bluuebunny/crossref_metadata_2025 huggingface dataset:
2770 A Unique Case of Bezoar and Incidental Situs Ambiguus
Authors: Pisipati Sailaja , Jones Blake , Freeman Alison
Published: October 2019

INTRODUCTION:

Situs ambiguous refers to abnormal arrangement of thoracoabdominal organs along left-right body axis, and is associated with multiple complex congenital cardiac as well as non-cardiac anomalies. This abnormal arrangement is different from orderly arrangement seen in situs solitus or situs inversus. We report a unique case of incidental situs ambiguous discovered during management of aspiration pneumonia caused by gastric outlet obstruction.

CASE DESCRIPTION/METHODS:

62-year-old gentleman presented with one month history of multiple episodes of non-bilious vomiting and watery diarrhea, two weeks of abdominal distension and discomfort. Semi-urgent esophagogastroduodenoscopy (EGD) revealed partially digested food particles with inadequate views (bezoar). Placement of a nasogastric tube (NGT) triggered gag reflux resulting in vomiting and aspiration of gastric contents, causing hypoxia needing emergent intubation. Chest x-ray revealed bilateral infiltrates with loss of lung volume on the right. Urgent bronchoscopy revealed food particles predominantly in right bronchus intermedius. Patient developed acute respiratory distress and septic shock from aspiration pneumonia. CT abdomen showed a grossly enlarged stomach (gastric outlet obstruction) on the right side of the abdomen (situs ambiguous) with bezoar. EGD revealed voluminous amount of residue in markedly distended stomach; three liters were suctioned using a large bore Edlich gastric lavage tube. Benign appearing tight stenosis was noted in the duodenal bulb. Biopsies were negative for Helicobacter pylori or lymphoma. Although endoscopic dilation of stricture was initially considered, gastrojejunostomy was performed to bypass the stricture given severity of illness and prolonged recovery.

DISCUSSION:

Situs ambiguus is classified into two groups. Group I has isomerism of right atrial appendage and is usually associated with absence of spleen (Asplenia syndrome). Group II has isomerism of left atrial appendage and is usually associated with multiple spleens (Polysplenia syndrome). Liver is usually centrally placed or may remain in right or left hypochondrium. Mortality up to 40% at a very young age up was reported. Our patient remained asymptomatic due to absence of cardiac anomalies. Edlich tube is a large bore 36Fr NGT, 36” long, with a closed tip and multiple eyes, a 140cc syringe with a quick connect adapter on the tube. It is used to irrigate or lavage the stomach and plays an essential role in breakdown and evacuation of bezoars.
2771 Acute Gastric Dilatation: A Cause for Concern
Authors: Shaikh Danial , Mehershahi Shehriyar , Jyala Abhilasha , Sinha Chandni , Chilimuri Sridhar
Published: October 2019

INTRODUCTION:

Gastroparesis in diabetics can be worsened by hyperglycemia. Acute elevations in blood glucose suppress the frequency and contraction amplitude of antral pressure waves while stimulating phasic pyloric pressure waves, which can result in Acute Gastric Dilatation (AGD). Though an unusual occurrence, it requires a high degree of suspicion to avoid its rare but life-threatening complications. We present our experience of two patients with AGD.

CASE DESCRIPTION/METHODS:

Case 1: A 30-year-old male presented to the ER with nausea, vomiting and abdominal pain. His comorbidities included type 1 diabetes and end-stage renal disease. On examination, his abdomen was notably distended and bowel sounds were sluggish. No guarding or rigidity was appreciated. He was hypotensive (76/49 mmHg) and hypoxic. Lab values were significant for blood glucose of 1155 mg/dL and a pH of 6.97. He was emergently intubated and started on IV insulin and Epinephrine. An abdominal plain film x-ray showed acute gaseous distention of the stomach. An NG tube was passed which drained 500cc of brownish gastric content. A repeat x-ray 4 hrs later revealed resolution of gastric dilatation which was confirmed by CT-abdomen. Patient's abdominal symptoms improved thereafter and he made a full recovery in time. Case 2: 59-year-old male was brought to the ER with an altered mental status. As per EMS, he had “very high” blood sugar levels. His comorbidities included diabetes mellitus and chronic hepatitis C. His abdomen was distended with decreased bowels sounds. His vital signs were stable. Lab values were significant for hyperglycemia (649 mg/dL), and a blood pH of 7.29. He underwent an abdominal x-ray which showed marked distention of the stomach. A follow-up CT abdomen confirmed the finding, with no mechanical cause of obstruction identified. He was started on IV Insulin, IV antibiotics and was planned for endoscopic workup, however, his conditioned rapidly deteriorated and he required pressors with mechanical ventilation. The patient eventually suffered a cardiac arrest and was unable to be revived.

DISCUSSION:

AGD presents with nausea, vomiting, succussion splash, and abdominal distension. Acute hyperglycemia in uncontrolled diabetics is the precipitating factor. If intragastric pressures exceed 20 cmH20 (lower limit of gastric venous pressure), it can cause mucosal ischemia and necrosis. This may be followed by perforation, which has a high mortality rate. Emergency decompression with NG tube seems to be the treatment of choice.
2774 Gastritis After Combination Ipilimumab and Nivolumab: A Rare Adverse Event After Immunotherapy
Authors: Mahpour Noah , Bhagat Vicky , Sarkar Avik
Published: October 2019

INTRODUCTION:

Immunotherapies are commonplace in the treatment of many neoplasms, and have an array of commonly reported toxicities. Among the reported gastrointestinal side effects, diarrhea and colitis are most frequently cited. However, there have only been a rare handful of reported cases of Immune-checkpoint modulator toxicity affecting only the upper GI tract. In this paper we report a case of Ipilimumab-Nivolumab associated Gastritis in a patient treated with these medications at our facility.

