bluuebunny/crossref_metadata_2025 huggingface dataset:
2724 Systemic Fungemia Following Gastric Ulcer Perforation in a Patient With Hepatocellular Carcinoma: A Case Report and Review of Literature
Authors: Qayyum Farhan , Alom Md S. , Chowdhury Nazif , Bank Lesile
Published: October 2019

INTRODUCTION:

The frequent overgrowth of Candida in the intestinal microbiota has made candidemia one of the most common bloodstream infections in the United States. Such infections are capable of infecting organs leading to several threatening conditions such as fungal endocarditis, meningitis, osteomyelitis, or Candida endophthalmitis. In rare occurrences, Candida species overgrowth has also been theorized to promote perforations of gastric ulcers.

CASE DESCRIPTION/METHODS:

We are reporting the case of a 56-year-old immunocompromised male with a history of cirrhosis of liver secondary to Hepatitis C, hepatocellular carcinoma and gastric ulcers who presented with generalized abdominal pain and distention. Physical exam showed him to be in moderate distress with diffuse severe tenderness to palpation with guarding and rebound tenderness. A CT of the abdomen revealed pneumoperitoneum, and a subsequent diagnostic laparoscopy discovered a 5 mm gastric ulcer perforation with an opening into the antrum of the stomach. Following surgical repair of the perforation, blood and peritoneal fluid cultures revealed the growth of Candida galbrata. Despite aggressive antifungal therapy, the patient expired due to multisystem organ failure.

DISCUSSION:

While most gastric perforations are caused by complications with peptic ulcer disease, nonsteroidal anti-inflammatory drugs, or certain neoplasms, studies have shown that Candida overgrowth may also promote the perforation of a pre-existing ulcer. Fungal overgrowth most frequently occurs in immunocompromised patients or those on certain medications. Patients with a Candida infection are at an increased risk for organ failure, surgical site infections, a prolonged hospitalization, and a significantly higher mortality rate.
2725 Electrode Perforation Into Stomach Complicating Gastric Electrical Stimulation
Authors: Kobeszko Matthew , Bardezbanian Bryce , Berkelhammer Charles
Published: October 2019

INTRODUCTION:

Gastric electrical stimulation is not FDA-approved, but available on a compassionate basis in the management of refractory gastroparesis. We describe a patient with refractory gastroparesis treated by gastric electrical stimulation who developed the rare complication of electrode migration into the lumen of the stomach.

CASE DESCRIPTION/METHODS:

A 31 year old female with idiopathic gastroparesis was refractory to maximal medical therapy including polypharmacy and feeding jejunostomy. Her gastric emptying was delayed with only 78% gastric emptying after 4 hours on gastric emptying scan (normal > 90%). A gastric electrical stimulator was placed 4 years prior to presentation, on a compassionate use basis. A battery change was required 2 years later. Settings were gradually increased to maximal, at 5 mA, pulse width of 360 us, rate 40 Hz, cycle on 2 seconds, cycle off 3 seconds. Two years later she complained of stabbing epigastric pain, and a recurrence of her gastroparesis symptoms, with nausea, vomiting, coffee ground emesis, and early satiety. On physical exam she was afebrile and non-toxic, with mild epigastric tenderness. CT showed a non-specific 3.7 cm fluid density adjacent to the stomach around the gastric pacemaker lead. Upper endoscopy revealed that two of the leads had penetrated into the gastric lumen. Gastric retention of food was also noted, even though the patient had been nothing by mouth for 12 hours prior to the procedure. Surgery confirmed that 2 of the gastric pacemaker leads had eroded into the stomach. The leads were removed, and new leads placed more proximally in the stomach. A surgical pyloroplasty was also performed. The patient did well in the 18 months of post-operative follow-up.

DISCUSSION:

Lead perforation into the stomach following gastric electrical stimulation is rare. As far as we are aware, there are 3 previously reported cases. In addition, there is one report of electrode perforation into the small bowel. We speculate that higher energy settings, and longer duration of cycles on may be a risk factor for this complication. Sudden epigastric pain, recurrence of gastroparesis symptoms, and a fluid collection at the electrode insertion site, may be clues as to the development of this rare complication.
2727 A Fatal Case of Disseminated Gastric Mucormycosis With Emphysematous Gastritis
Authors: Rotundo Laura
Published: October 2019

INTRODUCTION:

Gastric mucormycosis is a life-threatening opportunistic fungal infection that presents in immunocompromised individuals, such as those with diabetes mellitus, hematologic malignancies, sepsis, or chronic steroid use. Concomitant emphysematous gastritis is a rarely documented condition that can occur due to mucosal infiltration and is associated with increased mortality.

CASE DESCRIPTION/METHODS:

This is a case of a 24-year-old man with Stage 1 testicular cancer (non-seminomatous germ cell tumor) on cycle 2 of cisplatin/ etoposide who was found unconscious following a syncopal episode. He was intubated for worsening hypoxic respiratory failure secondary to klebsiella aspiration pneumonia, requiring sedation and paralytics for seven days. On day 12, he was noted to have significant bright red blood per rectum and his hemoglobin decreased from 9.9 to 7.3. CT abdomen revealed significant intramural emphysema within the stomach (Figure 1). Emergent upper endoscopy revealed severe gastritis with mucosal sloughing and transmural necrosis involving 90% of the stomach. Rush biopsies revealed mucormycosis; he was started on amphotericin and isavucionazonium. He underwent laparoscopic total gastrectomy with E-J anastomosis two days later. Five days later, he was noted to have large bloody output from his abdominal drains with resultant hypovolemic shock. He was urgently taken to the operating room, where he had a cardiac arrest and died. Autopsy findings revealed fungal hyphae disseminated throughout the abdominal cavity and an exudative hematoma extending to the diaphragm, liver, transverse colon, pancreas, and spleen.

