bluuebunny/crossref_metadata_2025 huggingface dataset:
1577 Right Side Ischemic Colitis or Colon Cancer: Case Reports
Authors: Bella Saif , Alom Md S. , Bank Leslie
Published: October 2019

INTRODUCTION:

Ischemic colitis remains an enigmatic disease with a wide array of pathogenic mechanisms and variable outcome. Recent series indicate that right-sided ischemic colitis (RIC) may have a worse prognosis compared to left-sided colitis (LIC). We are presenting two interesting cases of RIC believed to be colon cancer.

CASE DESCRIPTION/METHODS:

1st case: An 82-year-old Caucasian female who has a pertinent medical history of hypertension, GERD, dyslipidemia, and gout. She presented with right lower quadrant abdominal pain. The pain was followed by a loose non-bloody bowel movement. Her symptoms were associated with tiredness, nausea, subjective fever, and chills. She had normal hemodynamics upon presentation. Her exam was benign except for RLQ fullness. Initial blood work was consistent Leukocytosis. CT scan of the abdomen and pelvis mass like thickening of the proximal right colon which was concerning for colonic neoplasm (Figure 1). CEA was within normal. Fecal calprotectin level was increased at 309. Stool studies were negative for enteric pathogens or C. difficile infection. Colonoscopy demonstrated an area of moderately congested and ulcerated mucosa in the ascending colon and cecum. These findings were suspicious for ischemic colitis. Biopsies confirmed ischemic colitis and ruled out dysplasia or malignancy. She was treated successfully with intravenous fluids, bowel rest regimen, and IV antibiotics. 2nd case: A 70-year-old male who underwent CABG for underlying CAD. Postoperatively, he complained of right lower quadrant abdominal pain. CT scan of the abdomen and pelvis showed Cecal mass concerning for colon cancer (Figure 2). Colonoscopy revealed findings consistent with ischemic colitis (Figure 3). Patient treated with IV fluid and Antibiotics. He did well. 8 months later, colonoscopy was repeated and showed complete resolution of his colitis.

DISCUSSION:

RIC differs from left-sided ischemic colitis. RIC diagnosis could be challenging. Most common reported presentations were weight loss, diarrhea, vomiting or ileus, and no rectal bleeding. We are presenting rare cases of RIC misdiagnosed initially as colon cancer.
1590 Another Case of Duloxetine-Induced Lymphocytic Colitis
Authors: Prato Marie D. , Daid Sarav , Toubia Nabil
Published: October 2019

INTRODUCTION:

Microscopic colitis comprises two histologic subtypes; Collagenous colitis (more severe) and Lymphocytic colitis (LC). The pathogenesis is unclear but likely multifactorial with some associations to smoking and diseases with autoimmune background. Potential causative drugs have also been implicated with the most common being NSAIDS, PPI and Selective serotonin-reuptake inhibitors (SSRI). We are reporting a case of Duloxetine, a selective serotonin and norepinephrine-reuptake inhibitor (SNRI), causing LC.

CASE DESCRIPTION/METHODS:

A 49 yo F, caucasian with PMH of GERD and recent diagnosis of fibromyalgia was referred to gastroenterology clinic for diarrhea of unexplained origin for 1 month. Patient claimed diarrhea began 6 weeks after starting Duloxetine. She reported around 5 episodes of explosive watery, brown bowel movements daily with bloating. She also endorsed fatigue, dizziness and joint pains. She denied fevers, chills, blood in the stools, abdominal pain, nausea, vomiting. She denied any recent travel, new food trial, sick contact, new medications other than Duloxetine. She didn't use NSAIDs or PPI. Her other home medications were Levothyroxine and Lisinopril. Her symptoms of upper body pain, loss of energy and mood swing had improved considerably, and her rheumatologist doubled the dose of Duloxetine and the patient noted that the number of daily bowel movements increased. Physical exam showed hyperactive bowel sounds and colonoscopy revealed a completely normal colon. The pathology of the biopsy taken reported diffuse mixed colonic inflammation, marked intraepithelial lymphocytosis and focal acute cryptitis favoring lymphocytic colitis with no evidence of collagenous colitis. Infectious etiologies were ruled out. Decision was made to taper the Duloxetine, and patient was started on Loperamide. Upon follow-up visit two months later, pt reported complete resolution of the diarrhea, but recurrence of her fibromyalgia symptoms for which she was given cyclobenzaprine, which seemed to be have helped.

DISCUSSION:

Lymphocytic colitis is often insidious but sudden onset was reported in forty percent of patients. There were two other published case reports of duloxetine-associated LC, and just like this case, discontinuation of the medication resulted in prompt resolution of the diarrhea. Microscopic colitis has been associated with excessive fluid loss and malabsorption caused by the inflammation and can easily result in dehydration, dizziness and weight loss affecting quality of life.
1612 Olmesartan Enteropathy and Pancolitis
Authors: Tabbalat Aya , Curras-Martin Diana , Pittman Meredith E. , Maltz Charles
Published: October 2019

INTRODUCTION:

Olmesartan enteropathy is a well-documented uncommon cause of diarrhea. However, olmesartan induced colitis is an under-recognized entity. We report a case of olmesartan enteropathy and colitis in a patient on olmesartan for hypertension for over a year who presented with chronic diarrhea.