CASE DESCRIPTION/METHODS:

The patient is a 78-year-old male with Stage IV Melanoma who presented to the hospital with nausea, vomiting, weight loss, and reduced oral intake for two weeks. The patient had most recently received 2 rounds of Ipilimumab and Nivolumab for his Melanoma 2 weeks prior to his presentation to our hospital, concurrent with the start of his symptoms. There had been no history of NSAID usage during this time, and physical exam was notable for mild epigastric tenderness. A Computed Tomography scan of the Chest/Abdomen/Pelvis showed diffuse thickening of the stomach, compatible with gastritis. Upper Endoscopy revealed diffuse severely erythematous mucosa with bleeding on contact in the entire examined stomach, and patchy, mildly erythematous mucosa without bleeding was found in the duodenal bulb, with the second portion of the duodenum being normal. The pathology report revealed subacute gastritis with acute inflammatory exudate consistent with an area of mucosal ulceration, with other etiologies of gastritis ruled out. The patient was begun on glucocorticoid therapy, with rapid resolution of his symptoms. Repeat endoscopy 2 weeks later revealed resolution of the previously noted gastritis and inflammation. Pathologic examination of biopsies confirmed resolution of the inflammatory process.

DISCUSSION:

On review of the literature, gastritis resulting from immune-checkpoint modulators has rarely been reported on. Some common side effects associated with these immune modulating medications, colloquially called immune-related adverse events (irAEs), include diarrhea, colitis, and hepatitis. However, there are a few case reports concerning the development gastritis without enterocolitis after Nivolumab treatment alone. Approximately 3 case reports and 1 case series of 20 patients describe such a side effect, To date, there are no reported cases of a patient treated with both Nivolumab and Ipilimumab who developed gastritis as the only adverse event.
2776 Not for Human Consumption: Caustic Ingestion Causing Delayed Gastric Outlet Obstruction
Authors: Wang Joy I. , Chen Patrick , Agrawal Sangeeta
Published: October 2019

INTRODUCTION:

Corrosive injuries from acid ingestion can cause scarring and fibrosis of the pyloric antrum. Scar formation of the gastric outlet may be evident as early as three weeks, occurring within eight weeks in 80% of cases. We present a rare case of caustic ingestion causing a delayed onset of gastric outlet obstruction.

CASE DESCRIPTION/METHODS:

A 55-year-old male with a past medical history of hypertension and caustic ingestion of toilet cleaner as a suicide attempt in 1986 presented with intermittent dysphagia. Endoscopy in 2012 showed antral narrowing with a normal pyloric channel. Vitals were significant for blood pressure of 158/94 mmHg otherwise within normal limits. Complete blood count and complete metabolic panel were within reference ranges. Repeat endoscopy found a pyloric stricture and biopsies were negative for neoplastic changes. Patient was managed conservatively with lifestyle modifications.

DISCUSSION:

Gastric outlet obstruction is a late sequelae of caustic injury and is more common with acid ingestion. Concentrated acids, such as hydrochloric acid, are generally the active ingredient of toilet cleaners. Acids clear rapidly from the esophagus into the stomach and pool in the pre-pyloric area due to corrosive-induced pyloric spasms, leading to damage of the pyloric antrum through scarring and surrounding adhesions. Endoscopic evaluation of the upper gastrointestinal tract establishes the diagnosis and determines the extent and severity of injury. Intralesional triamcinolone injections have been proposed for preventing stricture formation, but its efficacy remains unknown. The treatment of choice for gastric outlet obstruction is endoscopic dilatation. Surgery is an option for endoscopic failure or for patients with complications from endoscopic dilatation.
2777 Nutritional Deficiencies in a Patient With Roux-en-Y Gastric Bypass Surgery
Authors: Al-Douri Abdul , Chambers Jessica , John Jaison
Published: October 2019

INTRODUCTION:

Bariatric surgery is one of the most commonly performed surgeries in the US. Several types exist including vertical sleeve gastrectomy (VSG), adjustable gastric banding (AGB), and Roux-en-Y gastric bypass (RYGB). VSG and RYGB work through caloric restriction and neurohormonal changes. While there are many benefits of bariatric surgeries, there are also many complications including malabsorption of nutrients.

CASE DESCRIPTION/METHODS:

A 41-year-old African-American female with prior RYGB in 2014 presented to the hospital with general malaise, crampy abdominal pain, back and joint pain, nausea, dyspnea, and intermittent headaches with photophobia and phonophobia for the past 1 month. Labs revealed moderate microcytic anemia with hemoglobin of 9. Reticulocytes were depressed at 13.8. Metabolic panel was within normal limits. Rheumatologic panel including ANA, C3/C4 was negative. On exam, pertinent findings included tachycardia and epigastric tenderness with deep palpation. She had multiple 1 cm hyperpigmented circular lesions on the forehead, upper back, and bilateral upper arms. This prompted testing for copper and zinc, which were decreased at 26 and 54, respectively. CT abdomen/pelvis with contrast showed a small pericardial effusion but was otherwise normal. MRI brain showed no changes to prior images. The patient was discharged on a multivitamin with zinc and copper to follow up with her PCP.