DISCUSSION:

Mucormycosis presents in the gastrointestinal tract in less than 10% of reported cases [1]. It is typically associated with upper gastrointestinal bleeding in immunocompromised patients. Furthermore, disseminated mucormycosis can result in vascular invasion, significant blood loss and multiorgan failure. Given that the finding of emphysematous gastritis is very rare since mucormycosis is not a gas-forming infection, sudden onset massive hematochezia and abdominal pain in at-risk individuals should raise concern for ischemic bowel necrosis from invasive mucormycosis. Because it carries a grave prognosis, rapid recognition and intervention of mucormycosis and its complications is necessary to avoid mortality.
2728 An Unexpected Cause of a Gastric Ulcer
Authors: Rojas Patricia Guzman , Gonzaga Ernesto Robalino , Catania Jelena , Moquete Mario
Published: October 2019

INTRODUCTION:

Mucormycosis is a rare rhino-orbital-cerebral fungal infection. The GI tract is involved in approximately 7% of the patients; however, this incidence may not be exact since several cases have been diagnosed postmortem. Within the GI tract, the stomach is the most frequently compromised organ, followed by the colon.

CASE DESCRIPTION/METHODS:

46-year old man presented to the ED with 1-week history of diffuse, crampy abdominal pain. His pain was associated with nausea, non-bloody vomiting, anorexia and watery non-bloody diarrhea for the past 3 days. His PMH is significant for HIV, well controlled on ART and DM complicated with gastroparesis. Laboratory results showed a CD4 of 540, normal WBC, A1C of 10.3% and negative infectious stool studies. The patient was admitted to the hospital and was placed on supportive treatment. Due to persistence of his symptoms, a CT of the abdomen was done showing gastric wall abnormalities (Figure 1). GI was consulted and a decision to perform an EGD was made. The EGD showed a large ulcerated irregular area in the stomach fundus (Figures 2 and 3). Biopsies were taken showing positive fungal stain compatible with mold from the order Mucorales. The patient was started on amphotericin B and then underwent a total gastrectomy with roux en Y reconstruction. Pathology results confirmed biopsy findings and culture was positive for Rhizopus species.

DISCUSSION:

Mucormycosis is an opportunistic infection that mainly occurs in immunocompromised states like DM, uncontrolled HIV infection and hematopoietic and solid organ transplant. GI invasion caused by Mucorales does not have a clearly understood mechanism; however, many authors propose that this starts after ingestion of fermented foods. Fungal hyphae can invade the blood vessels, leading to local ischemia, ulceration, infarction and necrosis of the affected tissue. Patients can present with nonspecific symptoms, which can delay the diagnosis, leading to mortality in 85% of the cases. EGD elucidates large ulcers that can be associated with emphysematous changes, as in our patient, but the diagnosis is made by fungal cultures of biopsies, since histopathological examination can be misleading. Treatment is based on amphotericin B or posaconazole, but surgical resection is necessary for cure. We report this case to increase awareness of mucormycosis as a cause of gastric ulceration in an immunosuppressed patient. Surgical treatment is encouraged, since delays are related to high mortality rates.
2730 Unexpected Cause of Globus Pharyngeous: Gastric Leiomyosarcoma
Authors: Gonzaga Ernesto Robalino , Guiance Irene Riestra , Parikh Jignesh , Vanar Vishwas
Published: October 2019

INTRODUCTION:

Soft tissue sarcomas (STS) are derived from smooth muscle cells and typically arise in adipose tissue, blood vessels or structural tissue surrounding the organs of the body. One of the most common types of STS is leiomyosarcoma (LMS) which account for 11% of all sarcomas diagnosed. Gastric LMS are exceptionally rare and make up 0.1% of all mesenchymal tumors of the stomach.

CASE DESCRIPTION/METHODS:

A 72 year-old male presented to the gastroenterology clinic with complains of globus pharyngeus, migrating abdominal discomfort and a 4-month 18 pound weight loss. Endoscopy revealed a large bloody friable mass in the posterior wall of the stomach. Biopsy demonstrated atypical spindle cell proliferation. Immunohistochemistry was positive for Smooth Muscle Actin (SMA), desmin and CD34; cKIT and DOG1 was negative. He was diagnosed with high grade LMS of the stomach with no metastasis after unremarkable positron emission tomography scan. The patient underwent total gastrectomy with splenectomy en-bloc resection to achieve wide negative margins.

