bluuebunny/crossref_metadata_2025 huggingface dataset:
1976 It's a Bloody Tumor: A Case of Rare Neuroendocrine Tumor Presenting as Rectal Bleeding
Authors: McDonald Emmanuel , Trejoss Marisol , Choi David , Frontela Odayls , Gonzalez Felix
Published: October 2019

INTRODUCTION:

Gastroenteropancreatic Neuroendocrine tumors (GEP-NETs) refer to a group of heterogeneous neoplasms arising from neuroendocrine cells of the embryological gut. Rectal NETs are rare and often discovered during routine colonoscopy screening. They are often incidental findings since 50% of cases present as asymptomatic. When symptomatic with rectal bleeding, bowel habits changes, weight loss, and even pain, patients often are in an advanced stage of the disease. The advances in routine endoscopic screening processes have increased the incidence and prevalence of rectal NETs over the course of the years. Rectal NETs have varied developmental processes, clinical presentations, and due to the lack of epidemiological research, risk factors are not well known. While routine screening has allowed for earlier detection of colorectal NETs, histology-specific management has not yet been established and the role of surgery has been questioned.

CASE DESCRIPTION/METHODS:

We present a case of a 67 year old male with PMHx of HTN, CAD, DM, and treated prostate cancer who presents to the outpatient clinic with three months of bloody bowel movements. He reported never having blood in his stool previously, and having about two to three normal bowel movements daily. Abdominal CT scan revealed a 1.5 cm extramural mass extending into the rectal fossa. He underwent flex sigmoidoscopy that revealed a large flat ulcerated mass which pathology confirmed as a neuroendocrine neoplasm of the rectum. Patient was referred to oncology and surgery for transanal resection.

DISCUSSION:

The incidence of NETs of the rectum has increased about ten-fold over the past 30 years and represent 29% of all GEP-NETs. Despite the increase in incidental findings attributed widely to the higher endoscopy screening rates, rectal NETs continue to be rare worldwide. Studies suggest genetics may be one predisposing factor as it is more commonly found in African Americans, Hispanic, and Asian populations. Due to the rarity of rectal NETs, there is a dearth of knowledge to the risk factors for disease. While new screening guidelines have allowed for earlier incidental findings for colorectal pathologies, there is yet to be a modified screening protocol. Because rectal NET can be indolent and has potential metastasize, there is an emphasis on timing of detection. This case study highlights the potential need to further study, modify and incorporate known risk factors to improve diagnostics and screening for rectal cancer.
1997 Isolated Duodenal Melanoma: A Rare Cause of Gastrointestinal Bleed
Authors: Shafiq Muhammad , Ullah Waqas , Rashid Mamoon Ur , Zafar Yousaf , Mehmood Asif
Published: October 2019

INTRODUCTION:

Melanomas are known to be the worst dermatologist nightmare, being notorious due its widespread metastasis and recurrence. They can present with any symptom based on the involvement of the organ but it is exceedingly rare for melanoma to present as an isolated duodenal mass in the absence of skin lesions.

CASE DESCRIPTION/METHODS:

A 79 years old white male, with history of coronary artery disease was admitted with exertional shortness of breath and atypical chest pain. His symptoms started over a course of few days and was associated generalised weakness and fatigue. He never had an upper gastrointestinal endoscopy done and colonoscopy two years was normal. His home medications included aspirin and beta blocker. On examination, he was tachycardia with a heart rate of 100 bpm and blood pressure was 90/60. He was afebrile but tachypneic with a respiratory rate of 22/min. Systemic examination was unremarkable except pallor and rapid thready pulse. The laboratory investigation showed a hemoglobin of 8 g/dL, MCV of 80, platelet count of 189,000/mL and white blood cell counts of 8,000/mL. Esophagogastric duodenoscopy (EGD) was performed on the second hospital day which revealed a duodenal nodule. Biopsy was obtained from the lesion, no signs of active bleeding was observed. The biopsy was positive for metastatic melanoma. Immunohistochemical stains on parts A and B revealed the tumor cells to be positive for S100 and SOX10, and negative for synaptophysin, panCK, c-kit, and Dog 1.(Figure 1) Patient’s whole body was scanned but it did not show any other melanoma lesion and there was no primary melanoma on the skin either. Helicobacter pylori stains, performed on the gastric and duodenal biopsies, were negative. He was managed conservatively with pantoprazole 40 mg and regular follow up as patient refused surgery.

