bluuebunny/crossref_metadata_2025 huggingface dataset:
1474 Cowden and MAP Syndrome: The Untold Story of a Screening Colonoscopy—Case Report
Authors: Fernandez Wilfor Diaz , Tiriveedhi Kiranmaye
Published: October 2019

INTRODUCTION:

Cowden syndrome is a rare autosomal dominant condition associated with PTEN gene mutation. MUTYH-associated polyposis (MAP) is inherited by autosomal recessive fashion. Cowden syndrome presents with multiple hamartomas in a variety of tissues, oral fibromas, and punctate palmoplantar keratoses, and an increased risk of breast, endometrial, thyroid, kidney and colorectal cancers. MAP syndrome is associated with adenomatous polyps and colon cancer predisposition.

CASE DESCRIPTION/METHODS:

51-year-old female underwent screening colonoscopy and was found to have multiple polyps throughout the colon. Biopsy showed ganglioneuromas and hamartomous polyps. Medical history was significant for hypothyroidism and hypoparathyroidism secondary to thyroidectomy for a goiter, bilateral mastectomy for a ductal carcinoma in situ, hysterectomy for fibroids, palmar keratosis and oral papillomatosis. Family history was relevant for breast cancer in her mother at age 50. Genetic analysis revealed mosaicism for a loss of function variant in PTEN and autosomal recessive pathogenic single MUTYH variant which confirmed Cowden Syndrome and carrier state for MAP syndrome. Appropriate cancer surveillance was arranged for our patient according to the National Cancer Center Network Guidelines through multidisciplinary approach.

DISCUSSION:

PTEN gene is a tumor suppressor responsible for regulating the cell cycle. Because of her mutation, our patient is susceptible for an array of different malignancies. Her genetic profile showed mosaicism for PTEN genetic variant. Adequate cancer surveillance for colon cancer, renal cell carcinoma and recurrence of breast cancer were discussed with our patient. MUTYH variant mutation was found in this patient. However, she inherited only one single copy of this recessive gene expecting not to develop clinical MAP syndrome. Risks associated with a single variant in MUTYH are unclear. There are some reports that suggest an inconsistent increased risk of colon, endometrial, and breast cancer. National Cancer Center Network Guidelines has created surveillance guidelines for individuals with a single MUTYH variant but cautioned that these guidelines are likely to change over time. Uniquely, extracolonic neoplastic complications were detected before the diagnosis of Cowden in our patient. High clinical suspicion and early diagnosis of this condition is crucial for effective prevention of colonic and extracolonic malignancies that these individuals are at high risk for.
1476 Early Detection of Mantle Cell Lymphoma Recurrence With Colonoscopy
Authors: Singh Amardeep , Bali Atul , Bal Bikram
Published: October 2019

INTRODUCTION:

Non-Hodgkin Lymphomas (NHL) are a group of malignancies that are derived from immature B cells, T cells and natural killer cells. The incidence of NHL is 19.6 per 100,000 per year in the United States. Mantle cell lymphoma (MCL) is a type of NHL which arises from mature B cells and has a more aggressive clinical course, accounting for 6% of all NHL cases. This amounts to approximately 4200 new cases in the US every year. MCL has a strong predilection for the gut with 92% of patients exhibiting gastrointestinal infiltration.

CASE DESCRIPTION/METHODS:

Our patient is a 68-year-old Caucasian male referred for a routine screening colonoscopy. History was notable for MCL involving the hard palate diagnosed in February 2013. This was initially treated with R-CHOP therapy with subsequent Rituximab maintenance. Patient relapsed in February 2015. His relapse was treated with FCR therapy which was completed in June 2015. Follow up bone marrow biopsy was negative. In June 2016 he had recurrence of the malignancy on his hard palate, requiring treatment with local radiation. After completion of radiation, surveillance imaging with integrated whole body PET/CT demonstrated no further activity. He was deemed to be in remission and maintained routine biannual oncologic follow up for three years. Routine screening colonoscopy performed in May 2019, revealed a polyp in the transverse colon, and an additional polypoid lesion in the rectum. Biopsy revealed atypical lymphoid infiltrate consisting of medium sized lymphocytes that were positive for CD5, CD20, CD10, PAX5, Bcl-2, and cyclin D1. Morphology, immunofluorescence, and FISH were positive for t11:14, with pathology being consistent with mantle cell lymphoma. Patient has been referred back to his oncologist to discuss further treatment options.

DISCUSSION:

Our case illustrates the importance of endoscopic surveillance in patients with MCL. While PET/CT is invaluable in the surveillance of multiple malignancies, it maybe inadequate in determining remission and recurrence of MCL. The National Comprehensive Cancer Network (NCCN) recommends that both upper endoscopy and colonoscopy be performed to assess treatment response and remission in this population. Given the high incidence of GI involvement in MCL, incorporating routine endoscopic surveillance as part of MCL management may be an important step for early detection of disease recurrence in this high-risk population.
1483 Full Thickness Resection Device for the Removal of a Submucosal Sigmoid Carcinoid Tumor
Authors: Patel Pratik , Phan Ethan , Gollol Raju Narasimha Swamy , Mudireddy Prashant
Published: October 2019

INTRODUCTION:

Colonic neuroendocrine tumors (NETs) are rare neoplasms, but they carry the worse prognosis. Management of these tumors is difficult and may result in repeated interventions and prolonged surveillance. Endoscopic Full Thickness Resection (FTR) is not currently included in the guidelines for management of NETs. This case describes a technically and histologically successful FTR of a sigmoid goblet cell carcinoid tumor.