DISCUSSION:

This case highlights an unexpected cause of globus pahryngeus: Gastric LMS which is important to differentiate from gastrointestinal stromal tumor (GIST) as its management and prognosis differ. LMS represent 0.1% of all gastric tumors, and 3% of all gastrointestinal malignancies. In contrast, GIST has annual incidence of 11-14.5 per million population. LMS and GIST appear similar on gross assessment and clinical symptoms and need to be differentiated via immunohistochemical staining. LMS are actin and desmin reactive with DOG1.1 typically being absent. Further, LMS lack cKIT and PDGFRα mutations that are seen in GIST. Management of GIST with tyrosine kinase is potentially lifesaving, whereas no such treatment exists for LMS where the cornerstone of treatment is surgery. Chemotherapy and radiation have been shown to be only helpful for palliative measures. They are intrinsically aggressive tumors and 90% are moderate to high grade at time of diagnosis with evidence of metastatic disease. We are far from understanding the pathology of LMS and its risk factors. This case confirms our present understanding of LMS; as shown by positive markers as well a diagnosis of high grade tumor on presentation. However, it also challenges our current understanding of LMS in its unusual symptomatology and lack of metastatic disease. Due to its low incidence, it is crucial to report cases such as this in order to further our understanding of the tumor.
2738 A Rare Cause of Dyspepsia: Gastric Sarcoidosis
Authors: Gala Khushboo , Luckett Robert T. , Shah Nihar
Published: October 2019

INTRODUCTION:

Dyspepsia is one of the most commonly addressed gastrointestinal problems in the outpatient settings, globally thought to affect 7-45% of the population. The majority of cases with dyspepsia are functional, as defined by the Rome Criteria, and have no organic cause. A rare cause of organic dyspepsia is gastric sarcoidosis, with only 40-60 cases described in literature so far. We present a case of new onset dyspepsia secondary to sarcoidosis.

CASE DESCRIPTION/METHODS:

Our patient was a 48 year-old African American female with a history of pulmonary sarcoidosis, which had been treated with systemic steroids and methotrexate and had been stable off medications. During a routine healthcare visit, she reported new onset of nausea and heartburn for one month, failed trial of PPI and then was referred for an EGD. Endoscopy showed grade A gastro-esophageal junction esophagitis and erosive gastritis. Biopsies of gastric antrum and body showed severe active chronic gastritis with non-necrotizing granulomatous inflammation, with negative staining for fungi, mycobacteria and H pylori, diagnosed as gastric sarcoidosis.

DISCUSSION:

Dyspepsia is a constellation of upper GI symptoms, including the presence of upper abdominal pain or discomfort with or without other symptoms such as nausea, belching and vomiting. Less than 30% of cases of dyspepsia are found to have an organic cause, the most common of which are chronic peptic ulcer disease, gastroesophageal reflux (with or without esophagitis) and malignancy. Among the rarer causes is sarcoidosis. Sarcoidosis is a multi-systemic disease characterized by the histological presence of non-caseating granulomas, which commonly has pulmonary manifestations. Gastrointestinal involvement is extremely uncommon in sarcoidosis and usually asymptomatic, with only 0.1-0.9% of all cases of GI sarcoidosis displaying symptoms. The mainstay of diagnosis is endoscopy with biopsy showing the characteristic non-caseating lesions, after ruling out infections and other etiology. Management consists of immunosuppressive therapy, including corticosteroids. Although rare, it remains the second most common cause of granulomatous gastritis in developed countries and should be kept in mind investigating GI symptoms especially in patients with preexisting disease. Our case also highlights the importance of appropriate upper endoscopy evaluation in cases of new-onset dyspepsia.
2739 A Rare Case of Multifocal Gastrointestinal Stromal Tumor
Authors: Kaushik Chandni , Bilal Mohammad , Parupudi Sreeram
Published: October 2019

INTRODUCTION:

Gastrointestinal stromal tumors (GISTs) are mesenchymal tumors most often located in the stomach and proximal small bowel although they can occur in any part of the gastrointestinal tract and occasionally in omentum, mesentery, and peritoneum. GISTs are traditionally thought of as solitary tumors that rarely present with multiple lesions. We present a unique case of multifocal GIST that was incidentally found on imaging.

CASE DESCRIPTION/METHODS:

A 44-year old woman with no prior medical history presented to the emergency department with a one-day history of left lower quadrant abdominal pain. A CT scan of abdomen and pelvis demonstrated acute diverticulitis, and incidentally a 6.2-cm heterogeneously enhancing exophytic mass along the inferior margin of the gastric body was seen. In addition, two lesions measuring 3.4 cm and 1.1 cm were seen adjacent to the gastrohepatic ligament (Figure 1). The patient’s abdominal pain improved with intravenous antibiotics. Gastroenterology was consulted given the mass lesions, and an endoscopic ultrasound was performed which showed three distinct heterogeneously hypoechoic masses (Figure 2), and fine needle biopsy (FNB) was performed. All three lesions were biopsied using three separate needles to avoid cross-contamination. Pathology of all three lesions was consistent gastrointestinal stromal tumor (GIST). Immunohistochemical staining was positive for DOG1 (Figure 3). The patient has been established with medical oncology for neoadjuvant therapy with Imatinib.

DISCUSSION:

Many GISTs are incidentally discovered on imaging or endoscopy. They are more frequently associated with early satiety, bloating, and bleeding although larger tumors can cause pain and symptoms of obstruction. Multifocal GISTs are exceedingly rare, other than exceptions in pediatric population, metastatic spread and hereditary syndromes. Newer studies suggest patients with multifocal GISTs may actually have multiple primary GISTs rather than metastatic spread, and molecular characterization can allow for proper staging and treatment planning. Multifocal GISTs have also been reported in patients with neurofibromatosis (NF) type I. However, our patient did not have any symptoms or signs suggestive of NF. It is important for gastroenterologists to know that multifocal GISTs can present in adults, and if suspicion is high, all lesions should be evaluated individually, and smaller lesions should not be attributed to metastasis unless proven otherwise.
2740 IgG₄-Related Disease: A Gastric Mass With an IgG4 Surprise
Authors: Lopez Dylan , Cepeda Cristina , Desmedt Cleo , Lalonde Christian P. , Montes Rogerio , Menjivar Juan J. , Mendez Oscar , Mendez Diego
Published: October 2019

INTRODUCTION:

IgG₄-related disease is a rare autoimmune syndrome that causes fibrosis of glands, most commonly of the pancreas and biliary tract1,3. The overall prevalence is unknown, with an estimated less than 1:100,000 of the general population typically found in middle-aged males2,3. Diagnosis is made with IgG₄ levels at least 2x the upper limit of normal and dense lymphoplasmacytic infiltrate, however, it may be seen with normal IgG₄ levels6. Although rare, it can present similar to GI malignancies and should be considered in the differential for patients with autoimmune disease1,3,4,5. Here we present one of those unusual cases.