DISCUSSION:

It is exceedingly rare to have isolated duodenal melanoma in the absence of skin lesions and physicians should keep a high index of suspicion for these rare cases. Local resection of the mucosal melanoma (including in stomach and small intestine), with negative margins, should be considered first line treatment in patients without distant metastasis while conservative management with surveillance in patients can be considered in selected cases.
2017 An Uncommon Etiology for Gastrointestinal Bleed in Elderly: Blue Rubber Bleb Nevus Syndrome
Authors: Chandra Chakinala Raja , Kumar Anila , Li Lanxin , Olivier Sarah , Tewari Virendra
Published: October 2019

INTRODUCTION:

Blue rubber bleb nevus syndrome (BRBNS) is a rare congenital anomaly characterized by multiple venous malformations that can appear anywhere on the body, but most often involve the skin and gastrointestinal (GI) tract. GI bleeding usually presents in childhood or early adulthood as iron deficiency anemia. We report a case of BRBNS as a rare presentation of GI bleeding in an elderly patient with no prior history of cutaneous or GI tract involvement of the disease.

CASE DESCRIPTION/METHODS:

87-year-old man with a past medical history of hypertension, coronary artery disease and atrial fibrillation (on Xarelto) was transferred to our hospital for evaluation of melena. He presented to an outside institution initially with complaints of dizziness and black tarry stools for 5 days prior to admission. He was hypotensive, labs were significant for hemoglobin (Hgb) of 5.5 g/dL and a positive stool occult blood test. Anticoagulation was discontinued. He underwent esophagogastroduodenoscopy (EGD), which showed friable mucosa in the duodenal bulb but no active source of bleeding. He received 8 units of packed red blood cells (PRBC), but his Hgb only improved to 7 g/dL. A repeat EGD was also unrevealing. He then underwent a nuclear scan, which showed a focus of bleed in left hemi-abdomen, but it was unclear if it was from the small or large bowel. On presentation to our hospital, his Hgb was 6.6 g/dL and he continued to have melena, requiring multiple PRBC transfusions. Push endoscopy revealed diffuse discontinuous multiple vascular blebs of the mucosa in the mid jejunum (Figure 1a), one of which was found bleeding (Figure 1b). Successful hemostasis was achieved with cauterization of the bleeding bleb with argon plasma coagulation (APC) (Figure 1c,d) and a hemoclip placement 2 cm distal to the lesion. Post-procedure, his Hgb remained stable above 8 g/dL throughout the hospitalization.

DISCUSSION:

Although BRBNS lesions can occur anywhere from mouth to anus, the small bowel is the most common site of GI tract involvement. Its presentation can vary from iron deficiency anemia to massive hemorrhage, intestinal torsion, and rupture. Some patients require lifelong iron replacement and repeated blood transfusions. Push endoscopy is the most important diagnostic modality for GI lesions. Treatment depends on the severity of lesions and can range from supportive therapies such as iron supplementation and blood transfusion to more invasive therapies such as mucosal resection, APC, sclerotherapy or bowel resection.
2033 Gastrointestinal Bleeding: A Rare Manifestation of Renal Cell Carcinoma
Authors: Kaimakliotis Pavlos , Thaker Sarang , Kang Jennifer , Ramadugu Ajit , Khan Ruben , Brown Russell D.
Published: October 2019

INTRODUCTION:

We describe a rare cause of gastrointestinal bleeding in a patient with metastatic renal cell carcinoma (RCC) and discuss consideration and workup of this manifestation, as it is becoming more common given improved survival of this patient cohort.