CASE DESCRIPTION/METHODS:

A 61-year-old male presents for screening colonoscopy and was found to have an 8 mm submucosal mass in the distal sigmoid. Pathology of biopsies showed hyperplastic colonic mucosa with marked reparative stromal and epithelial changes and mixed features of prolapse. He was referred to our institution for EUS of the submucosal lesion, which revealed hypoechoic submucosal lesion in distal sigmoid measuring 7.4 × 4.7 mm. FNA was attempted but unsuccessful as the mass was small and mobile. Therefore, decision was made to perform endoscopic mucosal resection (EMR). Pathology on EMR of sigmoid lesion revealed goblet cell carcinoma. Deep and lateral margins were positive. Chromogranin A level was mildly elevated. He was referred to surgical oncology who recommended 3 month surveillance colonoscopy given low Ki index. CT Scan of Abdomen and Pelvis as well as Octreotide scan were both negative for distant metastases. At 3-month follow up colonoscopy, the decision was made to use Full Thickness Resection Device (FTRD) of the sigmoid lesion given positive margins. Pathology of FTRD was consistent with neural sheath tumor and deep and lateral margins were negative. Repeat colonoscopy revealed well healed scar at site of FTRD and cold biopsies around the scar were benign. He will follow up in 3 years for repeat colonoscopy.

DISCUSSION:

Primary colonic neuroendocrine tumors are rare but are generally more aggressive and carry the worst prognosis dependent on stage. Current consensus guidelines for the management of local regional NETs recommend endoscopic resection via polypectomy, EMR or endoscopic submucosal dissection. There have only been a few reported cases of the use of FTRD to treat submucosal carcinoid tumors in the colon. Success rates for endoscopic full thickness resection of gastric tumors has been described in the literature with success rates of up to 100%. High success rates of FTRD on colorectal lesions, not NETs, have also been noted. Given this, FTRD should be considered as a more definitive modality for treatment involving submucosal carcinoid tumors.
1491 Colo-Colonic Intussusception: An Unusual Complication of Bowel Preparation
Authors: Le Han N. , Kwiatt Michael E. , Chaaya Adib
Published: October 2019

INTRODUCTION:

Intestinal intussusception is the telescoping or invagination of a proximal bowel segment into a distal segment. It is a relatively common entity in the pediatric population, but only about 5% of all intussusceptions occur in adults. Approximately 90% of adult intussusceptions are secondary to an anatomical or pathological condition. We present a case of colo-colonic intussusception induced by bowel preparation for colonoscopy in the setting of large transverse colonic mass.

CASE DESCRIPTION/METHODS:

A 57-year-old gentleman with a history of metastatic melanoma was evaluated for iron deficiency anemia. On physical examination, the patient was pale and chronically ill appearing with a benign abdominal exam. Endoscopic evaluation showed an ulcerated mass in the duodenum and a large 5 cm tumor in the proximal transverse colon. While undergoing bowel preparation for repeat colonoscopy to assess response to chemotherapy, the patient developed acute, diffuse abdominal pain associated with nausea and vomiting. He was found to have an acute colo-colonic intussusception with total colonic obstruction. The patient underwent emergent surgery and recovered well.

DISCUSSION:

We hypothesize that our patient's colo-colonic intussusception was induced by hyperperistalsis of the colon as a result of bowel preparation. The patient was already at risk for both small bowel and colonic intussusception given the large size of both intestinal masses. Our case is unique in that he developed the intussusception while taking the bowel preparation. The altered peristaltic activity of the bowel in the setting of a large colonic mass created an area of constriction and distal relaxation which led to the invagination of the proximal bowel segment into the distal segment. With advances in endoscopy and new techniques, such as endoscopic submucosal dissection, we have the ability to remove larger polyps measuring more than 5 cm in size. Endoscopists need to inform their patients of the potential complication of bowel preparation induced colonic intussusception requiring emergent surgery while prepping for large polyp removal.
1495 A Case of Non-Typhoidal Salmonella (Salmonella Saintpaul) Bacteremia
Authors: Ramachandran Rajarajeshwari , Azhar Maria , Jani Niraj
Published: October 2019

INTRODUCTION:

The Center for Disease Control and Prevention (CDC) estimates 1.2 million illnesses and 450 deaths occur due to non-typhoidal Salmonella annually in the United States. Among the different kinds of Salmonella, S. typhimurium and S. enteritidis are the most common serotypes. S. Saintpaul infection is rare and the last outbreak was reported in 2008. We are presenting the case of a 52-year-old woman with S. Saintpaul bacteremia.

CASE DESCRIPTION/METHODS:

53-year-old woman with history of bipolar disorder and gastroesophageal reflux disease (GERD) was admitted to the hospital with diarrhea for 2 days. She was noted to be in septic shock and was treated with fluid resuscitation and vasopressors. Examination: temperature 37 °C, blood pressure 66/36 mmHg, pulse 111/minute and saturating 97% on room air. Cardiovascular and respiratory examinations were normal. Abdomen - no tenderness, no peritoneal signs and hyperactive bowel sounds. Laboratory data: white cell count 2.82 × 103/μL, hemoglobin 8.2 g/dL, platelets 152 × 103/μL, sodium 129 mEq/L, potassium 2.6 mEq/L, chloride 93 mEq/L, bicarbonate 15.2 mEq/L, creatinine 5.0 mg/dL, AST 93 IU/L, ALT 35 IU/L, alkaline phosphatase 145 IU/L, total bilirubin 0.5 mg/dL. Blood culture -positive for group B Salmonella. Clostridium difficile PCR - negative. Stool culture - positive for group B Salmonella and was later identified as Salmonella Saintpaul serotype. CT abdomen and pelvis without contrast - wall thickening and inflammatory stranding involving the right hemicolon and the hepatic flexure. Patient was given intravenous antibiotic therapy and follow up blood cultures did not demonstrate growth of Salmonella. Patient's condition steadily improved and she was eventually discharged home.