CASE DESCRIPTION/METHODS:

A 69-year-old man, with history of hypertension, on olmesartan for 1.5 years presented with 5 weeks of 4-5 daily episodes of watery, non-bloody diarrhea associated with nocturnal fecal incontinence, nausea, and vomiting. He had no abdominal pain, melena, weight loss, NSAIDs use, or recent travel. Patient had had multiple admissions for dehydration, and suspected infectious etiology for which he was given empirical antibiotics without clinical improvement. On exam he was afebrile, hemodynamically stable, with unremarkable physical exam. Laboratory testing revealed WBC of 10.8 × 103/ul, hemoglobin of 14.5 g/dL, creatinine of 1.53 mg/dL, and potassium of 2.8 mEq/L. Inflammatory markers and liver function test were not elevated. Stool PCR and C. Difficiletoxin were negative, as was anti-TTG with normal IgA levels. A CT abdomen and pelvis was unrevealing. EGD revealed blunted duodenal mucosa with biopsy showing chronic enteritis with villous shortening, crypt hyperplasia, and increased intraepithelial lymphocytes (Figure 1). Colonoscopy demonstrated multiple scattered non-bleeding aphthous ulcers in the entire colon (Figure 2). Colonic pathology showed focally active colitis and intraepithelial lymphocytes without granulomas (Figure 3). Olmesartan enteropathy was suspected and the medication was discontinued. The patient’s diarrhea resolved two weeks after olmesartan was discontinued.

DISCUSSION:

Olmesartan enteropathy can manifest with diarrhea, weight loss, iron deficiency anemia, dehydration, hypokalemia, and renal insufficiency. It mimics celiac disease clinically and microscopically, with the presence of villous atrophy in the small intestine biopsy. A negative celiac disease serology helps to distinguish between these two entities. In addition, drug-induced colitis has also been reported in patients on olmesartan. The presence of lymphocytic infiltrate, preserved architecture, and absence of granuloma on colon biopsy helps differentiate this entity from IBD or infectious colitis. Symptoms of olmesartan enteropathy may develop months or years after the initiation of therapy. However, mucosal changes in small and large intestine will resolve after discontinuation of olmesartan.
1620 Pneumatosis Intestinalis Associated With Clostridium difficile Colitis in Crohn’s Disease
Authors: Abraham Ann A.
Published: October 2019

INTRODUCTION:

Pneumatosis intestinalis (PI) or pneumatosis cystoides intestinalis is defined as the presence of extraluminal bowel gas that is confined within the bowel wall. Characterized by intramural gas in the gastrointestinal tract, PI represents an alarming radiographic sign rather than a specific diagnosis. PI is associated with a wide spectrum of underlying pathological processes such as bowel ischemia, mechanical trauma, inflammatory/autoimmune bowel disease, intestinal neoplasms, bacterial infections like C. Diff, drug-induced including immunosuppression therapy. Differentiating these causes is critical in directing an appropriate care plan and specific treatment is best directed at the underlying disease process. Described here is a case of pneumatosis intestinalis associated with Clostridium Difficile infection in the setting of Inflammatory Bowel Disease (IBD).

CASE DESCRIPTION/METHODS:

11-year-old white male with Crohn's Disease on remission on Remicade and Methotrexate, presented with severe periumbilical pain radiating to right lower quadrant associated with fever, multiple episodes of loose stools and vomiting. Denied recent travel, sick contacts or recent exposure to antibiotics. On exam he had significant right lower quadrant abdominal tenderness with no guarding or rebound. Lab data only revealed mild elevation of CRP. US abdomen showed poorly visualized appendix. Subsequent CT abdomen revealed pneumatosis of ascending colon without wall thickening. Following, he was admitted and considering his stable clinical conditions and lab assays, he was treated conservatively with IV antibiotics and bowel rest. A day later, stool studies returned positive for C. Diff toxins. He was started on oral Vancomycin. Serial abdominal X-rays revealed disappearance of PI. Patient began to show clinical improvement, tolerating feeding advances gradually over the next four days.

DISCUSSION:

IBD is a rare cause of PI. Concurrently, patients with IBD are at increased risk of developing C. Difficile infection. C. Diff infections have a different and often more severe clinical course in patients with IBD. PI patients should be carefully evaluated for possible surgery due to the risk of severe complications. However, management decisions should be made on combined clinical, lab findings and underlying etiology. As in the above case, supportive care and appropriate antibacterial agents sufficed to alleviate symptoms and resolve the pneumatosis.
1628 Cecal Metastasis From Renal Cell Carcinoma Five Years After Nephrectomy: A Case Report and Review of the Literature
Authors: Graff Erica , Panara Ami , Bhamidimarri Kaylan R.
Published: October 2019

INTRODUCTION:

The incidence of renal cell carcinoma (RCC) was 16.4 per 100,000 people in the United States between 2011 and 2016 (1). Common sites of metastasis include lung, bone and liver (2). More rare sites of metastasis include the tongue (3), small intestine (2), and colon (4, 5). There have been a few reported cases of metastatic RCC in the colon following a nephrectomy (6-8), however, most reported cases have been 7 or more years following surgery.