CASE DESCRIPTION/METHODS:

A 65-year-old male with history of RCC treated with left nephrectomy complicated by local recurrence and pancreatic tail involvement, on nivolumab, presented with melena and dyspnea. Vitals were notable for orthostasis, melena on rectal exam, and labs revealed a Hgb of 5.6 gm/dL. After resuscitation, the patient underwent push enteroscopy and colonoscopy which did not reveal a source. The following day, the patient developed large volume hematochezia with lightheadedness, hypotension, and acute blood loss anemia requiring transfusion. Given his negative endoscopy and known metastatic RCC, CT angiogram was performed demonstrating an enhancing left upper quadrant soft tissue mass invading into the small bowel lumen. Interventional Radiology was consulted and recommended against embolization due to high risk of small bowel necrosis. Subsequently, Surgery was consulted and requested video capsule endoscopy, but the patient deteriorated requiring emergent surgery. An ileal mass, confirmed to be metastatic RCC, was resected. The patient had no further bleeding and was discharged home; he continues to follow closely with Oncology.

DISCUSSION:

Metastases to the small bowel are a rare cause of GI bleeding, but are often due to malignancies of the breast, cervix, lung, and melanoma. RCC metastatic to the small bowel has only been described in case reports thus far, but may become more common. Advances in targeted chemotherapeutics of the VEGF and mTOR pathways lead to improved survival and thus, more opportunities for metastases. Patients may present with intussusception, bowel obstruction, or GI bleeding alone, with bleeding favored by their vascular nature. Patients will undergo extensive upper and lower endoscopic evaluation without localizing the source, prompting cross-sectional imaging which is more sensitive for confirming the diagnosis. Surgery is often required, as tumors supplied by branches of the mesenteric arteries pose significant risk of small bowel infarction if embolized. In patients with known history of RCC who present with GI bleeding, small bowel metastases should be considered as an etiology if endocscopy is negative, and obtaining CT imaging urgently may lead to timely management of such lesions.
2076 Nasal Crohn’s: Rare but Real Possibility!
Authors: Vekaria Pratikkumar , Mao Johnnie , Patel Ravish , Vaishnani Devin , Raiyani Tejas
Published: October 2019

INTRODUCTION:

Crohn’s disease(CD) is an autoimmune IBD that can occur anywhere along GI tract. Its pathology show transmural granulomatous inflammation that can include all layers of GI lining. Extra-intestinal manifestations can be seen in multiple organ systems like skin, joints, eyes, and mouth. These symptoms are common in patient involving large intestine compare to involving only small-intestine. Nasal involvement is rare with CD and very few cases have been reported so far.

CASE DESCRIPTION/METHODS:

32-year-old female with PMH of CD, pyoderma gangrenosum and rectovaginal fistula presented with bloody diarrhea and abdominal pain for week and a half. Her abdominal pain was located in RLQ and epigastric region. She denied chest pain, dyspnea. She had fever for 2 days. Physical exam was significant for RUQ, RLQ, and epigastric tenderness. CT abdomen showed mild transverse colitis and MRI of pelvis showed anal fistula with no abscess. Her stool was positive with WBCs. Gastroenterologist put her on wide-coverage empiric antibiotics. As her abdominal pain improved, she began to complain of severe headache and developed erythematous swelling on dorsum of nose. CT head showed paranasal sinus (PNS) mucosal thickening. Multiple IV pain medications didn’t help her pain. ENT was consulted and given her history, believed she might have CD. Trial of IV steroids was given and her symptoms improved. ENT subsequently obtained nasal biopsy. Report showed chronic inflammation, edema, and fibroplasia that was consistent with CD. Gastroenterologist began Adalimumab and her symptoms improved.