DISCUSSION:

Copper and zinc are essential nutrients for humans and act as cofactors for a variety of metalloenzymes that participate in critical body functions. Deficiency in these nutrients is rare in the US as it’s found in commonly consumed foods. Copper deficiency results in brittle hair, skin depigmentation, neurologic dysfunction, and osteoporosis. Zinc deficiency can result in pustular skin rash, impaired taste, and immune dysfunction 4Zinc and copper are usually not added to multivitamins and not routinely measured by physicians, however patients with modified GI physiology due to bariatric surgery can be at risk. RYGB reduces the stomach’s capacity and re-routes ingested food to bypass the duodenum, where copper and zinc are absorbed. Patients with a history of gastric bypass surgery and ill-defined symptoms should be tested for trace mineral deficiencies. Patients who recently underwent a gastric bypass, particularly a RYGB, should be placed on a multivitamin that includes zinc and copper.
2778 A Cytomegalovirus Masquerade
Authors: Diallo Souleymane Y. , Haris Muhammad , Garapati Karthik , Parker Allan L. , Brady Charles
Published: October 2019

INTRODUCTION:

Plasmablastic lymphoma (PBL) is a very rare but highly aggressive lymphoma seen in HIV patients. It is typically seen in the oral cavity and extraoral involvement is even rarer. We present a unique case of gastric plasmablastic lymphoma initially thought to be cytomegalovirus (CMV) gastritis.

CASE DESCRIPTION/METHODS:

A 30-year-old HIV positive female presented with epigastric pain. She had an esophagogastroduodenoscopy (EGD) that showed non-bleeding erosive gastropathy 6 weeks before presentation. Biopsy showed CMV gastritis. She was given valganciclovir. Repeat EGD 4 weeks later showed a cardia ulcer with an adherent clot and oozing that was treated with epinephrine. She was given a proton pump inhibitor and valganciclovir. Her pain worsened after discharge despite treatment leading her to present to our facility. She was tachycardic and tender to palpation of the abdomen. Labs revealed CD4 246, viral load of 2760 and platelets of 1.1 million. A CT scan showed diffuse gastric thickening up to 2 cm (Figure 1.) EGD revealed an edematous, friable and oozing mucosa with scattered Forrest III ulcerations (Figure 2). Gastric biopsies were consistent with plasmablastic lymphoma without H pylori. She had six cycles of chemotherapy with complete response at 6 months. Repeat EGD at 6 months showed erythematous gastropathy (Figure 3.) Biopsies revealed chronic active gastritis with H. pylori and no lymphoma. She completed quadruple therapy for the H. pylori infection.

DISCUSSION:

PBL is a rare disorder seen in the HIV population, usually involving the oral cavity. EBV is seen in 74% of AIDS-related PBL. There has been no association with CMV or Helicobacter pylori reported in the literature. PBL is associated with an aggressive course and poor survival. Despite good initial response to chemotherapy, relapse rates are as high as 54% within the first year. The endoscopic appearance of gastric lymphoma is nonspecific presenting as tumor lesions, thickened folds, ulcerative, infiltrating, bulky, or as gastritis-like changes. CMV gastritis is typically seen with CD4 count < 50. A high index of suspicion was required to make an alternative diagnosis of PBL in this patient with a CD4 count > 200.
2780 A Case of a 20-Year-Old Female With Hereditary Diffuse Gastric Cancer Syndrome With Synchronous Diffuse Gastric Cancer and a Giant Uterine Tumor
Authors: Rosenkranz Laura , Kitano Mio , Hopp Grace
Published: October 2019

INTRODUCTION:

Hereditary Diffuse Gastric Cancer (HDGC) is defined by germline autosomal dominant mutation in the CDH1 gene causing an inherited form of diffuse gastric cancer. There are no reported cases of HDCG presenting with a synchronous giant uterine tumor.

CASE DESCRIPTION/METHODS:

A 20-year-old female with known pathogenic CDH1 mutation presented with 3 days of pelvic pain and a palpable lower abdominal mass. She underwent a CT abdomen/pelvis which revealed a large uterine tumor measuring 16 cm. The patient’s family history is notable for maternal grandmother and maternal uncle who were diagnosed with and died of gastric cancer at 46 and 55, respectively. Her mother, the proband, was diagnosed with stage IV diffuse gastric cancer at age 46, underwent genetic testing and was found to have a pathogenic mutation in the CDH1 gene. The patient’s 42-year-old maternal aunt, who also tested positive, underwent prophylactic gastrectomy. There was no evidence of gastric adenocarcinoma on pathology. The patient also tested positive for CDH1 mutation and was counselled about prophylactic gastrectomy. Given she had just turned 20, the patient was not offered immediate surgery. She underwent a baseline upper endoscopy prior to planned hysterectomy. Random endoscopic biopsies revealed diffuse poorly differentiated carcinoma with signet ring features. Given poor histology and diffuse nature, the patient received 3 cycles of neoadjuvant chemotherapy before undergoing total gastrectomy with Roux-en-Y reconstruction and uterine myomectomy. She opted for myomectomy to preserve fertility. Pathology revealed diffuse pT1aN0M0 poorly differentiated G3, stage IA gastric adenocarcinomaand a benign leiomyoma.

DISCUSSION:

HDGC is exceedingly rare, accounting for only 1% of all gastric cancers. The median age to develop gastric cancer in pathogenic CDH1 carrier is 33 to 40. The risk of developing gastric cancer is less than 1% in patients under the age of 20. HDGC has penetrance of up to 80%. Our patient’s 42 year old aunt had a pathogenic CDH1 gene; however, her final pathology following prophylactic gastrectomy did not show any evidence of cancer, highlighting the small possibility of having no disease manifestation. Lastly, our patient had a synchronous, yet separate, primary uterine tumor at the time of presentation. In reviewing the literature, there are no other reported HDGC cases with a concurrent separate primary uterine tumor.
2783 The Extreme of Morning Sickness: A Case of Gastric Adenocarcinoma in Pregnancy
Authors: Munoz Anisleidys , Pendela Venkata Satish , Soliman Youssef , Soliman Megan
Published: October 2019

INTRODUCTION:

Gastric adenocarcinoma usually presents in advanced stages and after 40 years of age. Presentation in pregnancy is rare, occurring in less than 0.1% of all pregnancies, and it presses additional challenges as the symptoms are usually overlooked. Reports of gastric adenocarcinoma in pregnancy undergoing different mainstays of therapy have been described. Here, we present a case of poorly differentiated gastric adenocarcinoma diagnosed at 26 weeks gestation, who had to undergo an individualized and multi-disciplinary approach, with a favorable outcome thus far.