CASE DESCRIPTION/METHODS:

A 73-year-old woman presented to the hospital complaining of fever for several days, despite a 10-day course of levaquin for a suspected URI. The patient had a history of hypertension and RCC; status post left nephrectomy and partial right middle lobe pneumonectomy for mediastinal metastases in Venezuela 5 years prior to current presentation at our local safety net hospital. The patient received adjuvant sorafenib, which was continued until 2 months prior to hospitalization. For the last few weeks, the patient noted 1-2 bowel movements a day that were dark colored and decreased in caliber compared to her normal. She denied abdominal pain, weight loss, or night sweats. The patient did report a recent history of anemia, one-year prior, requiring multiple blood and iron transfusions and erythropoietin; however, her fecal occult blood test was negative at that time and she never underwent an endoscopic evaluation. On presentation to the emergency room, she had a microcytic anemia, with a hemoglobin of 6.3 ultimately consistent with iron deficiency anemia (Fe level 11). CT abdomen demonstrated a 5.2 cm lobulated cecal mass. She was admitted for anemia evaluation and abdominal pain. Colonoscopy showed a polypoid partially obstructing 4-cm cecal mass without active bleeding. Biopsies from the mass were PAX8 and CAIX positive, consistent with clear cell renal carcinoma.

DISCUSSION:

Colonic metastasis of RCC is an uncommon occurrence after curative surgery. Most cases in the literature presented more than 5 years after nephrectomy and without signs of obstruction or anemia (Table 1). Therefore, the provider should have a high index of suspicion when a patient presents with change in bowel habits or abdominal pain. With early diagnosis these patients can be placed on appropriate therapy for recurrence.
1636 Diverticulitis Complicated by Fusobacterium Nucleatum Brain Abscesses
Authors: Sharma Bashar , Shah Mili , Antoine Marsha , Dawod Enad , Manocha Divey
Published: October 2019

INTRODUCTION:

Diverticulitis is one of the manifestations of diverticular disease in which the colonic wall diverticula get inflamed. About 25% of patients with acute diverticulitis can develop complications including local abscess formation, fistulation, contained micorperforations or macroperforations leading to generalized peritonitis. Rarely, it can disseminate forming distant abscesses. We are reporting a case of diverticulitis complicated by brain abscesses.

CASE DESCRIPTION/METHODS:

A 55-year-old male presented to the ED with a 4-day history of lower abdominal pain. Physical examination showed left lower quadrant tenderness. Vital signs were all within normal limits. Lab testing was significant for elevated WBC at 17,000 cells/microliter. CT abdomen/pelvis showed sigmoid diverticulitis with a phlegmon and a focus of contained microperforation with extraluminal free air (Figure 1). He was discharged home on a 3-week course of oral amoxicillin/clavulanic acid with improvement of his symptoms. Three months later, he presented to the hospital with decreased vision in his left eye. Physical examination showed left hemianopsia. He was febrile at 38.4C. Lab testing was significant for WBC 27.3 cells/microliter. MRI brain revealed multiple supratentorial ring-enhancing lesions in both cerebral hemispheres with a dominant lesion within the right occipital lobe measuring 3.3 × 2.8 × 3.0 cm (Figure 2a,b). CT abdomen showed sigmoid diverticulosis without diverticulitis and blood cultures were negative. He underwent right parietal lobe craniotomy and drainage of the larger occipital lobe abscess, with cultures growing Fusobacterium nucleatum. He was started on IV ceftriaxone and oral metronidazole and was discharged home. On follow up, he finished 9 weeks of the aforementioned antibiotics followed by 1 month of oral moxifloxacin with follow up imaging showing resolution of his abscesses.

DISCUSSION:

In literature, there are only a few reported cases of brain abscesses secondary to diverticulitis. The isolated organisms were of gut flora with Streptococcus milleri and Enterococcus faecium species reported. Fusobacterium nucleatum is an anaerobic oral flora that is involved in periodontal disease, preterm deliveries and diverticular disease. Our patient did not have any periodontal disease and the source was assumed to be diverticulitis. Treatment usually involves IV antibiotics and drainage of the abscesses. Prognosis seems to be overall good with combination approach seem to be effective in ensuring recovery.
1640 Case Report: Diffuse Large B-Cell Lymphoma Presenting as Multiple Lymphomatous Polyposis
Authors: Joseph Dijo , Carrion Andres F. , Ernstoff Nathaniel
Published: October 2019

INTRODUCTION:

Diffuse Large B Cell Lymphoma (DLBCL) is the most common type of Non-Hodgkin’s Lymphoma (NHL) in the U.S. accounting for one third of all newly diagnosed NHL’s. The gastrointestinal (GI) tract is the most common site of extra nodal involvement with mucosa-associated lymphoid tissue (MALT) lymphoma and DLBCL accounting for 70-95% of all GI lymphomas. Multiple lymphomatous polyposis (MLP) is a rare presentation of GI lymphoma characterized by diffuse proliferation of lymphocytes that present as multiple polypoid tumors involving long segments of the GI tract. MLP classically presents in mantle cell lymphoma, but can also present, although less frequently, in MALT and follicular lymphomas. We present a unique case of a patient that presented initially with lower GI bleed and was subsequently found to have extensive polypoid lesions in the entire colon. Histological evaluation revealed DLBCL, a rare etiology of MLP.