DISCUSSION:

Extra-intestinal involvement can be seen in almost 36% of cases of CD. Nasal manifestation occur rarely. Common presentation can be nasal obstruction, bleeding, mucosal inflammation and septal perforation. Our patient did not have these manifestations, but she presented with severe headache that even strong pain medication didn’t help much. This is unusual presentation of CD. Furthermore, there are various treatment options available in case of nasal CD from steroids to leukocytapharesis. In our case, new biologics therapy, TNF-α Inhibitor, worked better in combination with steroids. It would be interesting to know if nasal steroid has any role to play in local remission. From our and other case reports, we suggest that patient with CD, especially large intestinal involvement, when present with headache, fever or PNS symptoms, should warrants careful evaluation to rule out nasal CD.
2096 Leukocytoclastic Vasculitis Related to Ustekinumab in a Crohn’s Disease Patient
Authors: Costa-Moreira Pedro , Lopes Susana , Santos Ana Luísa , Pedrosa Ana Filipa , Andrade Patrícia , Portugal Raquel , Macedo Guilherme
Published: October 2019

INTRODUCTION:

Leukocytoclastic vasculitis (LV) is a single-organ, skin-isolated small vessel vasculitis or angiitis, without systemic vasculitis or glomerulonephritis. This vasculitis is often mediated by immune complex deposition in the small vessels. Many drugs or inflammatory diseases may cause immune complex formation.

CASE DESCRIPTION/METHODS:

We report a case of a 28-year-old female patient followed in our outpatient clinic since the age of 20-years-old, with colonic Crohn's disease with perianal involvement (A2L2B1p). After the first pregnancy, she became steroid-dependent initiating immunomodulator and biologic therapy with partial response, with persistent perianal disease activity. Due to refractory disease, a diverting ostomy was made and ustekinumab 90 mg (every 8 weeks) was begun with no adverse events. Three years later, she presented painful and palpable purpura in the lower abdomen and both legs. The laboratory study performed to exclude a systemic disease as the cause of cutaneous vasculitis (liver and kidney function tests, serologies and immunological study with serum antibodies, cryoglobulins and serum complement levels) was normal. Ustekinumab was stopped until a diagnosed was achieved. A skin biopsy was performed that showed granulocytic dermatitis associated with the presence of fibrinoid material in the cutaneous small-vessels wall. Therapy with prednisone was started with symptomatic relief and resolution of cutaneous lesions. After this period, a new dose of ustekinumab was administered, with the reappearance of the same cutaneous lesions. The reappearance of cutaneous lesions following ustekinumab administration gave us a cause-effect relationship between the drug and cutaneous disease. Ustekinumab was permanently discontinued, with complete resolution of the cutaneous disease.

DISCUSSION:

In this report, we describe the first case of LV after a long term exposure to ustekinumab in a patient with IBD. When an adverse drug reaction occurs infrequently, it is unlikely to be detected in premarketing clinical trials. It is therefore important for the physician to recognize and report clinically significant adverse.
2109 Metastatic Crohn’s Disease: A Case of a Rare IBD-Related Entity at Initial Presentation
Authors: Kim Christopher , Guzik Paul , Kumbum Kavitha
Published: October 2019

INTRODUCTION:

Metastatic Crohn’s disease (MCD) is a rare cutaneous entity of Crohn’s disease that mandates specific histopathologic findings and exclusion of other granulomatous diseases and infectious processes for a diagnosis. Due to its heterogeneous clinical presentation, MCD poses a diagnostic challenge for providers. We present a case of MCD in a woman with previously undiagnosed Crohn’s disease at initial presentation.

CASE DESCRIPTION/METHODS:

A 68-year-old woman presented to the Emergency Room with an acute onset of left-sided abdominal pain. She also noted a 6-month history of watery diarrhea with up to 8 bowel movements daily, describing them as bloody with a jelly consistency. On examination a painful 8 cm ulcer within her intergluteal fold extending to the anus was observed. Other “knife-like” ulcerations were noted of the left inframammary breast, under the pannus and bilaterally in the inguinal folds. She underwent a flexible sigmoidoscopy which demonstrated edematous and friable mucosa with a cobblestone appearance extending from the descending colon to the rectum. Mucosal biopsies and serologic testing were both diagnostic of Crohn’s disease. Punch biopsy of the pannus ulcer showed non-caseating granulomas and was negative for mycobacterial or fungal organisms, confirming the rare diagnosis of MCD. The patient was treated with systemic and topical steroids with subsequent symptomatic improvement of both her Crohn’s flare-up and cutaneous ulcerative lesions.