CASE DESCRIPTION/METHODS:

A 24-year-old woman with no significant history, gravida 2, para 1 at 26 weeks gestation presented with hyperemesis, dehydration and anorexia requiring inpatient management. She had lost 19 Kgs during the second trimester. Lab work revealed hypokalemia of 2.8 mEq/L, and transaminitis: AST 206 U/L, ALT 354 U/L. MRI abdomen without contrast showed mild distention of the proximal stomach of unclear significance. Ultrasound of the liver, kidneys and appendix were non-revealing. Symptoms progressed; therefore, she underwent upper endoscopy, which revealed inflamed antral mucosa with nodularity. Biopsy did not show H. pylori, but rather poorly differentiated adenocarcinoma with signet ring features. This was further classified as IHC positive for CDX-2 and E-cadherin, HER-2+ (IHC 2+, FISH amplified). The patient was initially treated with neoadjuvant FOLFOX for 4 cycles given concurrent pregnancy, followed by induction of pregnancy at 36 weeks gestation. She then underwent surgical resection with total gastrectomy, omentectomy and lymphadenectomy. Surgical biopsy showed metastatic disease stage ypT3N1. Currently, 7 months after diagnosis, the patient is tolerating adjuvant chemotherapy with FLOT (5-FU, oxaliplain, docetaxel). Radiation therapy is planned following chemotherapy. The patient’s baby is alive and thriving.

DISCUSSION:

Gastric adenocarcinoma rarely presents in pregnancy and is often overshadowed by pregnancy-related symptoms as these may overlap. Thus, red flags such as extreme weight loss in pregnancy should raise suspicion for underlying pathology. Diagnosis and treatment pose challenges as these can encompass risks for the fetus, especially early on gestation. Nevertheless, gastric adenocarcinoma often presents as poorly differentiated disease in pregnancy warranting prompt diagnosis, staging and expeditious intervention with chemotherapy and surgical resection.
2784 Steroid Responsive Gastric Dysmotility - Seronegative Autoimmune Autonomic Neuropathy
Authors: Harris Samar , Greenan Garrett , Naina Harris , Harris Adam , Philip Justin , Phillips Lauren
Published: October 2019

INTRODUCTION:

Gastrointestinal motility disorders are complex conditions manifesting with a wide array of symptoms. In recent years, the increasing discovery of autoantibodies targeting the nervous system has led to the recognition of new neurologic autoimmune disorders (NAD) which present with the subacute development of profound neurological impairment and gastrointestinal motility disorders which when promptly treated with immunotherapy, may show dramatic improvement.

CASE DESCRIPTION/METHODS:

A 32 year old woman with a history of undifferentiated connective tissue disease presented to establish care for known gastroparesis Her symptoms started following an upper respiratory infection the age of 15 years, which was followed by development of arthralgia, rash, raynaud's, tonic pupils, and distal sensory symptoms. She also developed orthostatic intolerance and was diagnosed with severe gastroparesis with over 40 lb weight loss. Her medications included Plaquenil and methotrexate, as well as Zofran. She underwent extensive testing with autonomic function testing showing moderate sympathetic adrenergic dysfunction and distal sudomotor impairment which indicated a limited autonomic neuropathy and skin biopsy showed small fiber neuropathy. Paraneoplastic antibody testing, GAD antibody and ganglionic Acetylcholine receptor (gAChR ab) was negative. A trial of IVIg was started for suspected autoimmune GI dysmotility but this was complicated with pancytopenia. On exam she was malnourished with a BMI of 15, normal reflexes, and decreased distal sensations. She underwent repeat autonomic function testing which was normal. A 4 hour solid gastric emptying was performed which showed delayed emptying at 4 hr of 80%. She was underwent a 5 day infusion of IV Solumedrol at 1000 mg daily for suspected autoimmune dysmotility. A daily GCSI-DD ( gastroparesis cardinal symptom index- daily diary) score showed a >50% improvement in scores on Day 0 to Day 5 and normalization of 4 hour solid GES and was then started on IV Rituximab.

DISCUSSION:

This case highlights that importance of considering a diagnosis of neurologic autoimmune disorders which can present with as solitary GI dysmotility. Seronegative autoimmune autonomic neuropathy is a clinical entity which shows prominent sympathetic failure, sensory symptoms and is steroid responsive.
2787 Gastric Amyloidosis With Arteriovenous Malformation: A Rare Etiology of Upper GI Bleeding
Authors: Gujjula Srilaxmi , Barakat Mohamed , Aloreidi Khalil , Xiao Philip , Boire Nicholas , Reddy Madhavi , Gurram Krishna C.
Published: October 2019

INTRODUCTION:

Amyloidosis refers to group of conditions caused by a build-up of amyloid fibrils in organs and tissues throughout the body. We present a very rare case of localized amyloidosis of the stomach presenting with an upper gastrointestinal bleeding (UGIB) due to arteriovenous malformation (AVM).