CASE DESCRIPTION/METHODS:

A 93-year-old woman with chronic thrombocytopenia suspicious for low-grade MDS and history of a large tubulovillous adenoma without high-grade dysplasia or cancer for which she had undergone a right hemicolectomy, presented to the emergency department with intermittent rectal bleeding, severe anemia, fatigue, decreased appetite, and a 17 pound weight loss over the past 2 months. Her hemoglobin level on admission was 6.5 g/dL (baseline Hgb 11 g/dL) and all other cell counts were otherwise normal. Her last colonoscopy ten years ago was normal and she was given the choice to continue or forego colon screening given her age. She had no family history of colon polyps or colorectal cancer. Colonoscopy revealed approximately 50-100 sesile polypoid lesions from the ileocolonic anastomosis to the distal rectum, ranging in size from 2-40 mm. The larger lesions were predominantly located in the proximal colon and were ulcerated and friable. Multiple biopsies were obtained and pathology results revealed diffuse large B-Cell lymphoma. Further studies revealed stage IV DLBCL without bone marrow involvement and she was started on mini R-CHOP chemotherapy.

DISCUSSION:

Although DLBCL is a rare cause of MLP, it should be included in the differential diagnosis in patients with multiple polypoid lesions throughout the colon that do not fit the typical phenotype for hereditary polyposis syndromes. Lymphomas associated with MLP include MALT and follicular lymphomas; however, DLBCL and other less common lymphomas should be considered when evaluating patients with this entity.
1654 An Unusual Colon Lesion: Colon Metastasis From Primary Lung Adenocarcinoma
Authors: Meade Charles , Hansel Stephanie
Published: October 2019

INTRODUCTION:

Primary lung cancers infrequently metastasize to the gastrointestinal tract. We describe one case of isolated colonic metastasis identified at diagnosis of the primary lung malignancy and the associated immunohistochemical pattern.

CASE DESCRIPTION/METHODS:

An 80-year-old man presented for evaluation of subacute onset shortness of breath. CT imaging showed a spiculated mass with associated ipsilateral intrathoracic lymphadenopathy. PET-CT was performed for staging and revealed a hypermetabolic focus in the left colon with recommendation for follow up colonoscopy. No other significant lesions or evidence of distant metastatic disease were seen and subsequent biopsy of a subcarinal lymph node demonstrated primary pulmonary adenocarcinoma. The colonoscopy visualized a sessile 12 mm polyp in the recto-sigmoid colon (Figure 1). Prior colonoscopy within 5 years of presentation was normal. Colon polyp morphology showed moderately differentiated adenocarcinoma. Immunohistochemical staining of resected polyp was positive for TTF-1 and negative for CDX2. Oncology recommended tyrosine kinase inhibitor therapy for Stage IV disease and alectinib was initiated with good response at 6 month follow up.

DISCUSSION:

Non-small cell lung cancer metastatic to the colon is uncommon but can present as a spectrum from asymptomatic mucosal involvement to bulky obstructive disease. Autopsy series and published case reports suggest broad estimates of asymptomatic involvement in between 1-10% of lung primaries, with symptomatic gastrointestinal involvement in <1% of cases.1 Endoscopic presentation of metastatic disease to the gastrointestinal tract is often non-characteristic and differentiating adenocarcinoma tissue of origin is aided by immunohistochemical staining. TTF-1 staining has been shown to be highly specific to pulmonary adenocarcinomas.2 CDX2 expression is an important intestine-specific transcription factor, and CDX2 negativity suggests adenocarcinoma of non-GI origin.3 Used in conjunction, distant metastatic disease to the GI tract can be identified.
1663 Do Not Risk Your Colon: Beware of Hydrogen Peroxide Enema
Authors: Mann Rupinder , Gulati Abhishek , Bumrah Karandeep
Published: October 2019

INTRODUCTION:

Hydrogen peroxide is an oxidizing agent widely available in a variety of medical and household products. There are few reported cases of chemical colitis due to hydrogen peroxide enema used for constipation. We present an interesting case of chemical colitis due to hydrogen peroxide enema used by the patient for alcohol detoxification after reading on the internet.

CASE DESCRIPTION/METHODS:

A 33-year-old male with a history of alcohol abuse presented with complains of abdominal pain and hematochezia that started after self-administration of enema with 3% hydrogen peroxide diluted with saline for alcohol detoxification. On the abdominal exam, he had left lower quadrant tenderness. Vital signs were stable. CBC revealed mild anemia with hemoglobin (Hb) of 13 g/dl while BMP was unremarkable. CT scan of abdomen and pelvis showed mucosal thickening, edema and subtle pericolonic stranding changes of the rectosigmoid colon to proximal descending colon and no free air. Gastroenterology was consulted and the patient underwent flexible sigmoidoscopy which showed diffuse moderate inflammation in the rectum, sigmoid colon, descending colon and splenic flexure secondary to colitis. The patient was managed conservatively with bowel rest, fluid resuscitation and empiric antibiotics. Hemoglobin remained stable and he was discharged once he was able to tolerate diet and his symptoms resolved.

DISCUSSION:

Chemical colitis is the inflammation of the large intestine caused due to chemicals introduced into the colon after accidental contamination of endoscopes or administration of enemas containing various chemicals like hydrogen peroxide. Hydrogen peroxide produces highly reactive oxygen radicals which damages colonic mucosa. Diagnosis can be challenging if pertinent history is not obtained as patients with chemical colitis present with non-specific GI symptoms that mimic inflammatory colitis. Given readily availability of hydrogen peroxide and information on the internet to the public, patients should be educated about the dangers of hydrogen peroxide enema. Physicians should also be aware of these dangerous and life threatening ways their patients can attempt to relieve constipation or detoxification. It is very important to recognize this entity as it is entirely preventable.
1667 An Unusual Case of Ileocolonic Intussusception Masquerading as a Colon Mass
Authors: Khalid Ammara , Al-Salameh Nizar , Bergenstock Marika , Khara Harshit S.
Published: October 2019

INTRODUCTION:

Intussusception presents more frequently in the pediatric population versus adults, which only accounts for 5% of all cases. Primary (idiopathic) intussusception make up about 10% of all cases. Secondary causes result from a pathological lesion such as polyps, carcinomas, IBD or postoperative lesions. We describe an unusual case of an adult ileocolonic intussusception masquerading as a colonic mass lesion.