DISCUSSION:

MCD is a rare dermatologic manifestation characterized by its non-caseating granulomatous histopathology in non-contiguous areas from the gastrointestinal tract. Typically the GI disease precedes the skin disease for at least six months, however the skin manifestation can be the first sign of Crohn’s disease. The diagnosis should be suspected when “knife-like” ulcerations are seen on physical exam in a patient with known or suspected Crohn’s disease. Exclusion of other granulomatous diseases that could mimic MCD is required to confirm the diagnosis. Early recognition of this disease may ultimately spare unnecessary tests or treatments.
2128 Successful Treatment of Large Cavity Esophageal Disruptions With Transluminal Washout and Endoscopic Vacuum Therapy
Authors: Walsh Leonard , Manzo Carl , Loloi Justin , Mathew Abraham , Maranki Jennifer , Levenick John M. , Dye Charles , Taylor Matthew , Moyer Matthew
Published: October 2019

INTRODUCTION:

Acute, high-grade esophageal perforation and postoperative leak after esophagogastrostomy are associated with high morbidity and mortality due to the development of mediastinitis and thoracic contamination. Endoscopic vacuum therapy (EVT) has proven to be a feasible, safe therapy for management of esophageal wall defects, but there is limited data on the effiacy of EVT for large and severe collections. We demonstrate that large and even multiple collections could be managed by EVT with serial endoscopic debridement and washout.

CASE DESCRIPTION/METHODS:

We describe a retrospective single-center analysis of two patients who underwent EVT for significant esophageal disruptions. Patient 1 developed esophageal perforation from Boerhaave Syndrome with a 2 cm disruption and 10.7 cm cavity, and Patient 2 developed postoperative anastomotic leak after Ivor-Lewis Esophagectomy with two separate disruptions: a 2 cm proximal disruption with a 4 cm mediastinal cavity and 14 cm gastric pull up disruption with a cavity encompassing the entire central and lower right thorax. EVT was accomplished with the use of a standard upper video endoscope, nasogastric (NG) tube and vacuum-assisted closure dressing kit, with endoscopic placement of a polyurethane sponge and nasogastric tube assembly into the mediastinal/ thoracic cavity. Serial washout and debridement were performed prior to each sponge insertion. Data were collected on indication, size of the cavities, time to intervention, number of procedures, time to resolution, outcomes, and adverse events.

DISCUSSION:

Two patients underwent therapy with a mean age of 69.5. The median size of the collections via longest cross sectional diameter was 10.7 cm. The average number of EVT procedures performed was six and average duration of therapy was 49 days. Complete resolution was achieved in both patients. In conclusion, endoscopic washout and debridement followed by EVT can be effective for large, even multiple, thoracic and/or mediastinal contaminations following esophageal perforation and gastroesopagheal anastamotic dehiscence and leaks in appropriately-selected patients. Our technique involving EVT coupled with serial washout and debridement has the potential to change the current approach to the management of severe mediastinal or thoracic contamination from anastomotic dehiscence and other types of esophageal disruptions.
2141 “Knock Out” Pancreas: An Unusual Case of Isolated Pancreatic Duct Laceration in a Mixed Martial Arts Fighter
Authors: Makar Ranjit , Maklad Muthena , Aziz Hamza , Lankarani Daisy S. , Mubder Mohamad I. , Wahid Shahid , Ohning Gordon , Saud Bipin
Published: October 2019

INTRODUCTION:

Isolated Pancreatic duct laceration due to blunt trauma to the abdomen is very rare. Diagnosis requires a high level of suspicion as delay in diagnosis can lead to complications such as pseudocyst, abscess and duct stricture. We present an unusual case of pancreatic duct laceration complicated with pseudocyst formation due to blunt trauma to the abdomen during a Mixed Martial Arts fight.