CASE DESCRIPTION/METHODS:

An 81-year-old female with past medical history significant for hypertension presented with hematemesis of one day duration. Vital signs were within normal limits. Physical exam was significant for epigastric tenderness. Initial lab work revealed hemoglobin 8.4 g/dL, mcv 83 fL, wbc 11.2 K/cm, platelets 513 K/cmm. Complete metabolic panel was within normal limits. Esophagogastroduodenoscopy (EGD) demonstrated oozing of blood on contact with air insufflation from the lesser curvature, body and fundus of the stomach with normal duodenum. Interventional radiology angiogram and computed tomography angiography were performed and were unable to localize source of bleeding. EGD was attempted four days later and recurrent oozing of blood on mucosal contact with air insufflation occurred. She was subsequently placed on total parenteral therapy (TPN) and sucralfate for ten days to help heal the cause of the inflammation. A third endoscopy showed similar findings. Thus, biopsies were taken. Hemoglobin remained stable with no recurrent hematemesis episodes and patient was discharged on PPI, sucralfate and liquid diet. CD34 staining on biopsy reveals dilated and congested blood vessels suggestive of AVM and special stain (Congo Red) portraying apple green birefringence confirming diagnosis of amyloidosis (Figures 1 and 2). Serum protein electrophoresis exhibited gamma globulin spike portraying AL amyloidosis.

DISCUSSION:

A single case of intraabdominal arteriovenous malformation and localized amyloidosis of an abdominal mass has been reported. This is the first reported case of localized gastric amyloidosis with AVM presenting with an UGIB. The association between AVM and amyloidosis is hypothesized to be due to amyloid proteins deposition predilection around leaky vasculatures, which was proven in mice. AVM causes amplified plasma flow and increased amyloid deposition leading to vessel friability and ischemia, ultimately resulting in mucosal ulcerations with delayed healing. This is our postulated mechanism as to why our patient had persistent gastric ulcer bleeding not amenable to multiple therapeutic/follow-up EGDs.
2790 Autoimmune Hemolytic Anemia and a Gastric Mass in a Patient With Acute Epstein-Barr Virus
Authors: Rosa Cesar J. , Foster Daniel , Fenderson Joshua , Thompson Misty , Gonzales Paul
Published: October 2019

INTRODUCTION:

Angioimmunoblastic T-cell Lymphoma (AITL) is a rare peripheral T-cell lymphoma. This is the first reported case of AITL presenting with a gastric mass. There is an association with Epstein-Barr Virus (EBV), though its role in pathogenesis is unclear.

CASE DESCRIPTION/METHODS:

A 64-year-old female presented for abdominal pain with a suspicious gastric mass and lymphadenopathy. She developed autoimmune hemolytic anemia during the hospital course with Coombs testing revealing mixed warm and cold agglutinins. Anti-smooth muscle antibody was positive along with serology consistent with an acute EBV infection. Gastric mass biopsy returned inconclusive. Steroids were indicated but held given suspicion for lymphoma and need for accurate tissue samples. A blood transfusion was given and resulted in an appreciable increase in bilirubin level. Following lymph node resection, methylprednisolone was given and the patient’s hemoglobin stabilized. A tissue diagnosis of AITL was made and chemotherapy led to subsequent improvement in her anemia.

DISCUSSION:

Since AITL was first described in the 1970s, there has been a clear association with auto-immune phenomenon and correlation with EBV. This is the fourth reported case presenting with an acute EBV infection and the first presenting as a gastric mass.1,2 The presence of active EBV infection could potentially steer away from more insidious processes.1 Unfortunately, AITL is aggressive and has a bleak prognosis. Despite advancing treatments, median survival is only 3 years.3,4 The presence of active EBV infection can lead to misdiagnosis as there is some overlap in symptoms and presentation. High suspicion must be maintained for malignancy with this constellation of unusual hematological abnormalities.
2796 Possible Predictors of Gallbladder Stasis: Why Not Vitamin D?
Authors: Atem Ngum Kikah , Atem Folefac , Olanipekun Titilope , Weerakoon Sitara M.
Published: October 2019

INTRODUCTION:

Gallbladder (GB) stasis is highly prevalent in the general population, especially amongst females. It is also one of the most common gastrointestinal causes of hospital admission. A limited number of studies have shown no association between vitamin D levels and gallstone disease in the general population, despite an established association between vitamin D deficiency among pregnant females and GB stasis among pregnant females.

METHODS:

We used the Framingham Heart Study database and performed descriptive and multivariate tests to identify possible confounders not limited to vitamin D levels that are associated with GB stasis. Unadjusted tests were based on t-test and chi-square test when appropriate. Logistic regression analyses were performed with possible confounders of GB stasis. In order to understand the high prevalence of GB among females, both univariate and multivariate tests were performed on the sub-sample of females.

RESULTS:

Gender was predictive of GB stasis, with females being more likely to have GB stasis (P < 0.0001). Age (P < 0.0001) and body mass index (P < 0.0001) were associated with GB stasis in the entire study population. In the sub-sample of females only, high density lipoprotein cholesterol (HDL) showed a significant association to GB stasis with a negative estimate of the coefficient of interest, signifying that higher levels of HDL were protective against GB stasis among females. However, there was no significant difference in GB stasis based on Vitamin D levels (P = 0.3213).

CONCLUSION:

Vitamin D levels are not significantly associated with GB stasis in the general population. However, a closed study of age of onset of GB stasis, sex differences in GB stasis, effect of BMI, and the effect of HDL to GB stasis require much more attention to the understanding of the disease.
2800 Safety of ERCP in People Older Than 90: Nationwide Analysis
Authors: Al-Aboodi Yasir , Al-Chalabi Ahmed , Kobeissy Abdallah , Sodeman Thomas , Nawras Ali
Published: October 2019

INTRODUCTION:

The aim of this study is to examine the Endoscopic Retrograde Cholangiopancreaticograhy (ERCP) related complications and (all causes mortality in people above the age of 90 years who were hospitalized for Choledocholithiasis related admission.

METHODS:

National inpatient data sample(NIS) is used in this study. NIS is the largest publicly available all-payer inpatient care database in the United States, containing data on more than seven million hospital stays. Choledocolethiasis related admissions who had ERCPs during hospitalization are identified using the International classification of disease version 9(ICD9). We compared the ERCPs related complications and overall mortality between people above the age of 90 year old and people between the age of 70-89. A logistic regression is used to evaluate if there is any difference and SPSS Version 25 is used to execute the statistical analysis.

