to severe disease is possible.
1406 “Windsock” Duodenal Diverticulum Resulted in Recurrent Pancreatitis and Gastric Outlet Obstruction
Authors: Liu Yingheng , Saleh Jean
Published: October 2019

INTRODUCTION:

“Windsock” or intraluminal duodenal diverticulum (IDD) is a rare congenital abnormality caused by an improper luminal recanalization of the foregut during embryological development. Most patients are asymptomatic. We present a case of recurrent pancreatitis and gastric outlet obstruction (GOO) caused by IDD in a young man with chronic alcohol use.

CASE DESCRIPTION/METHODS:

A 30-year-old man presented with severe nausea, vomiting and abdominal pain and found to have a third episode of acute pancreatitis in one month. Medical history was notable for alcohol abuse. However the patient stated that his last drink was more than a month ago. Lipase on admission was 130 U/L and he was found to have acute kidney injury (AKI) with creatinine 4.1 mg/dL. Magnetic resonance imaging without contrast revealed severe gastroduodenal obstruction and acute pancreatitis with pancreatic head pseudocysts. Esophagogastroduodenoscopy revealed nearly complete obstruction of the second portion of duodenum that the scope could not traverse. The patient was managed for acute pancreatitis, resulting most likely from paraduodenal pancreatitis causing GOO. After 10 days of aggressive treatment, the patient's pancreatitis has clinically much improved with better relief of the abdominal pain and resolution of the AKI. However he remained obstructed as large volume was drained from the nasogastric tube. A subsequent abdomen and pelvis computed tomography (CT) revealed interval decrease of the cluster pseudocysts previously seen by the pancreatic head but showed a “windsock” duodenal diverticulum. With conservative management, parental nutrition, intravenous fluids and pain control, the patient was able to tolerate frequent small portions of regular diet on hospital day 23. He was then discharged for elective surgery and resection of the IDD.

DISCUSSION:

Patients with IDD may present with chronic non-specific symptoms such as epigastric pain, nausea, vomiting, post-prandial fullness or rarely acute complications such as obstruction, hemorrhage, or pancreatitis. Radiologic diagnosis by CT or upper gastrointestinal series shows a typical “windsock” appearance hence the name. Endoscopic diagnosis may be challenging as the diverticulum can collapse and be unnoticed, or be mistaken for a polyp or a mass. Surgery has been the mainstay of treatment. However endoscopic techniques have been described in recent literature. IDD should be considered in the context of unexplained duodenal obstruction or recurrent pancreatitis.
1446 A Rare Tumor in the Common Bile Duct: A Case Report of Plexiform Neurofibroma in the Common Bile Duct
Authors: Alkayali Talal , Salem Ahmed I. , Ricardo Juan , Amer Bahaa , George Justin , Rahal Kinan
Published: October 2019

INTRODUCTION:

Plexiform neurofibroma (PN) is a benign tumor that originates from nerves. This tumor is usually associated with neurofibromatosis type1 (NF1) and found in young patients. Common places of growth include head, neck and maxillofacial area. We report a rare case of common bile duct plexiform neurofibroma.

CASE DESCRIPTION/METHODS:

A 69-year-old female with history of cholecystectomy had incidental finding of dilated pancreatic duct (PD) on chest CT during pneumonia work up. Patient denied abdominal pain, weight loss, change in bowel habits, jaundice or itching. Physical examination was normal. Laboratory tests including CBC, LFT, CA 19-9 were unremarkable. MRCP showed extrahepatic biliary ductal dilation measuring 8 mm, minor intrahepatic ductal dilation involving left lobe, diffuse PD dilation from the ampulla to the body, involving the major and minor ducts with acinarization, and abrupt change in the main PD at the junction between the body and tail of pancreas, no masses were seen. EUS showed a CBD of 8 mm and a hypoechoic mass measuring 8.8 × 5.6 mm in the common hepatic duct (CHD) with mild dilation of the left hepatic duct measuring 6 mm. PD was dilated between the pancreatic head, and body measuring 8 mm without mural nodules, and 1.5 mm in the distal body and tail of pancreas. No obvious abnormality was visualized at the transition point. Previous findings were concerning for segmental main duct IPMN. ERCP performed, ampulla appeared normal without “fish mouth” appearance, and no filling defect in PD. Cholangiogram and biliary ductosccopy using Spyglass were performed and showed low-grade stricture in the CHD. Biliary epithelium was endoscopically normal in the strictured area. Biopsies obtained using Spybite. EUS and FNA of the hypoechoic area in the CHD was performed after the ERCP. Biopsies obtained with Spybite showed benign appearing ductal epithelium with fibrotic tissue. However, FNA cytology showed rare cluster of atypical glandular cells. Patient was referred to surgery. Pathology of the common bile duct showed a 7 mm plexiform neurofibroma with clear border resection without evidence of malignancy.