CASE DESCRIPTION/METHODS:

33-year-old MMA fighter with no past medical history sustained a blunt trauma to the abdomen during a fight resulting in a knockout. Patient was emergently transferred to the hospital for evaluation. Lab work revealed elevated lipase >2000 IU consistent with acute traumatic pancreatitis. CT of the abdomen revealed diffuse edema of the pancreas with suspicion for possible laceration of the pancreatic duct. Patient was conservatively managed and later discharged once pain improved. Patient continued to have abdominal pain and returned to the emergency room 3 months later with abdominal distention associated with nausea and vomiting. Repeat CT of the abdomen revealed a 13 cm × 12.5 cm cystic lesion around the body of the pancreas with communication with the pancreatic duct (Image 1,2). MRI revealed a large cystic lesion with potential communication with the pancreatic duct seen on T2 images (Image 3).An ERCP was attempted but due to the mechanical compression caused by the cyst, the ampulla could not be accessed. An Endoscopic Ultrasound guided placement of a 10 × 10 mm cyst gastrostomy stent resulted in successful drainage of the pancreatic pseudocyst. Patient was later discharged and followed up in 1 month with repeat imaging showing complete resolution of the cyst. Endoscopy was repeated 4 weeks later with removal of the cystgastrostomy stent. Patient has since been doing well and awaits ERCP to evaluate the anatomy of the pancreatic duct.

DISCUSSION:

Isolated laceration of the pancreatic duct due to blunt trauma to the abdomen is very rare. Sudden severe impact to the abdomen, such as a punch, compresses the pancreas against the vertebral column resulting in pancreatic laceration. Diagnosis requires a high degree of suspicion and imaging confirmation. Management can be challenging as most pancreatic duct lacerations are often missed resulting in complications such as in our patient. There have been case reports of successful management with early endoscopic pancreatic duct stent placement. Refractory cases often require complex abdominal surgeries such as pancreatico - jejunostomy.
2160 Transpapillary Drainage of Persistent Pseudocyst Causing Dysphagia
Authors: Kim Grace E. , Lo David
Published: October 2019

INTRODUCTION:

Pseudocysts (PC) are well-known complications of acute and chronic pancreatitis. Symptoms can include abdominal pain, early satiety and weight loss. We present a unique case of a PC presenting with dysphagia.

CASE DESCRIPTION/METHODS:

A 47-year-old female with history of acute on chronic pancreatitis due to alcoholism complicated by a persistent PC presented with weight loss and progressively worsening dysphagia for one year. Prior attempted surgical cystgastrostomy and percutaneous aspiration of her PC were unsuccessful. Esophagram showed a stricture of the distal esophagus, without passage of a barium tablet, and computed tomography and magnetic resonance imaging demonstrated a 6 × 5.3 cm PC compressing the distal esophagus (Figure 1). Esophagogastroduodenoscopy with balloon dilation was not efficacious. Endoscopic ultrasound cystgastrostomy was attempted but not feasible due to the proximal location of the PC. Endoscopic retrograde cholangiopancreatography (ERCP) was consistent with severe chronic pancreatitis by Cambridge classification; there was a high-grade stricture at the genu with upstream pancreatic duct (PD) dilation and communication with the PC. The stricture would only allow dilation initially with a 5-4-3 cannula, which allowed placement of a 5-French PD stent to bridge the stricture, and a 10-French double pigtail stent for transpapillary drainage of the pseudocyst (Figure 2). Stricture brushings were negative for malignancy. Her dysphagia resolved with resulting weight gain, and subsequent ERCPs (with serial PD stenting to 10-French) demonstrated resolution of her PC and PD stricture.

DISCUSSION:

Dysphagia due to PC has been rarely reported. It is usually due to mediastinal extension of a PC, which has been treated by endoscopic (e.g. transpapillary and transmural drainage), radiologic, and surgical means with good technical success1,2. In our case, due to the proximal position of the PC which prohibited transmural drainage, along with failure of prior surgery and percutaneous aspiration, transpapillary drainage was necessary and effective. Resolution of the inciting PD stricture by stenting was of paramount importance for the prevention of PC recurrence.
2188 Off-label Use of Lumen-Apposing Metal Stent for Gastro-Jejunal Anastomotic Stricture Following Roux-en-y Gastric Bypass
Authors: Dellatore Peter , Tawadros Augustine , Reja Debashis , Sarkar Avik , Tyberg Amy , Kahaleh Michel , Shahid Haroon
Published: October 2019

INTRODUCTION:

Roux-en-y gastric bypass (RYGB) is the second most common bariatric surgery performed after sleeve gastrectomy. A complication of this procedure is a gastrojejunal (GJ) anastomotic stricture. A lumen apposing metal stent (LAMS), which was initially used for draining pancreatic fluid collections/cystogastrostomy, is now being used in various locations throughout the gastrointestinal tract due to its novel dumbbell shaped design. In this case report we present a case of GJ anastomotic stricture successfully managed with LAMS after failure of serial balloon dilations.