CASE DESCRIPTION/METHODS:

A 21-year-old female presents with 3 days of intermittent right lower quadrant (RLQ) abdominal pain and constipation. Physical exam revealed RLQ tenderness without peritoneal signs. An abdominal CT scan showed a 7.7 cm mass in the cecum/proximal ascending colon (Figure 1) concerning for malignancy. She underwent a colonoscopy which revealed that the mass was an ileocolonic intussusception into the ascending colon with a prolapsed ileum completely filling the right colonic lumen (Figure 2). The distal ileal lumen was intubated with the colonoscope and showed had severe ileitis with erosions and inflammation (Figure 3) but could not be reduced back endoscopically. An exploratory laparoscopy with reduction of ileocecal intussusception and ileocecectomy with anastomosis was then done. Post procedure, she was pain free and had return of bowel function. The surgical pathology showed ischemic injury to the bowel wall with acute serositis. The patient had a negative workup for IBD, celiac disease, malignancy or polyps, as evaluated with serology, MR enterography, EGD, and video capsule endoscopy for further workup.

DISCUSSION:

Adult intussusception occurs mainly in the small bowel, with 52% found in the small intestine and 38% in the large intestine (17% ileocecal). Most cases are caused by a structural lesion with neoplasms causing 66% of colonic intussusceptions and 30% of cases in the small bowel. The mechanism is believed due to lesion caught during peristalsis initiating the telescoping process. Those older than the age of 60, bowel resection is recommended given the high incidence of malignancy. Small bowel intussusceptions are more likely to reduce spontaneously and resection is not indicated unless there is ischemia or obstruction. This was a rare presentation of an idiopathic ileocolonic intussusception in an adult presenting as a colonic mass on imaging, diagnosed with colonoscopy and promptly resolved with timely surgical intervention.
1668 A Rare Cause of Cyclical Rectal Bleeding: Sigmoid Endometriosis
Authors: Subbaraj Lakshmipriya , Singh Aparajita
Published: October 2019

INTRODUCTION:

Endometriosis can frequently involve the bowels with rectosigmoid involvement being the most common. Although serosal infiltration is not uncommon, mucosal involvement is rare, hence presentation with rectal bleeding is rare. Diagnosis without pathology is difficult given symptoms frequently mimic IBS, IBD or malignancy. Here, we present a case of a woman with a history of breast cancer who presented with rectal bleeding ultimately found to have infiltrating sigmoid endometriosis.

CASE DESCRIPTION/METHODS:

A 40-year-old woman with a history of ER+/PR-/HER2+ breast cancer in remission on maintenance tamoxifen presented with worsening rectal bleeding for one year. Interestingly, hematochezia occurred cyclically every month seemingly coinciding with menses. It was associated with dyschezia, abdominal pain, loose stools, and dysmenorrhea. Hemoglobin and rectal exam were normal. Due to her history of breast cancer, a CT scan was done which demonstrated a focal area of sigmoid wall thickening and luminal narrowing with a 3 cm × 4 cm filling defect. Primary colonic malignancy and metastatic lesions were considered in the differentials. Colonoscopy revealed an area of extreme tortuosity in the sigmoid colon that could not be traversed. Several hypervascular polypoid lesions were noted in the proximal sigmoid colon at the site of narrowing. Cold forceps biopsy of the lesions showed endometriosis on pathology. Immunohistochemical stains positive for CD10 and estrogen receptor further supported the diagnosis. The patient was treated with Goserelin acetate with complete resolution of her rectal bleeding. After a year, she discontinued Goserelin due to side effects of fatigue and joint pains and has been on Danazol suppositories. Surgery was deferred as she did not have colonic obstructive symptoms.

DISCUSSION:

Here, we report a rare case of sigmoid endometriosis presenting as cyclical rectal bleeding with a lesion that masqueraded as malignancy on CT scan. Gastroenterologists should be aware of this differential in women in their reproductive years and be familiar with its unusual endoscopic appearance. This case also emphasizes good history taking, where the cyclical nature of rectal bleeding coinciding with menses is a clue for diagnosis. While symptoms of colonic endometriosis are typically chronic, late diagnoses can lead to unfortunate sequelae including acute bowel obstructions. Early diagnosis is clinically important to attempt medical therapies before complications necessitate surgical intervention.
1668A An Unusual Presentation of Abdominal Tuberculosis
Authors: Majeed Muhammad , Agrawal Rohit , Attar Bashar M. , Sidhu Gurpartap , Palacios Pedro , Vohra Ishaan , Gandhi Seema
Published: October 2019

INTRODUCTION:

Peritoneal tuberculosis (TB) is an uncommon manifestation of extrapulmonary infection associated with significant mortality (51%). The delay in diagnosis due to insidious nature of disease and lack of specific symptoms result in significant morbidity and mortality. We report an unusual case of abdominal tuberculosis presenting with abdominal pain and vomiting.