DISCUSSION:

PN is a rare benign tumor that develops from schwann cells in a bundle of nerves involving cutaneous nerves or internal nerve fibers. PN has substantial risk to transform into malignant peripheral nerve sheath tumors, therefore surgical resection is advised. PN is usually associated with NF1. However, few cases without clear etiology were reported with no link to the syndrome.
1459 A Curious Case of Progressive Iron Deficiency Anemia
Authors: Bhakta Dimpal , Latorre Melissa
Published: October 2019

INTRODUCTION:

Iron deficiency anemia is a common condition that often leads to evaluation of the gastrointestinal tract for sources of blood loss. Parasitic infections are uncommon causes of gastrointestinal blood loss. Here we present a case of progressive iron deficiency anemia due to Trichuris trichiura (whipworm) infection.

CASE DESCRIPTION/METHODS:

A 65-year-old male, originally from the Philippines, with a past medical history of hypertension and coronary artery disease (on aspirin and clopidogrel) presented with progressive worsening fatigue for four weeks with new onset small volume rectal bleeding for three days. Travel history was notable for a recent trip to Mexico complicated by a self-limited diarrheal illness six weeks prior to presentation as well as frequent travel to the Philippines. Physical exam was notable for pallor and a rectal exam with no evidence of external hemorrhoids and brown stool. Labs were notable for hemoglobin of 7.5 g/dL from a baseline of 14 g/dL one year prior to presentation. Other pertinent labs included a mean corpuscular volume of 80 fL, iron saturation of 4% with a ferritin of 7 ng/mL. An upper endoscopy and colonoscopy was performed. The upper endoscopy was unremarkable with no source of blood loss anemia. The colonoscopy was notable for internal hemorrhoids and evidence of worms found in the cecum. A worm was obtained and sent for microscopic evaluation with final speciation revealing T. trichiura (whipworm). The patient also underwent a video capsule endoscopy as an outpatient two weeks after discharge which was unremarkable. The patient was treated with a three day course of mebendazole and initiated on iron supplementation with interval outpatient follow up revealing resolution of iron deficiency anemia within 6 weeks post-treatment with subsequent hemoglobin of 13.7 g/dL.

DISCUSSION:

Parasitic infections, especially those without significant concurrent gastrointestinal symptoms, can lead to a diagnostic delay as a potential cause of iron deficiency anemia. Whipworm infections occurs through ingestion of whipworm eggs that are then passed in the feces of infected individuals. Many cases of T. trichiura infection are asymptomatic however a high worm burden can lead to diarrhea and anemia. The pathophysiology of resulting iron deficiency anemia from T. trichiura is thought to be from worm consumption of blood and possible colonic lesions leading to occult gastrointestinal bleeding. A thorough history, including travel history, remains crucial for diagnosis.
1462 Yellow Jacket in the Colon: An Incidental Finding During Screening Colonoscopy
Authors: Gollol Raju Narasimha Swamy , Aboutaleb Eslam , Ali Muhammad , Ali Eslam
Published: October 2019

INTRODUCTION:

Findings arthropods in the GI system is rare, especially intact arthropods. We here by describe an intact yellow jacket found during a routine screening colonoscopy.

CASE DESCRIPTION/METHODS:

A 52-year-old Caucasian male presented for routine screening colonoscopy. His past medical history was significant for hypertension and anxiety. He had used standard polyethylene glycol solution bowel preparation the day prior to the procedure. Physical examination was unremarkable. Colonoscopic examination was unremarkable except for an intact dead yellow jacket in the descending colon. The insect was not retrieved.

DISCUSSION:

Findings arthropods in the GI system is rare. Ants and wasps in the stomach and cockroach, drosophila and flour bugs in the colon have been reported. In majority of the cases, these findings are likely due to inadvertent accidental ingestion. In some cultures, insects such as flour bugs are consumed intentionally and may be rarely found in the colon during colonoscopy. Majority of the reported arthropods in the GI system were intact denoting likely resistance of their complex exoskeleton to the human digestive system. Majority of the ingested arthropods pass through the GI tract uneventfully but rarely can cause barely noticeable local reaction to severe system anaphylactic reaction. Our patient denied any knowledge of how the insect could have entered in to his gastrointestinal tract. It is likely that he inadvertently swallowed the yellow jacket in his bowel preparation solution and the insect made it to the descending colon intact likely aided by the rapid transit effects of the polyethylene glycol solution.
1468 Left-Sided Chest Pain Following Colonoscopy: Think Outside the Colon!
Authors: Khan Zarak H. , Korpole Pranay R. , Jarodiya Vijay , Singh Tejveer , Sultani Nabil
Published: October 2019