DISCUSSION:

Salmonellae are Gram-negative, rod-shaped bacilli and are classified into typhoidal and nontyphoidal groups based on their serotype. Common sources of non-typhoidal Salmonella infection are contaminated food or water and contact with infected animals. In our patient's case, her family raised chicken for eggs and we suspect that to be the source of infection.
1499 Segmental Colitis Associated With Diverticulosis (SCAD): A Rare Cause of Hydroureteronephrosis
Authors: Bazarbashi Ahmad Najdat , McCarty Thomas R. , Al-Obaid Lolwa , Homenko Daria
Published: October 2019

INTRODUCTION:

Segmental Colitis Associated with Diverticulosis (SCAD) is a rare inflammatory condition affecting segments of bowel with diverticulosis. We present a case of a patient with imaging revealing left colonic wall thickening and left sided hydroureteronephrosis, and work-up confirming a diagnosis of SCAD.

CASE DESCRIPTION/METHODS:

An 85-year-old female with a history of cognitive impairment, uterine cancer status post hysterectomy, and previous episode of diverticulitis 5 years prior presented to our institution with fevers, chills, and flank pain. Symptoms began 3 days prior to presentation with no associated abdominal pain, nausea, vomiting, hematochezia, or changes to her bowel movements. Upon arrival, her vital signs were within normal limits and physical exam disclosed left flank tenderness. Laboratory data revealed leukocytosis to 17 K/uL with unremarkable hematocrit, basic metabolic panel, and liver chemistries. Urinalysis was positive for pyuria with nitrites and leukocytes. CT abdomen and pelvis revealed short segment of sigmoid colonic, adjacent lymphadenopathy, left psoas abscess, and moderate left hydroureteronephrosis (Figure 1). She was initially treated with antibiotics and left-sided percutaneous nephrostomy tube placement. Colonoscopy was deferred due to concern for high risk of complications in favor of conservative management; however, repeat imaging 4 weeks later revealed unchanged thickening of the mid-sigmoid colon extending into left pelvic sidewall and interval increase in the left psoas collection with concern for fistulizing chronic diverticulitis or potential malignancy. She subsequently underwent exploratory laparotomy with lower anterior resection and ileoclonic resection for tethered and fistulizing small bowel to a left lower quadrant phlegmon. The sigmoid colon was also attached to the phlegmon and pathology revealed diverticulitis with extensive old fibrosis and reactive lymphadenopathy without evidence of malignancy or histology suggestive of IBD. As such, the final diagnosis was SCAD-associated hydroureteronephrosis, and she recovered well without complication.

DISCUSSION:

Often mistaken for IBD or colorectal cancer, SCAD is an inflammatory condition that should be considered in patients with history of diverticulosis and features suspicious for segmental colonic inflammation. This case reinforces understanding and highlights hydroureteronephrosis as a rare complication seen in a patient with SCAD.
1502 Colon Polyp as Rare Manifestation of Breast Cancer Metastasis
Authors: Ghavimi Shima , Nasir Umair M. , Panchal Dayna , Choi Catherine , Fidan-Ozbilgin Ozlem , Verma Siddharth
Published: October 2019

INTRODUCTION:

Breast cancer is the most common cancer in women worldwide. The leading cause of morbidity and mortality is due to distal metastasis. While metastasis to the brain, bones, lungs, liver and adrenal glands is usually seen, metastasis to the gastrointestinal tract is a rare, with colorectal involvement being an even rarer entity. We present a case of metastatic breast cancer presenting as a benign-appearing polyp on a colonoscopy.

CASE DESCRIPTION/METHODS:

A 56-year-old female with no significant past medical history except for schizophrenia presented with chief complaints of left breast mass with diffuse lymphadenopathy. Biopsy of the mass revealed invasive ductal carcinoma which was ER/PR (+) and HER2 (−) on immunohistology. PET/CT revealed diffuse bone metastasis. Contrast brain MRI showed isolated cerebellar brain lesion suggestive of neoplasm, likely secondary to the metastatic lesion. Patient was evaluated by Radiation oncology and radiation therapy started. During the hospital course, she was noted to have a gradual decrease in hemoglobin from 11 to 8.6 g/dl, while the reticulocyte count was normal. Although fecal occult blood testing was negative, Gastroenterology was consulted and EGD revealed gastritis and biopsies revealed inflammatory gastritis that was negative for H.Pylori. Colonoscopy revealed a 4 mm sessile polyp in the transverse colon (Figure 1). Biopsy of the polyp was consistent with adenocarcinoma which was ER/PR (+) (Figure 2) and HER2 (−) on immunohistology. Additional nuclear staining with breast markers including mammoglobin, and gross cystic disease fluid protein-15 was performed, and metastatic breast cancer was highly suggested. Unfortunately, due to the advanced nature of her breast cancer and poor overall nutritional status, the patient expired.