CASE DESCRIPTION/METHODS:

A 58-year-old man with no significant past medical history came to the emergency department with nausea, non-bilious vomiting and generalized abdominal pain for two weeks. On examination, he had mild abdominal distension and hyperactive bowel sounds. His labs were significant for hyponatremia (119 mEq/L), hypokalemia (2.9 mEq/L) and metabolic alkalosis (bicarbonate 49 mEq/L). Chest X-ray showed right basilar lung infiltrate concerning for aspiration pneumonitis and computed tomography (CT) scan of abdomen revealed fluid filled distension of stomach and duodenum with moderate volume ascites (Figure 1). Patient was started on supportive management with intravenous fluids and bowel rest for suspected small bowel obstruction. Push Enteroscopy showed bilious fluid in stomach and duodenum but no obstructing lesion was seen till proximal jejunum. Patient underwent diagnostic paracentesis revealing high serum ascitic albumin gradient fluid ( >1.1) with neutrophil predominance (85%) and elevated adenosine deaminase (ADA) level (142 IU/L). On laparoscopic examination, he had nodular thickening of peritoneum and dense adhesions (Figures 2 and 3). Histopathology of nodules confirmed presence of acid-fast bacillus in fibrotic nodules. Patient was started on intravenous anti-tubercular regimen with improvement in symptoms over next 2 weeks and was discharged home.

DISCUSSION:

Peritoneal TB is a chronic disease which commonly results from the reactivation of latent pathogen and accounts for 4.7% of all tuberculosis patients in the USA. Patient usually present with complex ascites, abdominal pain, and fever which can progress to bowel obstruction if remained undiagnosed. Diagnosis is usually confirmed by peritoneal biopsy but in patients without cirrhosis, ascitic fluid ADA level of >39 IU/L has sensitivity and specificity of 100% and 97% respectively. Due to lack of specific symptoms and high morbidity in undiagnosed cases, the initial differential diagnosis of patients with suspected bowel obstruction should also include peritoneal TB. Moreover, ascitic fluid ADA level can assist diagnosis of peritoneal TB.
1682 Jejunal Dieulafoy's Lesion
Authors: DeCino Andrea , Rampy Jacqueline , Malakouti Mazyar , Schindler Amy E.
Published: October 2019

INTRODUCTION:

Dieulafoy’s lesions (DLs) comprise 2% of acute gastrointestinal bleeds and are most commonly found in the stomach, though 3.5% of DLs occur in the small bowel. Jejunal DLs pose unique diagnostic and treatment challenges due to low incidence and the absence of standardized therapy. We present a case of acute, symptomatic anemia secondary to a jejunal DL.

CASE DESCRIPTION/METHODS:

A 64-year-old Hispanic woman with no significant past medical history presented with symptomatic anemia after three days of melena. She was hemodynamically stable with palpable internal hemorrhoids and brown stool on digital rectal exam. Her hemoglobin was 4.8 g/dL and responded to transfusion. Bidirectional endoscopy found antral erosions without stigmata of bleeding, small hemorrhoids, and dark stool throughout the colon. Capsule endoscopy revealed bright red blood at 23% progress through the small bowel. Subsequent anterograde single-balloon enteroscopy demonstrated an actively spurting DL in the mid-jejunum. Hemostasis was achieved with epinephrine injection and bipolar diathermy. The patient was followed for six months without evidence of re-bleeding.

DISCUSSION:

DLs are non-inflammatory, solitary mucosal defects with protrusion of an aberrant artery. Jejunal DLs comprise 1% of all DLs. Diagnosis is made endoscopically, but lesions are often unrecognized due to small size and preservation of surrounding mucosa. As such, multiple endoscopies are often required to reach a diagnosis. Initial endoscopy and colonoscopy are followed by capsule endoscopy in hemodynamically stable patients with suspicion of a mid-gastrointestinal bleed. Further approach with single or double balloon enteroscopy is preferred for the evaluation of jejunal DLs. With the expansion of endoscopic techniques, endoscopy has replaced surgery as first line treatment for small bowel DLs. However, there is no current standard endoscopic therapy, given that there is limited data directly comparing modalities for jejunal DLs. For general DLs, mechanical therapy is superior to either thermal or injection therapy. For ulcerative diseases, the use of two endoscopic techniques is superior to a single technique, alone. Thus, it has been suggested that the optimal treatment for jejunal DLs utilizes two endoscopic modalities, with one being mechanical, though further research is needed.

Watch the video: http://bit.ly/2YZE0Zj.
1685 Endoscopic Fistulectomy of an Obstructive Esophagogastric Mucosal Bridge
Authors: Vachaparambil Cicily , Mekaroonkamol Parit , Cai Qiang
Published: October 2019

INTRODUCTION:

Esophageal mucosal bridges are rare complications from many causes including congenital abnormalities, radiotherapy, sclerotherapy, nasoenteric feeding tubes, or Crohn’s disease. Mucosal bridges are made of smooth muscle crossing gastrointestinal lumen and resulting in a double barrel appearance on endoscopy. Pathogenesis may involve mucosal undermining by ulceration followed by healing, re-epithelialization of the mucosal undersurface, and formation of a mucosal tube attached to the non-ulcerated wall. Therefore, chronic, repetitive ulcerations and subsequent healing may lead to bridge formation. Another theory is that inflamed walls of esophagus contacting one another allows granulation tissue to form adhesions resulting in a mucosal bridge. This could explain fistula formation in inflammatory bowel disease.