INTRODUCTION:

Colonoscopy is considered to be a low risk procedure performed regularly worldwide. The most common complications include hemorrhage and bowel perforation which are 1% and 0.1% respectively. The incidence of spleen rupture is estimated to be between 0.00005 and 0.017%. However, due to its nonspecific presentation many cases may be misdiagnosed and up to 11% of these patients will be discharged with a different diagnosis. Therefore, the actual incident is likely higher. We present a case of a 76-year-old female with spleen rupture 16 days after a routine colonoscopy.

CASE DESCRIPTION/METHODS:

76-year-old female with past medical history of atrial fibrillation on apixaban, coronary artery disease, recurrent bladder cancer and chronic obstructive pulmonary disease presented for sudden onset of chest pain. Pain was 10/10 in intensity and located in the left anterior chest wall with radiation to the left shoulder. She also had associated nausea without vomiting. Patient denied any history of trauma. Patient underwent an uncomplicated colonoscopy 16 days earlier during which a 1.3 cm polyp was excised. Upon presentation, vital signs were significant for a blood pressure of 96/58. Labs were significant for hemoglobin of 7.2 and INR of 1.6. CT scan of the abdomen showed findings suspicious for splenic rupture. Patient received 2 units of packed RBCs in the ED and was then taken to the OR for emergent exploratory laparotomy. Intra-operatively, the spleen was found to be ruptured and splenectomy was performed. She did not have any complications during or after the splenectomy and was discharged 6 days after the procedure in stable condition. Appropriate vaccinations were administered upon discharge.

DISCUSSION:

There are many proposed mechanisms for spleen injury during colonoscopy; these include tension on the splenocolic ligament, tension on pre-existing intra-abdominal adhesions and direct injury to the spleen during passage of the colonoscope through the splenic flexture. We speculate that our patient's use of apixaban might have played a contributing role. To our knowledge, only 5 cases of splenic injury have been previously reported with time of presentation greater than 16 days post-colonoscopy. Our patient's symptoms and location of pain are not typical for splenic injury. With our case, we intend to spread awareness about this not so uncommon and possibly fatal complication of colonoscopy with delayed and sometimes atypical symptoms.
1508 A Rare Case of Lobular Breast Cancer With Metastasis to the Colon
Authors: Shah Kinnari , Chuang Keng-Yu , Srinivasan Indu
Published: October 2019

INTRODUCTION:

Metastasis from infiltrating lobular cancer (ILC) preferentially involves bones, peritoneum and liver. Metastatic involvement of the gastrointestinal (GI) tract is very rare and if present usually involves the stomach and small intestine. Colorectal involvement is extremely rare. We present a rare case of an elderly female with a history of ILC who presented with GI symptoms that led to subsequent diagnosis of colon metastasis.

CASE DESCRIPTION/METHODS:

This is a 68 years old female diagnosed with ILC of the right breast six years ago treated with lumpectomy and chemotherapy. She also had peritoneal carcinomatosis. Six years later, she presented with abdominal pain and dark stools mixed with blood. CT scan of the abdomen showed ascites, peritoneal thickening and normal appearing bowel. Colonoscopy showed internal hemorrhoids, melanosis coli and erythema in the transverse colon (Figure 1). Biopsy from transverse colon revealed atypical cells in the lamina propria in “Indian file pattern” with Immunohistochemistry (IHC) positive for CK-7, mammaglobin and negative for CDX2. A positive CK7 and mammaglobin in the colon suggest ILC metastasis (Figures 2 and 3) whereas a negative CDX2 excludes primary colon cancer. She was started on palliative chemotherapy.