CASE DESCRIPTION/METHODS:

A 65-year-old lady with PMH of DM2 and Sjogren's Syndrome (SS) who presented to the hospital with intractable nausea, vomiting, and failure to thrive for over 1 month. The physical exam, labs that included CMP, LFTs, and serology was unremarkable; previous EGD revealed diffuse thickening of the gastric submucosa. Biopsy via open gastrectomy revealed chronic inflammation with multiple IgG₄ plasma cells and no signs of lymphoma, suspicious for IgG₄-RD. After the partial gastrectomy, serum Na levels were 162, which improved with DDAVP and was later confirmed to be diabetes insipidus (DI). Further workup and imaging were negative and baseline IgG and IgG₄ levels were 1178 and 61, respectively. Treatment included steroid therapy and DDAVP which improved her symptoms and preceded an uneventful hospital course.

DISCUSSION:

IgG₄-RD is a disease with numerous presentations based on the organs involved. It presents as a GI-specific illness due to its affinity for the pancreas and biliary tract1,2,3. As seen in our patient, although rare, it may also affect the stomach, form mass lesions and cause symptomatology similar to a GI malignancy3,5. In patients with autoimmune diseases, where GI malignancy is considered, it is reasonable to include IgG₄-RD in the differential. IgG₄-RD may mimic symptoms of SS, and therefore case-patients with SS should also be considered for IgG₄-RD. This patient also experienced DI which may be a manifestation of IgG₄-RD, as the syndrome may affect the pituitary4. This case is one of the few instances reported to have pituitary involvement after the onset of multiorgan involvement4. Like other autoimmune disorders, IgG₄-RD is responsive to steroid therapy or rituximab. Therefore, a timely diagnosis can help slow down or prevent symptomatic manifestations, as seen in the case. Clinicians should be aware of this clinical presentation.
2741 Emphysematous Gastritis: A Real Indication for Emergent Surgical Intervention?
Authors: Riaz Sana , Kudaravalli Pujitha , Saleem Sheikh A. , Sapkota Bishnu
Published: October 2019

INTRODUCTION:

Emphysematous gastritis (EG) is a rare, life-threatening form of gastritis caused by gas-forming microorganisms which has a high mortality rate of 62%. Microorganisms associated with EG include Streptococcus, Escherichia coli, Enterobacter, Clostridium, Pseudomonas aeruginosa, Staphylococcus aureus, Candida, and Mucor. Only 40 cases of EG have been reported in English-language literature, and there are no guidelines available for the management of EG. We would like to highlight the importance of early diagnosis and optimum management of EG.

CASE DESCRIPTION/METHODS:

A 96-year-old male with a history of aortic valve replacement on aspirin and warfarin presented with epigastric discomfort, coffee ground emesis, and melena. He was hemodynamically stable on presentation. He had epigastric tenderness on examination. Blood work showed leukocytosis, thrombocytopenia, elevated blood urea nitrogen with normal creatinine level. Blood cultures were unremarkable. He underwent computed tomography (CT) of the abdomen, which showed gastric wall thickening along with gas. Esophagogastroduodenoscopy (EGD) showed findings consistent with gastric wall necrosis. He was managed conservatively with nasogastric tube (NG) gastric decompression, intravenous (IV) Pantoprazole, broad-spectrum IV antibiotics, and IV fluids. The patient did very well with conservative management and was discharged home in stable condition.

DISCUSSION:

The predisposing factors for EG are alcohol abuse, abdominal surgery, diabetes, immunosuppression, and phytobezoars. It is diagnosed based on the clinical presentation of an acute abdomen associated with systemic toxicity along with imaging findings. CT is the diagnostic imaging modality, which shows gas bubbles in the stomach wall. Management includes intravenous fluids and anti-microbial therapy covering gram-negative bacteria, anaerobes, and fungi. Emergent surgical intervention is indicated in the presence of gastric perforation and clinical deterioration despite medical management. Our patient did not have any known risk factors and was successfully managed conservatively after he was diagnosed with EG. Through this case, we want to highlight that EG can be successfully managed conservatively in selected patients without the need for surgery.
2742 A Unique Presentation of Scurvy in the Modern Era
Authors: Bhagavathula Anita , Linsteadt Joanna
Published: October 2019

INTRODUCTION:

Although rare in modern times, scurvy can present among elderly with malabsorptive syndromes, anorexia, or ESRD requiring hemodialysis. Below is a case of a middle-aged male without typical risk factors who was diagnosed with severe ascorbic acid deficiency. The purpose of this report is to highlight the importance of proper history taking that can aid in the early diagnosis and treatment of nutritional deficiencies, thereby reducing overall cost and length of hospital stay for these patients.