DISCUSSION:

In a review of cases reporting primary breast cancer with metastasis to the gastrointestinal tract, invasive lobular carcinoma of the breast is much more frequently represented. In our case presented above, the diagnosis was invasive ductal carcinoma of the breast with metastasis to the transverse colon. Diagnosis of metastasis to the colon may be difficult, as symptoms may be nonspecific. Due to this, patients with this entity often present late in disease progression. PET/CT often are non-contributory and do not show colonic metastasis. In conclusion, while gastrointestinal, especially colorectal, metastasis is rare, metastatic breast cancer can mimic a benign-appearing colon polyp on colonoscopy.
1503 A Rare Case of Nivolumab-Induced Early Onset Immune-Mediated Colitis With Normal Appearing Mucosa
Authors: Shahzad Sheikh , Mansoor Muhammad Sohail , Naseer Usman , Khan Abdul Moiz , Batool Asra
Published: October 2019

INTRODUCTION:

Programmed Cell Death Protein 1 (PD-1) inhibitor, nivolumab, is increasingly being used for the treatment of advanced neoplasms including melanoma, renal and metastatic lung cancers. Side effects of nivolumab include Immune-mediated colitis (IMC) with a median time to onset between 6-18 weeks. We present a patient with adenocarcinoma of the lung who developed IMC within a week of initiation of nivolumab.

CASE DESCRIPTION/METHODS:

A 75-year old male with a history of recurrent stage IIIA adenocarcinoma of lung presented with a one-week history of 5-6 non-bloody liquid bowel movements (grade 2 colitis) with nocturnal episodes. His symptoms started within a week of initiation of nivolumab. The patient had persistent diarrhea despite overnight fast and had associated severe abdominal cramps and nausea. His vital signs were stable on presentation and physical exam was significant for clinical dehydration and tenderness to palpation in the LLQ. CT A/P and AXR were unremarkable while infectious workup including C. Difficile was negative. His stool guaiac, fecal elastase, and serum lipase were negative while his inflammatory markers including ESR, CRP and fecal calprotectin (193 μg/g) were elevated. A colonoscopy was performed which showed normal appearing mucosa while random colon biopsy demonstrated increased intra-epithelial lymphocytes, surface epithelial injury, expansion of lamina propria by mononuclear inflammatory infiltrate and scattered crypt abscesses. CMV immunochemical stain was negative. Nivolumab was discontinued following biopsy result and the patient was started on oral prednisone 40 mg bid with the resolution of diarrhea within 2 weeks of treatment. He was later transitioned to oral budesonide.

DISCUSSION:

IMC is more commonly seen with Cytotoxic T-Lymphocyte Antigen 4 (CTLA4) inhibitors as opposed to PD-1 inhibitors especially nivolumab. Although the average time of onset of nivolumab associated colitis ranges between 6-18 weeks, early onset IMC is rare but possible as in our case. IMC can have an atypical presentation with early onset diarrhea and normal appearing mucosa as in our case. Clinicians need to have a high index of suspicion for IMC while taking care of patients receiving PD-1 inhibitors presenting with diarrhea or abdominal pain.
1505 Relapsed Angioimmunoblastic T-Cell Lymphoma Presenting as Severe Colitis With Bowel Perforation
Authors: Hussien Merna , Mehta Amit , Buffie Charlie , Tafesh Zaid , Wan David
Published: October 2019

INTRODUCTION:

Angioimmunoblastic T-cell lymphoma (AITL) is a subtype of the uncommon peripheral T-cell lymphomas that usually presents as acute onset of systemic B symptoms and generalized lymphadenopathy. Here, we report a case of a woman with relapsed AITL involving the descending, sigmoid colon, and rectum, presenting as persistent diarrhea and bowel perforation.

CASE DESCRIPTION/METHODS:

A 78-year-old woman who was diagnosed with AITL in 2002 and had been stable on continuous therapy of romidepsin for the past 2.5 years for relapsed disease, presented with a 6-week history of diarrhea, fatigue, and decreased appetite. The diarrhea was watery, non-bloody, occurred 4-5 times a day, with fecal urgency and incontinence. The patient denied any abdominal pain, nausea, vomiting, or fever. There was no recent change in her medications, and no recent history of travel or contact with children or pets. During the 6-week period, she was hospitalized twice and was initially thought to have infectious colitis, for which she was given ciprofloxacin, metronidazole, and re-hydration therapy. Abdominal CT showed severe left-sided colitis with multiple enlarged perirectal and mesenteric lymph nodes. Upon her third admission, infectious etiologies were ruled-out and sigmoidoscopy showed markedly edematous and erythematous rectum. Biopsies from the rectum and sigmoid colon showed dense atypical T-cell infiltration consistent with involvement of her previous AITL. Her hospital course was further complicated by bowel perforation and polymicrobial positive blood cultures. She refused surgery and was referred to home hospice for palliative care.

DISCUSSION:

AITL is an aggressive peripheral T-cell lymphoma that is believed to arise from CD4 positive follicular helper T-cells. It accounts for 1-2% of non-Hodgkin lymphoma cases and has a higher incidence among Asian/Pacific Islanders and Hispanic Whites in the United States. Initial presentation commonly includes generalized lymphadenopathy, fever, unintentional weight loss, and night sweats. With progression, it can commonly involve the bone marrow, spleen, skin and soft tissues. However, gastrointestinal involvement is rare. In 1996, Goenka et al. reported AITL presenting as colonic polyps. We are reporting a case of AITL progressing to involve the descending, sigmoid colon, and rectum, whose presentation was initially mistaken for infectious colitis. However, due to high clinical suspicion, sigmoidoscopy was performed and biopsies confirmed the diagnosis of AITL of the colon.
1506 Poisoned by Indian Herbal Medicine: An Inconspicuous Cause for Abdominal Pain
Authors: Srivats Sudarshan , Zhang Danmei , Buffie Charlie , Wan David , Maltz Charles
Published: October 2019

INTRODUCTION:

Symptoms of lead poisoning are nonspecific and include abdominal pain, constipation, irritability, weight loss, and anemia. Sources of exposure in adults are predominantly occupational (ex. batteries, paint, cable, or wires), but also include herbal remedies, or cookware. Here, we report a case of lead poisoning after oral intake of Ayurvedic supplements.