DISCUSSION:

Metastasis of ILC to the colon can manifest with a wide range of clinical and radiological features resembling various GI disorders. Further incidence of benign GI disorders in these patients is higher than metastasis, making the diagnosis a challenge. The presentation can range from asymptomatic abdominal mass to perforation, GI bleeding and obstruction. Radiology findings include normal appearing colon to diffuse or multifocal involvement, micro nodularity, tethering and stenosis. Colonoscopy with biopsy has moderate diagnostic yield especially in the absence of intraluminal lesion, and therefore in suspicious cases, a deep biopsy is indicated. Diagnosis is based on establishing similarities in the histology between a colon and breast tissue in terms of cellularity, growth pattern, hormonal status and IHC. ILC involves the layers of the colon in a “single file pattern” causing very subtle changes that can be missed on endoscopy. Treatment involves a multi-disciplinary approach including surgery, radiation and systemic therapy. Despite treatment colorectal metastasis from ILC has a poor prognosis with a median survival of 1-2 years.
1515 Portal Vein Thrombosis After Laparoscopic Sigmoid Colon Resection for Recurrent Diverticulitis
Authors: Bommena Shoma , Mehta Shivang
Published: October 2019

INTRODUCTION:

Portal vein thrombosis (PVT) following laparoscopic surgery is a rare complication. PVT after laparoscopic colorectal surgery is usually associated with inflammatory conditions like IBD and is more likely to occur after total proctocolectomy and in presence of postoperative intra-abdominal infection. We report a case of PVT in a patient with no identifiable hypercoagulable disorder who underwent laparoscopic sigmoid colectomy for recurrent diverticulitis.

CASE DESCRIPTION/METHODS:

A 54 year old male with a past medical history of gout and no known history of thrombosis had recurrent diverticulitis. He also had Clostridium difficile infection secondary to antibiotic use. CT showed diverticulosis, but no portal vein thrombosis. He underwent robotic sigmoid colon resection with an uneventful postoperative course. Six months later he started noticing right upper quadrant abdomen pain and diarrhea that went on for five weeks. He denied confusion, ascites and GI bleed. His PCP ordered a CT abdomen in that showed right hepatic lobe atrophy and non-opacification of branches of right portal vein consistent with prior intrahepatic portal vein thrombosis. Lab work revealed normal CBC, negative stool studies, slightly elevated alkaline phosphatase of 137, AST of 31, ALT of 28, total bilirubin of 1. He was referred to our hepatology clinic. We repeated MR abdomen with and without contrast that confirmed chronic non-occlusive thrombus in the right portal vein, left portal vein and main portal vein were widely patent. Further lab work by hematology showed no evidence of thrombophilic condition. Repeat labs after three months showed normal LFTS and intact liver function.

DISCUSSION:

PVT as a complication of laparoscopic surgery is uncommon. Local and systemic factors contribute to development of post-op PVT. Thrombosis related to CO2pneumoperitoneum may be caused by hemodynamic changes like decrease in superior mesenteric arterial and portal venous blood flow. Issues with PVT have been seen related to splenectomy, bariatric procedures, and right hemicolectomy. Pneumoperitoneum induced hemodynamic changes and local inflammation due to diverticulitis might have contributed to PVT in our case.
1526 Abdominal Tuberculoma in a Cirrhotic Patient With Disseminated Tuberculosis
Authors: Rezaie Aida , Ahmed Shifat , Mann Saba , Shaughnessy Richard
Published: October 2019

INTRODUCTION:

Disseminated tuberculosis (TB) is defined as two or more noncontiguous sites due to lymphohematogenous spread by Mycobacterium tuberculosis. Diagnosis is made through isolation of the organism from blood, bone marrow, or from two or more non-contiguous organs. Lymphocytopenia is a risk factor for dissemination. The incidence of disseminated TB is unclear, but of the cases reported in the United States in 2016, both pulmonary and extrapulmonary sites were reported in less than 10% of cases. We present a rare case of an abdominal tuberculoma in cirrhotic patient with disseminated tuberculosis.

CASE DESCRIPTION/METHODS:

72 year old Vietnamese female with a history of hepatitis C cirrhosis who presents with altered mentation concerning for stroke. CT head without contrast was negative. She subsequently developed melena with an associated hemoglobin of 6.2 overnight. She underwent upper endoscopy without significant findings. CT chest without contrast showed numerous noncalcified nodules bilaterally as well as the apices concerning for military tuberculosis. BAL positive with AFB stain. Lumbar puncture did not show significant pleocytosis, normal glucose and protein. CSF culture was negative for AFB, cocci, Cryptococcus. Blood cultures, HIV 1/2 Ag/Ab screen 4th generation and serum cocci were negative. CEA was 2.7. MRI head with and without contrast showed multiple enhancing lesions concerning for infection versus malignancy. CT abdomen/pelvis showed a colonic mass in the cecum and ascending colon with thickening in the ileum. Colonoscopy showed a non-obstructing large mas in the cecum. Biopsies of the ileum and cecum were consistent with granuloma formation with necrosis, acid-fast bacilli with confirmation on AFB stain. The patient was started on RIPE therapy. Unfortunately, her encephalopathy did not improve despite 2 weeks of treatment and she was placed on hospice.