CASE DESCRIPTION/METHODS:

A 47-year-old male with history of anxiety/depression presented with two weeks of progressively worsening bilateral lower extremity ecchymosis and aches with associated non-specific flank pain and dark yellow urine. Patient denied recent aspirin or NSAID use, trauma, and blood in stool, urine, sputum, or gums. He is an unemployed, former smoker with a penicillin allergy and no family history of bleeding disorders. He was taking bupropion and clonazepam as prescribed by his psychiatrist but was also treating his anxiety with a friend’s clonidine and HCTZ. Urine drug screen was positive for MDMA and benzodiazepine. Initial lab work revealed Hb 4.7, K 2.8, elevated ESR/CRP and D-Dimer. WBC, platelets, iron studies, creatinine kinase, fibrinogen levels, and CT abdomen/pelvis were unremarkable. Patient was transfused multiple units of blood. Extensive hematologic and rheumatologic workup over the next several days was negative. He continued to have lower extremity weakness that finally resolved after starting treatment for a serum vitamin C level of 0.0 µmol/L. Patient then revealed that he had an allergic reaction to fruit as a child. He had since eliminated all fruits and most vegetables from his diet.

DISCUSSION:

Ascorbic acid has a short half-life and is not stored in the body. Severe Vitamin C deficiency can be seen in extremes of age and can take up to 3 months to develop. Symptoms can range from fatigue in the early stages to anemia, bone pain, gum disease, perifollicular hemorrhages, mood changes, and convulsions in the more advanced stages. Supplementation with 1-2 g of Vitamin C for the first 3 days followed by 500 mg for the next week and 100 mg daily for the next month should result in complete recovery. The case presented is unique due to the patient’s age and lack of typical findings such as corkscrew hair and bleeding gums. Patient had a prolonged hospital course with a costly workup that could have been curtailed with attention to nutritional status on presentation.
2743 Tumor Seeding at Gastrostomy Site Secondary to Percutaneous Endoscopic Gastrostomy Placement in Esophageal Squamous Cell Carcinoma
Authors: Hayat Maham , Hanafi Muhammad Z. , Yohannan Bryce , Moten Aqsa , Hayat Muhammad Hashim , Grossen Alyssa , Kanagala Rajesh
Published: October 2019

INTRODUCTION:

Insertion of a percutaneous endoscopic gastrostomy (PEG) tube in many patients with oropharyngeal and esophageal cancer is standard of care to ensure enteral feeding. The most commonly applied pull-through insertion technique involves direct contact with the tumor. We present a case of direct invasion of tumor through stomach wall attributed to PEG tube placement via pull technique.

CASE DESCRIPTION/METHODS:

A 72-year-old female with squamous cell carcinoma of esophagus undergoing chemotherapy and radiation, s/p PEG tube placement, was hospitalized for femur replacement after a fracture of her right femur secondary to a minor fall. GI service was consulted for severe irritation visualised around the PEG site. Patient reported that her dysphagia symptoms had much improved owing to ongoing treatment, so she had not used her PEG in a few weeks. Physical exam revealed tenderness to deep palpation in left upper quadrant. External bolster of the PEG tube was noted at 7cm with purulent drainage, sloughed skin and erythema at the insertion site. She was started on broad spectrum antibiotics and CT scan was obtained to evaluate for deep infection which reported a superficial ulcerating wound with an 8.1 × 4.1 cm soft, tissue lesion along the track of the PEG tube concerning for seeding along the surgical tract. It extended from the skin to the greater curvature of stomach with loss of fat plane concerning for direct invasion. Biopsies from the gastrostomy site and right femur revealed squamous cell carcinoma. Direct seeding through the stomach wall at the time of PEG tube placement was the working diagnosis. Decision of not removing the PEG tube was made given extensive tumor at site and concern for non-healing fistula formation.

DISCUSSION:

Cancer metastatic to a PEG tube exit site is a dreaded complication with carcinoma of the upper aerodigestive tract. Rare reports in medical literature regarding increased risk of developing seeding from the "pull-through" technique of PEG tube placement. Use of laparoscopic, open, or the "push" technique of PEG tube placement in patients with head and neck cancer may prevent direct implantation of malignant cells into an enteral access site. Management involves multi-disciplinary approach with treatment options including radiation, resection of site and chemotherapy. However, our case further emphasizes the importance of avoiding techniques that may put patients at risk for a, albeit rare, disease and life altering complication.
2745 Intramural Gastric Abscess: A Rare Condition Diagnosed and Managed With Endoscopic Ultrasound
Authors: Odish Fadi , Patwardhan Soumil , Jacob Maryconi
Published: October 2019

INTRODUCTION:

Intramural gastric abscess are rare presentations of suppurative gastritis which are often challenging to diagnose and manage. The pathology of gastric abscess formation is not completely understood but theorized cause include hematogenous spread or direct gastric inoculation from trauma. Predisposing factors include diabetes, foreign objects, or gastric surgery. The most common organisms identified are Streptococci. Historically, the diagnosis and management included surgical intervention however advancements in the field of endoscopic ultrasound provide a minimally invasive, accurate, and economical alternative.