RESULTS:

924 patients with age above 90 are identified. (33.8%) are male, (66.2%) female, (82.4%) are white, 4%black, 7.6 Hispanic, 3.8% Asians, (0.2%) native, (1.6%) others. 8279 are in (70-89 years) group, 46.9% male, (53.1%) female. 71.1% white, 5.7% black, 9.8% Hispanic, 4.3% Asians, 0.6% natives Americans,2.5% other races. The percentage of post ERCP pancreatitis in the (70-89) vs (90 and above) group are 151(1.8%) vs. 17(1.8%). P > 0.05, OR = 0. 98. 95% CI (0.56-1.6). Post ERCP Cholangitis. are 169(2%) vs. 20 (2.1%), P = 0.86, OR = 1.01, 95% CI (0.6-1.65) respectively, Bleeding 5(0.1%) vs. 2(.0.2%). P > 0.13, OR = 3.51, CI 0.68-18.7 respectively. There were only 2 cases of perforation in the (70-89) group. All causes mortality is 206(2.5%) vs. 33(3.5%). P = 0.345, OR = 1.34, 95% CI (0.9-1.9).

CONCLUSION:

There are no morbidities or all-cause mortality differences in ERCPs related admissions in age group (90 and above) vs (70-90) group. Age by itself should not be an excuse to postpone, or cancel ERCP in this age group.
2802 Endoscopic Ultrasound (EUS)-Guided Needle Biopsy for Benign Pancreatic Diseases
Authors: Sánchez-Luna Sergio A. , Paleti Swathi , Gulati Rishabh , Wong Morgan , Sobani Zain A. , Rustagi Tarun
Published: October 2019

INTRODUCTION:

Endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA) is a well-established method for specimen acquisition in suspected pancreatic malignancies. However, the role of EUS-FNA for non-focal, non-neoplastic, benign pancreatic diseases such as chronic pancreatitis and autoimmune pancreatitis is diminished by the sample inadequacy and architectural distortion. This is evaded by histologic core biopsies obtained through newer generation EUS-fine needle biopsy (EUS-FNB). The aim of this study is to evaluate the feasibility, safety, and diagnostic yield of EUS-FNB for benign pancreatic diseases.

METHODS:

This is a retrospective review of a prospectively collected database of all patients who underwent EUS-FNB for suspected benign parenchymal pancreatic diseases from 02/2017 to 11/2018. The primary objective of this pilot study was to evaluate the feasibility, diagnostic adequacy, and safety of the newer 22-gauge EUS-FNB in the evaluation of benign pancreatic parenchymal diseases.

RESULTS:

Seven patients (mean age 36.5 ± 18.5 years; 57% males) were included in this study. The mean number of FNB passes was 1.7 (median 2, range 1-3) (Figure 1A and B). Adequate tissue for histopathogical diagnosis was obtained in all cases. Mean length of core biopsy specimen obtained was 12 ± 8.2 mm. Histopathologic diagnoses included: chronic pancreatitis in 2, autoimmune pancreatitis in 2 patients, and parenchyma with no diagnostic abnormality in remaining 3 patients. Two patients with autoimmune pancreatitis were treated with steroid therapy with excellent clinical response. No adverse events such as bleeding, perforation, or post-biopsy pancreatitis were observed on median follow-up of 8.3 (range, 1-21) months.

CONCLUSION:

EUS-FNB with the newer 22-gauge biopsy needle is a feasible and safe procedure, and provides adequate pancreatic tissue specimen (core biopsy) for histopathological diagnosis of benign pancreatic diseases such as chronic pancreatitis and autoimmune pancreatitis.
2809 The Role of Serum Total Bilirubin Level Pattern in Predicting Spontaneous Passage of Common Bile Duct Stones
Authors: Al-Ghanoudi Ashirf , Mardini Houssam , Frandah Wesam
Published: October 2019

INTRODUCTION:

In patients with suspected choledocholithiasis, total bilirubin (T. bili) level is widely accepted as a marker of biliary obstruction. We sought to evaluate the role of bilirubin decline pattern and extent in predicting spontaneous passage of stone in patients with suspected choledocholithiasis.

METHODS:

Patients who were 18 or older and admitted to our institution between October 2015 and December 2017 with ICD 10 code(s) commonly used in patients with confirmed or suspected choledocholithiasis were identified through the University of Kentucky Medical Services Database. Only pts with documented elevated T. bili with at least three measurements 12 hours apart were included for further review. Only pts with high-probability of choledocholithiasis based on very strong and/or strong clinical predictors of choledocholithiasis per ASGE guidelines were included in the final analysis. All selected pts underwent one or more of the following studies: MRCP, ERCP, EUS or IOC during their hospitalizations. Categorical variables were compared using chi square tests and continuous variables using two-sample t-tests. Odds ratios and 95% confidence intervals (CI) were calculated for variables of interest.

RESULTS:

825 patients were identified according to the screening criteria. 723 patients were excluded due to having pathologies other than documented or suspected choledocholithiasis and 102 patients (48 males and 54 females) were included in this study. Mean age was 57.4 years +/- 22. Of the 102 patients, 74 (72.4%) were eventually documented to have retained stones requiring clearance. 75 (73%) patients had consistent decline in T. bili ( > 3 measurements) while 33 (27%) had fluctuating levels. In patients with a consistent decline in T. bili, 26 (34.7%) were found to have retained stones while 49 (65.3%) were confirmed to have spontaneous passage of stone based on subsequent study. In comparison, significantly lower number (3; 7.4%) of patients with fluctuating T.bili level had spontaneous passage (OR 6.6; 95% CI 1.5, 30.2; P = 0.06). The mean change of T. bili in patients with and without spontaneous stone passage on day 2 was not significant (1.16 mg/dl +/-2.23 vs. 1.04 mg/dl +/- 1.17, P = 0.78).