CASE DESCRIPTION/METHODS:

A 68-year-old woman presented with a 6-year history of progressive solid food dysphagia and gastroesophageal reflux. Her past surgical history was significant for laparoscopic band surgery complicated by gastric band erosion into the stomach at the gastroesophageal junction that required subsequent gastric band removal and omental flap reinforcement of the gastric perforation nine years prior to presentation. A diagnostic upper endoscopy revealed an esophageal fistula at the gastroesophageal junction and biopsies at the junction showed chronic inflammation without dysplasia. The upper endoscope was advanced to the gastroesophageal junction at 37 cm from the entry site. Proximal to the gastroesophageal junction, two esophageal lumens were seen leading to the gastric lumen due to a thick mucosal bridge causing partial obstruction to the stomach. First, four hemostatic clips were placed at both ends of the stalk before mucosal incision to prevent bleeding. The bridge was grasped with forceps and fistulectomy was performed with a needle knife to incise the mucosal bridge between the clipped portion using electrocautery. On post-operative follow-up at week 6 and 12, the patient had complete resolution of dysphagia and no demonstrated recurrence of mucosal bridge formation.

DISCUSSION:

This is an unusual case of an esophagogastric fistula from a delayed adverse event of laparoscopic gastric band placement even after band removal and corrective surgery that caused dysphagia. It was successfully treated with endoscopic fistulectomy using hemostatic clips and a needle knife under direct visualization. This method has proven to be effective with no reported recurrences.

Watch the video: http://bit.ly/2Y0JNws.
1694 Endoscopic Ultrasonography With Fine-Needle Aspiration in the Diagnosis of Metastatic Rectal Adenocarcinoma in Left Atrium
Authors: Koneru Gopala K. , Shah Ishani , Kantamaneni Vamsi , Peck Joshua R.
Published: October 2019

INTRODUCTION:

Endoscopic ultrasonography(EUS) of the mediastinum with the use of fine needle aspiration(FNA) or biopsy can be used to characterize lesions that are within or adjacent to the esophageal wall, posterior and inferior mediastinum with minimal risk to the patient. EUS is an underutilized tool for identifying mediastinal masses and can help guide clinical decision making in patients with concerning lesions found on non-invasive imaging modalities.

CASE DESCRIPTION/METHODS:

A 71-year-old male with history of adenocarcinoma of the rectum with metastases to the liver and lung was treated with surgical resection and adjuvant chemotherapy. Patient responded well and was under regular surveillance when a new irregularly shaped abnormal soft tissue density measuring approximately 5.4 × 3.0 cm adjacent to the aorta and esophagus appearing to invade into the left atrium (Figure 1a) was found on a CT scan and confirmed on PET imaging. These findings favored rectal metastatic disease over thrombus but could not definitively rule out a new carcinoma. For that reason, an endoscopic ultrasonography was performed to determine the nature of the mass. A curvilinear array echoendoscope was used to visualize a 36 × 30 mm exophytic lesion within the left atrium which extended into the posterior mediastinum (Figure 2). Using Doppler to identify a vessel-free path, a 25-gauge needle was passed under ultrasound guidance through the esophagus and directly into the mass with the use of an endoscopic fine needle biopsy (FNB) device for three passes. Histopathological examination confirmed adenocarcinoma (Figure 3) and immunophenotype was compatible with colorectal primary which ruled out a pulmonary adenocarcinoma.

DISCUSSION:

The patient was determined to not be a surgical candidate due to the location of the mass and high risk nature of the surgery. The multidisciplinary team’s consensus was to repeat chemo-adjuvant therapy since he had responded so well previously. He received treatment and had follow up imaging six months after EUS diagnosis which showed decrease in size (Figure 1b) and activity of the mass. He is planned to have have stereotactic body radiation therapy to further decrease the size of the atrial mass. This case demonstrated how EUS with the use of FNA is a helpful tool in the prompt evaluation and confirmation of a mediastinal mass which allowed all physician’s involved in the care of the patient to develop and implement a treatment plan quickly.

Watch the video: http://bit.ly/2Giu99S.
1696 Is It Technically Feasible to Use Duodenoscopy in Endoscopic Submucosal Dissection for the Recurrent Laterally Spreading Ampullary Adenomas?
Authors: Li Wen , Wang Zikai , Liu Fang , Wang Xiangdong , Meng Jiangyun , Wang Jun
Published: October 2019

INTRODUCTION:

The management strategies of recurrent ampullary adenomas after endoscopic papillectomy is still a controversial issue regarding the best modality for treatment. The aim of the study is to assess the feasibility, efficacy and safety of duodenoscopic submucosal dissection (DESD) for the recurrent laterally spreading ampullary duodenal lesion.