CASE DESCRIPTION/METHODS:

A 75-year old female with a past medical history diabetes mellitus presents to the emergency department with epigastric pain. The patient’s symptoms started two days prior with progressive sharp epigastric abdominal pain with nausea and non-bloody non-bilious vomiting. Vitals revealed a temperature 100 °F, blood pressure 148/87 mmHg, heart rate 104 beats/min, and respiratory rate of 18 breaths/min, examination revealed a soft abdomen with epigastric tenderness with deep palpation. Initial lab work was only significant for a leukocytosis of 11,300 cells/mm3 with a left shift. She underwent computed tomography (CT) of her abdomen which revealed hypoenhancement possible abscess in the anterior wall measuring 2.5 cm in diameter. (Figure 1). EGD revealed a deformity consistent with extrinsic compression vs intramural lesion found in the gastric antrum. Upper endoscopic ultrasound (UEUS) revealed a 45 mm × 40 mm intramural (subepithelial) heterogenous density containing mass versus debris, FNA drainage produced 5mL of opaque, light brown/purulent thick fluid (Figure 3). Cultures Streptococcus intermedius and Micrococcus species. Pathology was negative. Patient symptoms improved the following day and she completed a 3 week course of oral levofloxacin and metronidazole. Four week follow up CT scan showed complete resolution of the abscess.

DISCUSSION:

This case outlines a rare condition of intramural gastric abscess managed successfully with UEUS. The patient had an unusual abrupt onset of symptoms and Streptococci intermedius cultures which has not been previously reported from our literature search. Surgical intervention has been the mainstay of treatment historically however endoscopic ultrasound imaging provides a favorable alternative which is safe, minimally invasive, and cost effective approach.
2746 Medical Management of Gastric Mucormycosis in an Immunocompetent Patient
Authors: Lankarani Daisy S. , Makar Ranjit , Aziz Hamza , Maklad Muthena , Jayaraj Mahendran , Ohning Gordon
Published: October 2019

INTRODUCTION:

Mucormycosis is a rare and life-threatening cause of invasive fungal infection largely found in immunocompromised patients. Prevalence has increased in patients without risk factors. This is a case of an otherwise healthy female, found to have invasive gastric mucormycosis, and her medical management.

CASE DESCRIPTION/METHODS:

54-year-old non-diabetic Ethiopian female with PMH HTN was admitted to the hospital with 2 months of nausea, vomiting, abdominal pain, fever, and melena. She reports use of omeprazole up to 4 times daily with no improvement. Pertinent findings include Temp 104 F, NIBP 90/40. Physical exam showed diffuse tenderness of the abdomen worse in epigastrium. WBC 22.8; other labs were normal. EGD showed a wide patch of necrotic and edematous folds of the fundus and proximal body of the stomach as well as submucosal hemorrhage in the fundus. Petechiae were seen in the antrum. Fundal biopsies were obtained, which showed invasive fungal hyphae, described as broad, non-septate, with branching consistent with the Mucor genus. Testing for TB, HIV, malaria, malignancy were negative. Fungal blood cultures were negative. Bone marrow biopsy was negative. Her only travel outside of the US in the last 10 years was to Ethiopia about 2 years prior. Her only non-US food source were chili peppers imported from Ethiopia. A course of liposomal amphotericin was recommended for 8 weeks for the mucor. Surgery recommended no intervention unless the patient developed peritonitis. She will be transitioned to oral posaconazole upon completion of the amphotericin. Her presenting symptoms, labs, and vitals have normalized.

DISCUSSION:

Mucormycosis is an uncommon cause of fungal infections of the GI tract with a high mortality. Most cases involve diabetics, neutropenic adults, immunocompromised patients, hematologic malignancy, or premature neonates. Our patient didn’t fall into any of these categories. The GI tract is only involved in approximately 7% of cases. The stomach being most common (58%) followed by the colon (32%). Endoscopic biopsy is needed for diagnosis where fungal hyphae are seen. Fungal cultures are positive in only 50% of cases. Because of the high risk of perforation and exsanguination, a combined approach of surgical and medical treatment is recommended. In this case, surgical intervention was only recommended in the case of an emergency. This patient without known risk factors for mucormycosis clinically improved without surgical resection.
2749 Looks Like a GI Bleed, Think Like a Gastroenterologist: A Case of Recurrent Bleeding in a Patient With Billroth II Operation
Authors: Chang Steven , Kim Denny , Saunders John K. , Popov Violeta
Published: October 2019

INTRODUCTION:

Anastomotic gastric adenocarcinoma (GAC) following distal gastrectomy Billroth II for peptic ulcer disease (PUD) has long been recognized but remains poorly studied.

CASE DESCRIPTION/METHODS:

A 65-year-old male with history of PUD status post Billroth II in 1991 presented with multiple episodes of melena and abdominal pain. EGD revealed friable gastric mucosa with oozing ulcers on the gastric side of the gastrojejunal anastomosis (GJA) (Figure 1a–c) and severe bile reflux. Stomach biopsies were negative for H. pylori or other pathology. Patient was subsequently admitted four more times that year for similar symptoms, each time presenting with symptomatic anemia that resolves with therapy, and EGD showing superficial erosions near the GJA. It was suspected however, that the initial biopsies were likely taken from areas far from the actively bleeding sites. Therefore, the GI team insisted on an outpatient EGD when the patient was asymptomatic to accurately investigate the GJA. After multiple missed appointments, he had an outpatient EGD (Figure 1d) with biopsies of the friable mucosa positive for GAC, and eventually underwent Roux-en-Y gastrectomy with esophagojejunostomy. Biopsy of the mesenteric nodules confirmed the diagnosis of moderately differentiated Stage IIIA GAC. Chemoradiation therapy was initiated, but patient left against medical advice and ended up in hospice care eight months later.