DISCUSSION:

Abdominal tuberculosis (TB) is reported in less than 5% of all cases of TB worldwide. It can present with non-specific symptoms such as fever, weight loss and abdominal pain. Endoscopic findings of intestinal TB vary from ulcers, strictures, nodules to deformed ileocecal valves and fistulas. Patients typically improve within weeks of initiating antituberculous therapy. One case report demonstrated correlation with carcinoembryonic antigen (CEA) pre -and post antituberculous therapy in a patient with multivisceral tuberculosis suggesting it could be a marker to trend response to therapy.
1528 No Drama: Cap-Assisted Endoscopic Mucosal Resection of an Incidental Colonic Traumatic Neuroma
Authors: Estifan Elias , Patel Varun , Grossman Matthew
Published: October 2019

INTRODUCTION:

A traumatic neuroma is a well-known complication after acute trauma to a peripheral nerve; the nerve tries to re-establish continuity by an orderly growth of axons from the peripheral to distal stump through the proliferation of Schwann cells. However, this process is not always perfect, and aberrant repair gives rise to a neuroma.

CASE DESCRIPTION/METHODS:

We present a 50-year-old female who underwent an initial colonoscopy for change in bowel habits and was found to have a 7 mm submucosal lesion in the proximal rectum (Figure 1). She denied any complaints of rectal pain or previous rectal manipulation. Endoscopic ultrasound was done which showed a hypoechoic lesion in the submucosal layer without muscularis propria invasion. The patient underwent successful cap-assisted endoscopic mucosal resection of the lesion without complication (Figure 2). Pathology of the specimen revealed a traumatic rectal neuroma with immunostaining positive for S100 (Figure 3).

DISCUSSION:

The usual presentation of a traumatic neuroma is of pain, however, our patient presented asymptomatically which can possibly be attributed to the lack of somatic innervation as opposed to neuromas located in an extremity. Interestingly, our patient never had a previous colonoscopy, rectal trauma/manipulation, or rectal intercourse, which could have precipitated a neuroma. In the only other case of a traumatic rectal neuroma, the lesion likely arose as a result of trauma to the submucosal Meissner's plexus fibers or Auerbach's plexus fibers during the polypectomy. To our knowledge, this is the second case of a traumatic rectal neuroma reported in the English literature.
1530 Colo Low Flow: A Case of Exercise-Induced Colon Ischemia
Authors: Marcuard Maurice , Oldfield Edward C. , Kulla Bakri , Chen Ian
Published: October 2019

INTRODUCTION:

Colon ischemia is the most common type of mesenteric ischemia and is responsible for 15% of hospitalizations for acute lower gastrointestinal bleeding.1 While it predominately affects the elderly, colonic ischemia can occur in younger individuals during periods of intense exercise, typically long-distance or marathon runners.2,3

CASE DESCRIPTION/METHODS:

A 28 year-old male with a past medical history of type 2 diabetes mellitus and obesity presented to the hospital with two days of generalized abdominal pain associated with fevers, fatigue, and general malaise. The patient denied any diarrhea, blood in his stool, or vomiting. The patient did report an intentional 60 lb weight loss in the last 6 weeks through a diet and exercise regimen including up to 60 minutes of exercise per day. Physical examination demonstrated mild right sided abdominal tenderness but was otherwise unremarkable. Initial imaging with CT abdomen showed thickening and inflammation in the cecum and terminal ileum (Figure 1). Laboratory studies were normal apart from mild elevations of lactic acid 1.0, CRP 14.4, and ESR 31. Subsequently, a colonoscopy was performed which showed mild to moderate colon ischemia at the ileocecal valve and in the proximal right colon (Figures 2a and b). Sources of potential ischemia were further investigated with a CT angiography of the abdomen and echocardiography, both of which were normal. Given that no source of ischemia could be identified, the patient was diagnosed with colon ischemia secondary to exercise and managed with supportive care and close follow-up.

DISCUSSION:

Our case highlights an episode of nonocclusive colon ischemia triggered by shunting of blood away from the colon during periods of exercise. Importantly, our patient's presentation was non-specific and not characteristic for colon ischemia, which is classically a disease of elderly patients with risk factors for atherosclerotic disease; furthermore, when colon ischemia is induced by physical activity, most case reports have shown it is due to prolong intense exercise in long-distance and marathon runners.2,3 The occurrence of colon ischemia with only a moderate level of activity may be a reflection of the significant increase in our patient's activity from baseline without complete physiological adaptation. As such, it is important that clinicians are cognizant of the possibility for colon ischemia in any patient with regular exercise patterns, in particular if this represents a recent behavior change.