CONCLUSION:

Patients with consistent total bilirubin decline beyond day two after initial presentation were seven times more likely to have had spontaneous passage of bile duct stone regardless of the decline level and can be used to determine need for further diagnostic and/or therapeutic interventions.
2812 Impact of Rapid On-Site Evaluation (ROSE) on Endoscopic Ultrasound-Guided FNA of Pancreatic Cysts: A Five-Year Comparative Study Between Two Academic Institutions
Authors: Al-Chalabi Ahmed , Khatib Hasan , Al-Abboodi Yasir , Plavnicky John , Kovar Sierra , Galka Eva , Sun Hongliu , Shadid Rana , Nawras Ali , De Las Casas Luis
Published: October 2019

INTRODUCTION:

Endoscopic Ultrasound Guided-Fine Needle Aspiration (EUS-FNA) is considered the modality of choice for diagnosing intermediate pancreatic lesions. Rapid-on site evaluation (ROSE), when performed by a cytopathologist, has been suggested to improve the diagnostic yield of EUS-FNA. Prior studies were inconsistent regarding the benefit of ROSE. In our study, we evaluated the diagnostic yield of EUS-FNA in the presence of an on-site cytopathologist providing real-time feedback to the endoscopist compared to EUS-FNA alone in two academic hospitals.

METHODS:

We conducted a 2010-2015 retrospective chart review of all EUS-FNA performed at two academic medical centers (UT and UR). The policy at UT is to perform all EUS-FNA with ROSE, whereas it is not routinely done at UR. Cases where included when surgical pathology was available. Patients’ demographics, pancreatic cyst characteristics and EUS techniques were analyzed. EUS-FNA were considered valuable when it provided a classifying cytopathologic diagnosis. Student T-test and Analysis of Variance (ANOVA) were performed when appropriate for descriptive purposes.

RESULTS:

Forty-five cases (13 at UT, 32 at UR) were identified. EUS FNAs coupled with ROSE (UT) rendered 100% (13/13) valuable diagnoses, while those done with no cytopathologist on site (UR) had valuable diagnosis in 37.5% of the cases (12/32, P < 0.0001). The sensitivity of EUS-FNA at UT was 85% compared to 33% at UR. There was no statistically significant difference in gender, age, site or size of the tumor. The mean number of needle passes at UT was 1.9 (range 1-6) vs. 1.1 (range 1-3) at UR. The majority of needles used were 19G (55%) at UT vs 22G (83%) at UR (P < 0.001). Only one patient at UR had a minor cyst bleeding to the main pancreatic duct that required no therapeutic action.

CONCLUSION:

The results highlight the advantage of bed-side cytopathologist interaction with the endoscopist during EUS-FNA of pancreatic cysts. Absence of malignant cells despite suspicious ultrasound findings may have prompted more needle passes. The use of 19G needle may have improved outcomes with no significant increase of complications. In addition to the small sample size and the retrospective nature, the study is limited by the variability in personnel experience (endoscopists and cytopathologists) and the techniques used, indicating that further studies are necessary to confirm these findings.
2814 Clinical Significance of an Impacted Bile Duct Stone at Duodenal Papilla
Authors: Guevara-Zavala Andrés E. , Monreal-Robles Roberto , Jáquez-Quintana Joel O. , González-González José A. , Maldonado-Garza Héctor , García-Compeán Diego , Garza-Galindo Aldo
Published: October 2019

INTRODUCTION:

An impacted bile duct stone at duodenal papilla or Impacted Papillary Stone (IPS) can lead to acute cholangitis (AC) or acute pancreatitis (AP) due to an almost complete obstruction of the common bile duct. This study evaluates the prevalence of these two diseases and the clinical characteristics when a gallbladder stone is impacted at the duodenal papilla.

METHODS:

This is a retrospective case-control study. Between March 2014 and January 2019, 394 consecutive cases of choledocholithiasis treated with endoscopic retrograde cholangiopancreatography (ERCP) were studied. Cases were divided into two groups: Patients with IPS and patients without impacted papillary stone.

RESULTS:

IPS group included 31 cases and control group included 363 cases without IPS. Fifteen patients in IPS group (48.4%) and 67 patients in control group (18.5%) were diagnosed with AC based on the 2018 Tokyo Guidelines (Odds Ratio: 4.14 [95% CI 1.95-8.79]; P < 0.01). AP was found in 9 patients in IPS group (29%) and 62 patients in control group (17.1%) (Odds Ratio: 1.98 [95% CI 0.87-4.5]; P = 0.14). Four cases in IPS group (12.9%) and 9 cases in control group (2.5%) were diagnosed with both AC and AP (Odds Ratio: 5.82 [95% CI 1.68-20.15]; P = 0.01). A higher count of white blood cell levels (Odds Ratio: 2.84 [95% CI 1.35-5.99]; P < 0.01) and ALT levels 4 times upper limit of normal were found in the IPS group (Odds Ratio: 2.61 [95% CI 1.17-5.83]; P = 0.02).

CONCLUSION:

IPS was found in 7.86% cases of choledocholithiasis and AC is more frequent than AP; IPS was found to be a risk factor for AC and AP with concomitant AC. Thus prospective trials are needed to confirm these findings to dictate a different approach whether IPS is found.
2815 Outcomes of Interventional Endoscopy for Gallstone Complications in Early Pregnancy
Authors: Azab Mohamed , Kam Kelli , Hong Annie , Volk Michael
Published: October 2019

INTRODUCTION:

Endoscopic retrospective cholangiopancreatography (ERCP) is a technically challenging procedure rarely associated with severe post-procedure complications. Pregnancy promotes cholelithiasis due to hormonal changes and ERCP may be indicated. Surgical intervention is preferred during the second trimester of pregnancy. However, limited data is available on the safety of ERCP in early pregnancy.