DISCUSSION:

We present a patient with persistent bleeding ulcers and symptomatic anemia 25 years after a Billroth II procedure, who despite multiple endoscopic evaluations with stomach biopsies, was not diagnosed on time. Eventually, the correct diagnosis of Stage III primary GAC was made after an outpatient EGD with targeted biopsies of the area associated with recurrent bleeding. Given the negative biopsies, the persistent gastric ulcers were thought to be complications of Billroth II with a short limb leading to bile reflux, or due to patient’s poor compliance and follow up. However, it was recognized that the patient had a higher risk of GAC as he was 15-20 years after Billroth II, and more importantly, that the inpatient EGD biopsies were not of the actively bleeding area of interest. Our patient presented after a long asymptomatic interval with symptoms initially misinterpreted as benign. It is therefore imperative to maintain a high suspicion of gastric malignancy for these patients to encourage earlier diagnosis.
2752 Nivolumab-Induced Hemorrhagic Gastroduodenitis
Authors: Tosounian Shannon L. , Goyal Abhinav , DePalma Richard
Published: October 2019

INTRODUCTION:

Immune Checkpoint Inhibitors are a growing class of cancer immunotherapy agents used to treat a range of malignancies including melanoma, lung cancer, & Hodgkin’s lymphoma. With their increased use, a number of gastrointestinal side effects have been recognized with the most common being colitis and pancreatitis. Few previous case reports have characterized gastroduodenitis as a complication of checkpoint inhibitors. We describe a case of severe hemorrhagic gastroduodenitis secondary to nivolumab, a PD-1 checkpoint inhibitor.

CASE DESCRIPTION/METHODS:

A 66-year-old female with history of Stage IV non-small cell lung cancer having recently received her fourth dose of nivolumab presented with one week of nausea, vomiting, and abdominal pain. The pain was sharp, 8 out of 10 in intensity, epigastric, non-radiating, and episodic. It was associated with nausea and non-bloody, non-bilious vomiting. There was no history of NSAID or alcohol use. Upon arrival to emergency department her blood pressure was 104/62 mmHg, heart rate 88 bpm, and temperature 36.7 degrees Celsius. She had epigastric tenderness without rebound or guarding. Laboratory workup revealed a normal complete metabolic profile and complete blood count. Her lipase was elevated at 394 IU/L (78 IU/L upper limit of normal.) A CT abdomen/pelvis demonstrated moderate diffuse gastric wall thickening with mucosal hyperenhancement, and mild peripancreatic edema. Patient was initially treated for pancreatitis with intravenous fluids and pain control. She continued to have severe epigastric pain on Day 4 of admission, thus upper endoscopy was pursued. Upper endoscopy showed diffuse severe inflammation with hemorrhage characterized by congestion, erythema, and friability in the entire examined stomach, and moderately diffuse erythema without hemorrhage in the duodenal bulb. Biopsies showed severe chronic active gastritis and were negative for H. pylori. She was started on prednisone 1 mg/kg daily, and symptoms improved. She was discharged to home with close oncology follow up.

DISCUSSION:

The increasing use of immune checkpoint inhibitors has led to a rising rate of immune-related adverse events affecting the gut. While gastroduodenitis is an uncommon side effect in comparison to colitis or pancreatitis, more cases are being reported in the literature. Early recognition of symptoms in relation to immunotherapy is important in providing timely removal of offending agent and treating appropriately.
2756 Metastatic Gastric Neuroendocrine Tumors in Non-Surveillanced Familial Adenomatous Polyposis
Authors: Harriss Patrick B. , Rashid Shazia , Mavuram Meher S. , Manas Kenneth J. , Samant Hrishikesh , Morris James D. , Jordan Paul
Published: October 2019

INTRODUCTION:

Familial adenomatous polyposis (FAP) accounts for 1% of colorectal cancers (CRC), and if left untreated, has a 100% lifetime probability of developing CRC. Close monitoring is required to mitigate effects. Though rarely reported in literature, neuroendocrine tumors are also noted to occur in FAP despite adenomatous predominance. Our case report describes a patient diagnosed with FAP that underwent prophylactic colectomy and initial treatment, and then decided to cease screening. 16 years later, she presented with metastatic disease arising from a gastric source of neuroendocrine origin. We highlight a rare case of gastric neuroendocrine tumor in FAP without surveillance, a less-understood disease process.

CASE DESCRIPTION/METHODS:

We present a case of a 38-year-old female with a past medical history of FAP diagnosed at age 22. She underwent prophylactic colectomy with internal ileostomy and treated for several years with imatinib; however, she stopped medication due to side effects, and chose to end routine surveillance. She presented with acute abdominal pain 16 years later, with physical exam findings of abdominal distension, epigastric tenderness, and palpable liver. CT abdomen/pelvis showed gastric mass, innumerable liver masses, and rectal masses. EGD revealed innumerable polyps carpeting entirety of stomach extending into duodenum, and a 5.3cm ulcerated gastric mass. Colonoscopy demonstrated diffuse polyps through the neo-rectal vault and anal canal. Multiple samples were obtained for study, including liver biopsy. Pathology revealed primary gastric neuroendocrine carcinoma with metastasis to liver, while rectal polyps were tubular adenomas. Whole-body imaging did not show any further spread. The patient was informed of her poor prognosis, and opted for discharge on palliative chemotherapy.