CASE DESCRIPTION/METHODS:

A 35 y/o man presented with 6 weeks of worsening diffuse abdominal pain and cramping, SOB, fatigue and nausea. Patient denied diarrhea, vomiting or weight loss. He traveled to India earlier this year. Examination was notable for severe abdominal tenderness and slight distention. Initial work up including CBC, CMP, UA and LFTs were notable for a normocytic anemia with a Hb 9.5 (baseline 16). Stool was brown and guaiac negative. Serum haptoglobin, LDH, B12 and iron studies were within normal limits. Abdominal CT and US were unremarkable. EGD showed no bleeding. Additional work-up such as GI PCR, Meckel scan, urine PBG, blood lead level (BLL) and C1-INH were ordered. However, Hb kept dropping without improvement in pain. On day 3 of hospitalization, he was started on laxatives for constipation and discharged after improvement in bowel movements and abdominal pain with outpatient follow up for his anemia. Lab results later revealed a BLL of 78.4 ug/dL, and a blood smear showed basophilic stippling of erythrocytes, consistent with lead poisoning. On further interview, patient noted taking Ayurvedic supplements obtained in India with last intake 3 weeks prior to admission. Patient stopped his herbal medication and was started on oral succimer and eventually switched to dimercaprol. Samples of the supplements were sent out for testing.

DISCUSSION:

Given that many differentials for abdominal pain and anemia were ruled out, less common causes were investigated, such as AIP, intestinal angioedema, and lead poisoning. Once absorbed, lead deposits in the blood, soft tissue and bone. The toxic effects of lead are due to oxidative stress caused by inactivation of anti-oxidant enzymes, which damages DNA, cell membranes and impairs DNA transcription. Common symptoms are microcytic anemia, abdominal colic, nausea, vomiting and neuropathy. Basic workup includes free erythrocyte protoporphyrin or zinc protoporphyrin, blood urea nitrogen, serum creatinine, and urinalysis for 5-Amino-laevulin acid. In this case elevated BLL and classic blood smear lead to the diagnosis of lead poisoning.
1513 Efficacy of the Traction Device “S-O Clip” Assisted ESD for the Colonic Tumor Involving a Diverticulum
Authors: Sakamoto Naoto , Fukushima Hirofumi , Murakami Takashi , Ueyama Hiroya , Nagahara Akihito
Published: October 2019

INTRODUCTION:

Background: Endoscopic submucosal dissection (ESD) allows en bloc resection of large gastrointestinal neoplasms regardless of the size. However, technical difficulties associated with ESD in the colorectum make it less widely applied in the treatment of tumors in this region. To address this difficulty, we designed a traction device, called S-O clip and reported previously (Endoscopy2008, Gastrointest Endosc 2009). ESD with this device was effective for complete resection of large tumors (LSTs) (Surgical Endoscopy2014). Although the lesions of unusual sites such as within the appendix and diverticulum are very difficultto remove by ESD and sometime surgical treatment is required, We reported the first case of aLSTs involving a diverticulum successfully treated by ESD with this device (Gastrointest Endosc 2016). Aim: To evaluate the efficacy and safety of S-O clip assisted ESD for the tumor of the colon involving a diverticulum.

CASE DESCRIPTION/METHODS:

Results: 4 cases are LSTs involving a diverticulum in the ascending colon. One case is in the sigmoid colon. All 5 cases were removed safely and successfully en bloc without any complications. Procedure time s were 67, 145, 25, 68 and 64 minutes, with resected specimens measuring 20, 32, 20, 18 and 30 mm, respectively.

DISCUSSION:

Conclusion: This limited case series demonstrate that S-O clip-assisted ESD is safe and effective for en bloc resection of the colonic lesion involving a diverticulum.
1514 Intestinal Tuberculosis Presenting as GI Bleed and Cecal Mass
Authors: Bommena Shoma , Mann Sarabdeep
Published: October 2019

INTRODUCTION:

Abdominal tuberculosis (TB) is rare and comprises only 5% of all cases of TB. Lower GI bleeding occurs in 5-15% of patients with intestinal TB, with the ileocecal region is the most common site of hemorrhage. We present a case of disseminated TB with intestinal involvement, presenting as a GI hemorrhage and cecal mass.

CASE DESCRIPTION/METHODS:

A 72-year-old female of Vietnamese origin with PMH of dementia and chronic hepatitis C presented to our hospital with a chief complaint of increased somnolence and melena. She was febrile, hypotensive, and tachycardic. Labs showed a hemoglobin of 6.2 and hematocrit of 20.3. She was admitted to the ICU for presumed sepsis due to a UTI, and was initiated on broad spectrum antibiotics. She was transfused packed red blood cells, and treated with IV pantoprazole and IV octreotide. Ultimately she underwent an EGD which was unremarkable. Subsequent workup with a chest CT revealed innumerable non-calcified bilateral lung nodules concerning for granulomatous disease. She underwent a bronchoscopy, and BAL was positive for AFB on cultures. Anti-TB therapy with rifampin, isoniazid, pyrazinamide and ethambutol was initiated. Due to ongoing encephalopathy an MRI of the brain was performed and showed multiple enhancing nodules suggestive of disseminated or metastatic disease. Ultimately a CT abdomen pelvis was performed showing a possible cecal and ascending colon mass with ileal thickening in the R pelvis. Subsequently a colonoscopy was performed which revealed an ulcerated non-obstructing mass at the ileocecal valve, with oozing and stigmata of recent bleeding. Biopsies showed granuloma formation with necrosis, with acid-fast bacilli confirmed on AFB stain.