METHODS:

Over a 7 year period, all pregnant patients with complicated gallstone disease were studied retrospectively at Loma Linda University Medical Center in California (n = 41). Five patients underwent ERCP during either the first or second trimester for choledocholithiasis or gallstone pancreatitis. One patient underwent laparascopic cholecystectomy during the same hospitalization. All patients underwent sphincterotomy and stone removal with balloon sweeps. Fluoroscopy was utilized in all five cases.

RESULTS:

Three patients delivered full term, healthy babies. Two of the patients experienced spontaneous abortions within one week after ERCP. Both cases of spontaneous abortion were in their first trimester of pregnancy. There were no other clear etiologies reported for cause of both abortions.

CONCLUSION:

ERCP is reported to be a relatively safe procedure in pregnancy. More studies are required to investigate the safety of ERCP in early pregnancy.
2816 Mortality of Different Etiologies of Acute Pancreatitis and Effect of Aggressive vs. Non-Aggressive Fluid Resuscitation
Authors: Kesar Varun , Mir Adil , Kanth Rajan , Mouchli Mohamad , Shakhatreh Mohammad , Yeaton Paul
Published: October 2019

INTRODUCTION:

Acute pancreatitis (AP) is a common cause of GI-related hospitalization. AP can be classified into mild AP, moderately severe AP and severe AP. Severe acute pancreatitis (SAP) and necrotizing pancreatitis (NP) or localized complications with infections account for > 40% of pancreatitis related mortality. Common etiologies include acute biliary pancreatitis (ABP) and alcohol ( AAP). We aimed to study the mortality rate and effect of fluid resuscitation in AP (SAP, NP).

METHODS:

Patients with SAP and NP who received PEG-J were collected retrospectively from a single tertiary care center by utilizing ICD-9 and ICD-10 codes (International Classification of Diseases). Each case was confirmed by manual review. SAP and NP were defined per the 2012 revised Atlanta classification. Descriptive analysis was done by Excel. Fluid resuscitation was defined as aggressive hydration (AH) infusion of crystalloids given at a rate of at least 3.0 mL/kg/h after a bolus of 10-20 mL/kg within 24 hours of presentation.

RESULTS:

Seventy-nine patients with SAP or NP underwent PEG-J placement. Demographics, labs and comorbidities (Table 1). Etiologies of pancreatitis were alcohol 30% (24), biliary 39%, idiopathic 23%. Distribution based on Atlanta classification (Table 2). All-cause mortality of the patients was 12 (15%) and among this group 7 (9%) were related to pancreatitis related complications whereas 4 (5%) patients opted for palliative care and 1 was found to have pancreatic cancer. Among AAP, 4 patients died from reasons not related to pancreatitis, as compared to 4 patients (13%) who died in ABP group which were all related to pancreatitis. In ABP, 28 (90%) patients had data available for fluid. 8 (29%) received AH within first 24 hours and none of them died. 20 (71%) did not receive AH and 3 of them died. This was not significant at P < 0.05 using Fisher exact test. In AAP, 21 (87.5%) had data for fluid. Six (29%) received AH and none of them died. Fifteen (71%) did not receive AH and 3 of them died but the deaths were not related to pancreatitis. Average ICU stay of the overall subjects was 8 days and median hospital stay was 12 days. Average duration of hospital stay in AAP was 19.8 days compared to 20.5 days in ABP. Average ICU stay was 9 days in both groups.

CONCLUSION:

ABP carries higher mortality and more LOS related to pancreatitis compared with AAP. The AH is associated with decreased mortality in ABP but was not statistically significant perhaps due to small sample size.
2818 Physician Perspective on Inpatient Constipation and the Use of the EMR for Prevention
Authors: Moore Andrew , Jones Sabrina K. , Kapil Anuja , Lee Salina
Published: October 2019

INTRODUCTION:

Constipation is a common problem among patients hospitalized in the United States. Hospitalized patients are particularly vulnerable to constipation due to increased age, decreased mobility, and administration of medications causing decreased bowel motility. Identifying those at risk for constipation on admission and properly discharging patients on bowel regimens when needed can significantly reduce morbidity and mortality of hospitalized patients and save facilities the added costs of complications from constipation. The objective of this study was to assess physician awareness of managing inpatient constipation and receptiveness to changes in the EMR to prevent development of constipation.

METHODS:

We surveyed residents and attendings within the department of internal medicine at an academic institution to assess awareness of inpatient constipation management and to determine if physicians would support a reminder system to start bowel regimens when appropriate within the EMR. Specific questions from the survey are listed below (Figure 1).

RESULTS:

73 resident and attending physicians were surveyed. Physicians marked “sometimes” most often when asked about history taking and medication reconciliation related to constipation on admission and discharge. Most physicians (63%) are in favor of using a protocol as part of the admission order set that would identify those needing to be started on a prophylactic bowel regimen for constipation based on risk factors. Most physicians (82%) do not use as part of their progress note checklist a reminder if patients are on a bowel regimen. Most physicians (79%) are in favor of having a protocol as part of the discharge order set to remind them to discharge patients on a bowel regimen if any constipating medication was prescribed (e.g. opioids).

CONCLUSION:

Constipation is a problem among many hospitalized patients and physicians frequently fail to implement strategies for prevention. More emphasis needs to be placed on preventing constipation from occurring in the inpatient setting. Limitations of the study are primarily the small sample size and its restriction to internal medicine. Future surveys should also be shared with other services including general surgery prior to implementing any changes. We propose an EMR notification system that identifies patients on admission and discharge who would benefit from a prophylactic bowel regimen based on risk factors, and most physicians at this institution would support such a change to the EMR system.