DISCUSSION:

A genetic risk for CRC exists in FAP patients, though they can also develop other cancers, as did our patient. Our case is unique in that a metastatic neuroendocrine gastric tumor in FAP has seldom been reported. An added angle of interest derives from the patient declining standard surveillance, which may have yielded prompt detection of disease progression. However, even if identified early, the paucity of understanding between FAP and neuroendocrine tumors still exists, limiting evidenced-based instruction for intervention and treatment. An inappreciable amount of such cases reported in literature means the association is poorly understood and warrants further study for clinical guidance.
2759 Eosinophilic Gastritis Responding to Proton Pump Inhibitor
Authors: Murthi Mukunthan , Chamarti Karthik , Murali Rangan
Published: October 2019

INTRODUCTION:

Eosinophilic gastritis is a rare condition that is part of a spectrum of gastrointestinal eosinophilic infiltration disorders which also includes eosinophilic esophagitis, enteritis, and colitis. They are characterized by excess eosinophils in the mucosal biopsy of one or more sites of the gastrointestinal tract in the absence of any specific causes of eosinophilia. Patients may present with symptoms including nausea, vomiting, abdominal pain, and weight loss. First-line of treatment is steroids. We describe a case of eosinophilic gastritis that was successfully treated with Proton pump inhibitor therapy.

CASE DESCRIPTION/METHODS:

A 23-year-old male presented to the outpatient clinic with a six-month history of episodic epigastric discomfort and retrosternal burning pain. Each episode lasted several hours and was precipitated by food intake. He had previously taken omeprazole 10 mg on and off for 4 weeks without any response. He had no history of any allergic disease. H.pylori stool antigen was negative. He was subsequently treated with four-week therapy of tricyclic anti-depressants with no response. Following this, he underwent upper gastrointestinal (UGI) endoscopy which showed mild erythema in the antrum. Gastric biopsy showed extensive eosinophilic infiltration with >50 cells/HPF in >5 HPF with normal esophageal and duodenal biopsy. Differential WBC count showed mild eosinophilia (7%). In line with a diagnosis of eosinophilic gastritis the patient was advised six food elimination which he refused. He was then started on Pantoprazole 40 mg once daily which was increased to twice daily after a week due to continued reflux symptoms. His symptoms gradually resolved over the next 12 weeks. On follow-up visit 3 months later he underwent repeat UGI endoscopy with biopsy which showed complete resolution of eosinophilic gastritis. The patient continues to remain asymptomatic.

DISCUSSION:

Eosinophilic gastrointestinal disorders can involve any part of the gastrointestinal tract from the esophagus to the colon. The antrum of the stomach is most commonly involved. There are no recognized guidelines for the treatment of eosinophilic gastritis, although steroid therapy is the mainstay of treatment. The role of PPI in the treatment of eosinophilic esophagitis is well known, but the utility of the same in eosinophilic gastritis has not been well defined. Our patient had symptomatic gastritis with biopsy revealing extensive eosinophilic infiltration. He responded excellently to 12-week pantoprazole therapy.
2765 A Rare Case of Diffuse Gastric Metastases Secondary to Breast Cancer
Authors: Sonti Sravanthi , Nagireddy Sumana , Parsa Laxmi , Birsan Christina
Published: October 2019

INTRODUCTION:

Breast cancer usually metastasizes to bone, lung, liver, or brain, and it is extremely rare to metastasize to gastrointestinal tract. We report a unique case of breast cancer metastasizing to stomach. We have noted only a few similar cases in current literature.

CASE DESCRIPTION/METHODS:

A 71-Yr-Old Caucasian female was referred for evaluation of upper abdominal pain, nausea, and occasional vomiting for 3months. Denies excess NSAID use, melena, or hematochezia. She has history of Hodgkin's lymphoma in remission after chemoradiation 40 years ago, and bilateral metastatic breast cancer diagnosed five years ago. She initially was found to have bilateral breast masses on mammogram. Biopsies showed invasive mammary carcinoma with extensive lobular pattern in right breast and invasive ductal carcinoma in left breast. PET-CT scan showed innumerable mixed sclerotic and lytic lesions throughout axial and appendicular skeleton. She was started on endocrine therapy as she declined chemotherapy. Laboratory values include normal liver function tests, and complete blood counts. Upper endoscopy showed moderately severe erythematous mucosa, and multiple small nodules throughout the stomach. Biopsies showed infiltrative tumor cells in nests and cords, some with signet ring cell features and mucin production. Immunohistochemical staining showed positive GATA-3 and ER which confirmed poorly differentiated adenocarcinoma of primary breast origin. She had another endoscopy a year ago which showed similar biopsy findings at an outside facility. Currently, she has been receiving capecitabine and following with oncology.

DISCUSSION:

Metastasis to gastrointestinal tract from other solid organ cancers is very rare. Breast cancer, mainly invasive lobular carcinoma, metastasizing to gastrointestinal tract, noted in <1% cases. It usually involves rectum, stomach, small bowel, and esophagus. Metastases to stomach mimic primary gastric cancer on imaging and endoscopically. Symptoms are nonspecific including abdominal pain, nausea, early satiety, bloating, and weight loss. Endoscopically, the stomach may have diffuse infiltration as linitis plastica, isolated, or multiple nodules, or a superficial mucosal lesion. Histological features especially immunohistochemical markers like GCDFP-15 and GATA 3 expression help to differentiate from primary gastric adenocarcinoma. Our patient had non-specific upper gastrointestinal symptoms. Endoscopy and biopsies confirmed the diagnosis.