DISCUSSION:

Intestinal TB is rare in Western countries and has a higher incidence in migrant populations. Its nonspecific features make establishing a diagnosis difficult. It should be considered in the differential diagnosis of GI hemorrhage in the appropriate clinical setting. As the presentation of colonic TB often mimics that of a neoplasm, colonoscopy with tissue biopsy remains the main stay of diagnosis.
1516 A Rare Cause of Diarrhea in the U.S.: Schistosomiasis Colitis Case Report and Literature Review
Authors: El Zein Mohamad , Ismail Hibah , Heif Muhannad , Kobeissy Abdallah , Sodeman Thomas , Nawras Ali
Published: October 2019

INTRODUCTION:

Schistosomiasis is one of the neglected tropical diseases and is endemic in more than 70 countries. Herein, we present a case of schistosomiasis colitis in the USA.

CASE DESCRIPTION/METHODS:

A 21-year-old man born in Libya, resident in USA for more than 9 years, was referred to the Gastroenterology consultation for chronic diarrhea (8 bowel movements per day of liquid feces), intractable diffuse abdominal pain, associated with subjective fevers, chills, nausea, vomiting (nonbloody), and decreased oral intake. Laboratory workup was negative for leukocytosis; stool cultures were negative. Computed Tomography (CT) abdomen and pelvis showed diffuse colitis with bowel wall thickening. Patient was treated with ciprofloxacin and metronidazole. Given no improvement in symptoms, Colonoscopy was performed showing diffusely congested and hyperemic mucosa. Random colonic biopsies were positive for parasitic infection associated with non-necrotizing granulomas most consistent with schistosomiasis. This was followed by a positive serology test for Schistosoma. He was started on praziquantel (40 mg/kg) with improvement in diarrhea frequency prior to discharge to follow up in clinic.

DISCUSSION:

Colonic schistosomiasis is common in endemic areas (Africa, South America and Asia) and the endoscopic findings can be confounded with inflammatory bowel disease with just a few reports published in these countries and very rare in the USA. The most common presentation is a form of symptomatic chronic active colitis with diarrhea and abdominal pain. The diagnostic gold standard is the histology. Even though new cases have not occurred recently in USA, we should remain aware of schistosomiasis colitis for patients who came from foreign epidemic areas.
1520 Colonic Webs—A Case Report Abstract
Authors: Singh Sohrab , Nustas Rosemary , Body Cameron B. , Shahnavaz Nikrad
Published: October 2019

INTRODUCTION:

Intestinal webs in adults are rare anomalies of the gastrointestinal tract associated with Non-Steroid Anti-inflammatory drug use often causing small bowel obstruction.
1,2
The presence of a colonic web found incidentally on a follow-up colonoscopy in an asymptomatic adult patient makes our case unique.

CASE DESCRIPTION/METHODS:

A 58-year old African American female with chronic NSAID (meloxicam) use for Ankylosing Spondylitis underwent elective superior hypophyseal artery aneurysm coil embolization without complications. After a drop in Hb and episode of melena, EGD and colonoscopy on 9/31/2018 revealed a superficial non-bleeding distal rectal ulcer, two duodenal ulcers and a pinpoint opening in the ascending colon, one fold distal to the cecum representing a Colonic Web (diaphragm) likely due to NSAID use. Lumen was narrow with no evidence of obstruction. Focused physical exam and imaging were benign. Patient was asked to stop NSAID and discharged on Proton Pump Inhibitor. Follow-up colonoscopy to assess ulcer healing on 12/18/2018 still showed the diaphragm but it was smaller and lumen was patent. No intervention was done again since patient was asymptomatic. Post procedure, she was discharged in stable condition and advised to continue avoiding NSAID, stay on stool softener and look for symptoms of obstruction.

Discussion:

Webs in the colon are a very rare entity. The investigation of choice remains capsule endoscopy or contrast study where non-passage of contrast distal to dilated segment in case of an obstructing colonic web indicates the level of obstruction. Intraoperative endoscopy and balloon dilatation help to relieve obstruction in symptomatic patients.
3
No intervention is suggested in asymptomatic patients. Use of NSAID is the likely cause of development of web-like strictures in the small bowel.
1,2
This case can be useful in the differential diagnosis of one of the rare causes of colonic obstruction.
1522 Energy Therapy—An Alternative Treatment of Anal Fissures
Authors: Malik Fahad , Kim Marina , Reyes Jonathan M. , Patel Bhavin , Gonzalez Manuel O. , Weissman Simcha , Aziz Muhammad , Wickremesinghe Prasanna
Published: October 2019

INTRODUCTION:

Energy Therapy has been a well known non-surgical, minimally invasive treatment option for symptomatic grades I and II internal hemorrhoids. This treatment has not yet been studied in anal fissures refractory to medical therapy. Anal fissures, like hemorrhoids, can severely disrupt the quality of life for patients. Currently, only a few non-surgical treatments are available for anal fissures which involve conservative and supportive measures that include: increasing dietary fiber intake, stool softeners, sitz baths, topical analgesics or vasodilators. The gold standard for chronic anal fissures (CAF) refractory to medical therapy is treatment with internal sphincterotomy. Unfortunately with this treatment there is a chance of relapse and a risk of anal incontinence. We propose the use of hemorrhoid energy therapy (HET) with bipolar cautery as a safer, less invasive and effective therapy for recurrent anal fissures refractory to conservative management.