CASE DESCRIPTION/METHODS:

We prospectively enrolled two patients with recurrent laterally spreading ampullary duodenal adenomas after successful papillectomy. Following marking the resection borders of the lesion using a Dual knife, a submucosal cushion is created by injecting a mixture of saline solution, methylene blue and adrenaline. A circumferential incision followed by submucosal dissection was performed using Dual knife and IT knife, then the lesion was resected using an electric snare. Hemostasis was applied using coagulation grasper during the procedure. Following dissection ERCP with biliary and pancreatic stenting was performed. Finally closure of the resection site was achieved using Endo-clipping in order to prevent complications such as secondary hemorrhage and delayed perforation. DESD followed by biliary and pancreatic stenting was performed successfully for two patients with recurrent laterally spreading ampullary duodenal adenomas. Table 1 shows the procedure details for the initial papillectomy which showed En-bloc resection of both lesions. Table 2 shows detailed current characteristics and procedure details for the recurrent lesions. Figures 1 and 2 Show endoscopic procedures. The average total procedure time was 95.5 mins, and the procedure time of DESD and ERCP was 38.5 mins and 15.5 mins respectively with no serious intra-or post procedure complication. The histopathological examinations revealed tubulovillous adenoma with negative resection margins in case 1. Unfortunately specimen of case 2 was not retrieved successfully. Follow up at the third, sixth and twelfth month showed no residual or recurrent lesions in ampullary areas, biopsy of resection site showed inflammation with absence of adenomatous tissues in both cases.

DISCUSSION:

In conclusion, DESD is technically challenging, potentially effective and curative for laterally spreading duodenal ampullary adenomas within 2 cm in diameter. It should be performed cautiously in selected patients by experts with abundant experience in performing not only ESD but also ERCP.

Watch the video: http://bit.ly/2Y4dE77.
1697 The Safety and Efficacy of Endoloop Ligation (“Loop-and-Let-Go”) of a Very Large Jejunal Lipoma
Authors: Ramsey Mitchell L. , Krishna Somashekar
Published: October 2019

INTRODUCTION:

Lipomas can occur anywhere throughout the gastrointestinal tract and can range widely in size. When symptomatic, these lipomas require removal, and several techniques have been described depending on the size of the lesion. Recently, a method utilizing an endoloop ligation has been proposed and validated for use in colonic lipomas. However, there remains a lack of literature on the safety and efficacy of endoloop ligation for the removal of symptomatic lipomas in the small intestine.

CASE DESCRIPTION/METHODS:

A 55-year-old male with a history of neurofibromatosis, prior prostate cancer, and tobacco use presented for evaluation of melena. He underwent an upper endoscopy which was reportedly normal and was transferred to our center for consideration of small bowel endoscopy. He continued to have melena and labile hemoglobin. A push enteroscopy revealed a long, submucosal lesion in the proximal jejunum with several areas of ulceration which were presumed to be the source of his bleeding. The mass was biopsied, and pathology was consistent with a lipoma. Subsequently, the patient underwent EUS and endoloop ligation. A video from this case is submitted to demonstrate the proper use of endoloop ligation of a large lipoma in the small intestine. Following placement of the endoloop ligature, the patient had no further bleeding and a follow-up enteroscopy one month later revealed complete loss of the lipoma with unremarkable appearing mucosa.

DISCUSSION:

In this case, we demonstrate that endoloop ligation is a safe technique for the removal of symptomatic large lipomas in the small bowel. In the video, we demonstrate how to apply the endoloop ligature to such a lesion effectively.

Watch the video: http://bit.ly/2JSdmLE.
1699 Stent Gone Rogue: Endoscopic Removal of a 3-Year-Old Embeded Cystgastrostomy Stent
Authors: Chittajallu Vibhu , Simons-Linares Roberto , Walsh R. Matthew , Chahal Prabhleen
Published: October 2019

INTRODUCTION:

We present a case of endoscopic removal of a delayed SEMS migration into the retroperitoneum, resulting in a perisplenic abscess and embedding of the SEMS into the gastric and retroperitoneal wall.

CASE DESCRIPTION/METHODS:

A 60-year-old man with idiopathic acute necrotizing pancreatitis complicated by walled-off pancreatic necrosis (WOPN) status post EUS-guided cystgastrostomy 3 years prior, presented with 3 weeks of worsening chronic abdominal pain and fever. Previous cystogastrostomy was performed with a through the scope 18 mm × 60 mm fully covered self-expandable esophageal metal stent (SEMS). Plan was to have SEMS removed after WOPN resolution; however, patient was lost to follow up. Abdominal CT scan revealed fluid collection in pancreatic tail measuring 4.8 × 1.9 cm and cyst-gastrostomy stent in place, splenomegaly measuring 15.5 cm with a perisplenic subcapsular collection along the lateral and superior splenic margin measuring 13.3 × 1.9 cm, thin fluid tract/collection extending from the pancreatic tail with more superior extension to questionably communicate with perisplenic collection. The 3-year-old SEMS was attempted to remove with a new through the scope fully covered 18 mm × 60 mm esophageal SEMS (Taewoong medical) but failed. Following, a new 20 mm lumen-apposing metal stent (LAMS) (Axios, Boston Scientific) stent was deployed within the embedded 3-year-old SEMS and it was secured to the embedded stent with standard clipping (Cook Medical), and CT abdomen 3 weeks after discharge noted improvement of perisplenic fluid collections. Follow up EGD/EUS allowed successful removal of 6F drainage catheter and inner Axios stent with rat tooth. After prolonged efforts, utilizing snare, biopsy, and piecemeal extraction, the embedded 3-year-old SEMS with wire struts and lattice fixed into the gastric wall and retroperitoneum was removed with no fragment remaining that was confirmed multiple times on endoscopy and fluoroscopy. Finally, Patient remained in good health without recurrence of symptoms at 6-months follow up in the outpatient clinics.

DISCUSSION:

This is the first case report of successful endoscopic removal of a 3-year-old embedded cystgastrostomy stent.

Watch the video: http://bit.ly/2Lvc78C.