CASE DESCRIPTION/METHODS:

53 year old obese heterosexual man presented with bright red blood per rectum for two months managed outpatient for chronic constipation. Rectal examination revealed a large clot with anal tenderness and few internal hemorrhoids. Colonoscopy revealed 3 internal non-bleeding hemorrhoids and slow oozing bleeding anterior anorectal fissure. The anal fissure exhibited characteristics of chronicity with base exposing to the internal anal sphincter, hypertrophic anal papilla and sentinel pile. HET therapy with bipolar cautery was applied to the bleeding anal fissure. The tissue consisting of anal fissure in bowel wall was compressed in a parallel fashion and bipolar radiofrequency energy was delivered until the temperature reached 55 C or 131 F (5-20 seconds) for approximately 1.5 to 2 seconds.

DISCUSSION:

The delivery of energy to a targeted region with temperatures between 50 to 55 C along with compression of the tissue can help obtain homeostasis for bleeding or CAF along with change of histology to mild scarring with fibrosis and occlusion of blood supply which would result in healing of the fissure. This intervention using bipolar cautery which could be an alternative treatment as a safer, less invasive and effective therapy for recurrent anal fissures refractory to conservative management prior to considering surgery. Our patient was followed up 2 years after the procedure with no recurrences of anal fissures or rectal bleeding, and reported improved quality of life with no complications from the procedure.
1527 Ulcerative Colitis With Concomitant Serrated Polyposis Syndrome
Authors: Smith Zachary , Yezaz Ghouri , Ibdah Jamal A. , Tahan Veysel
Published: October 2019

INTRODUCTION:

Ulcerative colitis (UC) is associated with increased risk of colon cancer. Current knowledge of UC with concomitant serrated polyposis syndrome (SPS) is limited and clinical guidelines regarding management is lacking. Sessile serrated adenomas and traditional serrated adenomas are precursors of at least 20% of sporadic colorectal carcinomas. Patients with SPS have higher risk of developing dysplastic lesions. We describe an interesting case of concurrent UC with SPS and a brief review of literature surrounding this association.

CASE DESCRIPTION/METHODS:

A 45-year old female with no significant past medical history presented to clinic for a 2-month history of change in bowel habits with bloating and occasional hematochezia. She denied a family history of colon cancer or inflammatory bowel diseases (IBD). Colonoscopy revealed three flat polyps measuring 2 mm, 7 mm and 8 mm in size at the cecal base, and two flat polyps each 11 mm in size in the ascending colon. All these polyps were removed and found to be of sessile serrated type on histopathology thereby meeting the WHO criteria for SPS. Patient was also found to have a 20 cm segment of inflammation in the rectum, biopsies showed diffuse chronic active proctitis with severe activity, meeting the criteria for ulcerative proctitis. Patient was started on mesalamine 1000 mg rectal suppository daily with plan for a repeat colonoscopy in 6 months to assess response. Laboratory analysis at time of colonoscopy showed C reactive protein <0.40 mg/dL, WBC count 6.12 × 10(9)/L and Hgb 12.5 g/dL.

DISCUSSION:

Frequency of occurrence of SPS among IBD patients seems to parallel that of general population. But the risk of colon cancer in this setting is unclear since IBD itself can give rise to colonic dysplasia. It has been suggested that a serrated pathway of carcinogenesis in inflammatory bowel disease is characterized by silencing of MGMT by gene promoter methylation, KRAS mutations, and potentially molecular alterations that are yet to be characterized and suspected to eventually lead to adenocarcinoma. Further studies are needed to define optimal management of these patients. This case highlights the complexity of managing this concurrent syndrome in patients with IBD.
1531 Failed Fecal Microbiota Transplantation for Fulminant C. difficile Colitis With Toxic Megacolon
Authors: Dong Michael Q. , Wentworth Brian , Hays R. Ann
Published: October 2019

INTRODUCTION:

Fulminant disease develops in 3-8% of patients with Clostridioides difficile infection (CDI) and may progress to toxic megacolon (TMC), the latter of which is typically managed surgically but has high mortality. Although fecal microbiota transplantation (FMT) is a well-established therapy for recurrent CDI, its utilization in cases of TMC is sparsely documented. Here we describe our experience with a patient who elected FMT over surgery and their clinical response.

CASE DESCRIPTION/METHODS:

A 74-year-old African-American woman with a recent perforated duodenal ulcer with surgical repair was transferred to our medical ICU (MICU) with septic shock from an initial CDI. She was previously treated with PO vancomycin, which was switched to fidaxomicin in the setting of continued diarrhea. On admission, she was afebrile with hypotension, tachycardia, and tachypnea. Labs showed leukocytosis, thrombocytopenia and an AKI. Physical exam revealed an acutely ill appearing woman with a diffusely tender, distended and tympanic abdomen. Fidaxomicin was stopped and PO/PR vancomycin and IV metronidazole were initiated. On day 3 of admission, the patient clinically deteriorated and abdominal x-ray demonstrated increased bowel distention. TMC was diagnosed and surgery was consulted. Colectomy was offered but she declined the procedure. FMT was discussed as an alternative, off-label therapy and she agreed to proceed with placement via colonoscopy. The elevated risk of perforation was deemed acceptable by the patient. Colonoscopy revealed pseudomembranes, deep ulcers, and friable mucosa. Donor stool was deployed at the hepatic flexure and the scope was carefully withdrawn. Over the 48 hours post-procedure, the patient had hemodynamic improvement and decreased pressor requirement. Her stool output decreased and abdominal exam improved. By 72 hours, however, the patient's condition again worsened and she elected palliative care and died shortly thereafter.

DISCUSSION:

While colectomy is standard treatment for fulminant CDI with TMC, FMT may represent a non-surgical alternative in selected cases. We describe transient, but profound, clinical improvement in patient parameters for 48 hours following FMT. The mechanism of benefit may be multifactorial, including repopulation of normal colonic flora and mechanical colonic decompression. Although our patient died, her case provides a framework for clinicians to consider this therapy and the expected response.
1533 Cytomegalovirus as the Forme Fruste of Colorectal Cancer in a Young Female
Authors: Thomas Michelle , Pinto Jonathan , Tan Zimri , Culpepper-Morgan Joan
Published: October 2019

INTRODUCTION:

Cytomegalovirus (CMV) infection is often seen in the GI tract among patients who are immunocompromised and most commonly affects the large bowel. Studies have shown CMV infection presenting as a colorectal cancer (CRC) like mass. We present a case of CMV presenting as the forme fruste of CRC.

CASE DESCRIPTION/METHODS:

A 31 year old Hispanic woman presented with a one week history of worsening abdominal pain, generalized weakness, hematochezia, and a 30 lb weight loss. She was a nonsmoker who had presented similarly 6 months prior to another institution and was diagnosed with CMV colitis by flexible sigmoidoscopy and biopsy of a rectal ulcer. Pathology revealed focal atypical epithelial proliferation, indefinite for dysplasia, and CMV immunostain was positive. The patient was treated with valganciclovir with improvement in symptoms, but later worsened. She denied change in bowel habits, history of anogenital warts, or HPV vaccination, but admits to a remote history of Chlamydia which was treated. History was also positive for chronic inactive HBV infection diagnosed 6 years prior to presentation. Significant labs were Hb 4.6 g/dL, MCV 65.9, Plt 466 K/uL, AST 43 U/L, ALP 111 U/L, HIV nonreactive, AFP 3.0 ng/ml, HBsAg reactive, HBV viral load of 613 IU/mL, HBcAb total reactive, HCV Ab nonreactive and CEA 44.6. CT abd/pelvis showed an inflammatory, ulcerated, rectal mass with wall thickening compatible with neoplasm (Figure 1). Large hypodensities were seen in both hepatic lobes consistent with metastases (Figure 2). Sigmoidoscopy showed an ulcerated partially obstructing mass in the rectum which was circumferential and friable and located at the anal verge and was approximately 10 cm in length. Biopsy of the mass showed scant adenocarcinoma admixed with ulcer and granulation tissue. Liver biopsy confirmed metastatic adenocarcinoma, colon primary.

DISCUSSION:

Potential previous exposure to oncogenic viruses such as HBV and HPV may have predisposed our patient to develop CRC at age 31. She had no other risk factors such as HIV infection, radiation exposure, or previous chemotherapy. Her underlying malignancy may have rendered her in an immunocompromised state that would have allowed CMV reactivation. Another possibility is exposure to multiple viruses caused immunocompromise allowing both CMV reactivation and CRC formation. CMV pseudo tumors are known to mimic CRC. Alarm symptoms such as weight loss and hematochezia in this patient warranted close follow up to complete resolution or alternative diagnosis.
1535 A Rare Case of Rectosigmoid Mucosal Schwann Cell Hamartoma
Authors: Abbas Syed Hassan , Shahid Tamoor , Hertan Hilary
Published: October 2019

INTRODUCTION:

Colorectal polyps of mesenchymal origin are rare. Mucosal Schwann cell hamartomas have a pure proliferation of Schwann cells in the lamina propria and show immunoreactivity to S-100 protein. To our knowledge, only 11 cases have been reported in the literature since it was first described in 2009.

CASE DESCRIPTION/METHODS:

We present a case of a 50-year-old African-American female who presented to us for routine screening colonoscopy. Her past medical history was only significant for a prolactinoma for which she was on cabergoline. The patient had no personal or family history of neural lesions or inherited syndromes such as NF1, Cowden syndrome or MEN 2B. The colonoscopy revealed a 2 mm polyp in the cecum and a 3 mm sized rectosigmoid polyp which were resected and sent to pathology. The cecal polyp showed a tubular adenoma. The pathology report for the rectosigmoid polyp was consistent with spindle-shaped lesional cells with immunohistochemical staining strongly positive for S-100. They did not have immunoreactivity for epithelial membrane antigen (EMA). Hence, supporting the diagnosis for Schwann cell hamartoma. The patient was made aware of pathology findings and reassured.

DISCUSSION:

Mucosal Schwann Cell Hamartoma is a rare and benign lesion that forms in the colon. It usually arises in older adults. The specific risk factors of Mucosal Schwann Cell Hamartoma are unknown. Most patients are asymptomatic however rectal schwannoma may cause symptoms such as obstruction, bleeding, and tenesmus. They are often found incidentally in the distal colon during a colonoscopy. These tumors are poorly circumscribed, with short fascicles of uniform spindle cells replacing the colonic lamina propria, especially the superficial lamina propria, and separating and entrapping the crypts. These tumors involve the mucosa but never the submucosa. Although the histological differential diagnosis of a mucosal Schwann-cell hamartoma can include a gastrointestinal stromal tumor (GIST), neurofibroma, mucosal neuroma, ganglioneuroma, or mucosal schwannoma, a mucosal Schwann-cell hamartoma is composed of single Schwann cells without other cells, such as axons or fibroblasts, and is uniformly stained for S-100. These cells do not have immunoreactivity for c-Kit, CD34, glial fibrillary acidic protein, epithelial membrane antigen (EMA), smooth muscle actin, or neurofilament protein (NFP). Due to the benign nature of Mucosal Schwann Cell Hamartoma, they do not generally require any treatment.