CASE DESCRIPTION/METHODS:

A 51-year-old woman with a history of RYGB in 2008, complicated by recurrent stricture of her GJ anastomosis, presented for treatment options of her stricture. She had undergone dilations in the past with no change in her symptoms of daily vomiting. The patient requested a more definitive treatment. The patient was taken for placement of a LAMS endoscopically. Her stricture at the GJ anastomosis measured 7mm in diameter and <1 cm in length. A hydrophilic wire was inserted into the jejunum under fluoroscopic guidance. A 15mm LAMS was advanced over the wire into the jejunal lumen. Placement was confirmed with endoscope and fluoroscopic image. Finally, a 12-13.5-15 mm CRE balloon was advanced over the wire and used to dilate the lumen of the stent. The patient returned to the clinic 5 weeks later with complete resolution of her symptoms. She will have the stent removed in 2 weeks.

DISCUSSION:

GJ anastomoses can initially be managed with pneumatic dilations. However, this requires repeat interventions with limited success. A common alternative is the fully covered self-expanding metal stent (FCSEMS). The FCSEMS has a high rate of adverse events including stent migration, perforation, and recurrence of strictures after removal. A LAMS has a novel dumbbell shape design that prevents leakage and migration due to 24 mm anchoring flanges, while also being shorter and smaller than FCSEMS. Additionally, because of the dumbbell shape, when inflated with a CRE balloon, the risk of migration is very low. For these reasons, in addition to its expanding use within the GI tract, it was used in our patient with success. This case demonstrates another use for LAMS that is safe and effective in an expanding population.
2190 A Unique Case Demonstrating the Endoscopic Management of a Duodenal Stump Fistula
Authors: Davis Sarah , Owen S. Craig , Magulick John
Published: October 2019

INTRODUCTION:

Medical procedures continue to evolve towards being more minimally invasive leading to significant advances in the endoscopic management of transmural defects of the gastrointestinal (GI) tract. These are typically divided into three primary types; anastomotic leaks, perforations and fistulas. Once the site of injury has been identified, basic management involves surgical debridement and drainage with subsequent closure, diversion or both. We present a case of a complicated fistula and a novel approach to closing it.

CASE DESCRIPTION/METHODS:

A 35 year old female presented to the emergency room following blunt abdominal trauma from a horse kick. She sustained significant injuries to the small bowel requiring emergent surgical intervention and ultimately a duodenectomy with gastrojejunostomy. She was left with a 6cm blind limb of native post pyloric duodenum that was drained percutaneously with a 32Fr Malecot catheter. Gastroenterology was consulted to assist with endoscopic drain removal and management of the residual fistula tract. The Malecot was replaced with a 24Fr percutaneous gastrostomy tube with subsequent downsizing procedures every 2-3 weeks. The end result was a 3-4mm duodenal-cutaneous fistula with persistent output. After fulguration of the surrounding area with Argon plasma coagulation a single running suture of 5 stitches was placed using the OverStitchTM device and the external opening was allowed to close by secondary intention. At a 2 week clinic follow up she had returned to her usual activities and a barium upper GI series at 4 weeks post closure confirmed no stump leak.

DISCUSSION:

There is a paucity of data to guide the gastroenterologist on duodenal stump defects. In the setting of a planned surgical fistula such as in our patient, the most appropriate treatment option was successive downsizing of the tract with definitive closure via endoscopic suturing. The unique location of the fistula in a blind pouch precluded the use of a self-expanding metal stent, the defect was too large to close with a through-the-scope clip, and there was a theoretical concern of retention in the stump if a larger over-the-scope clip was employed. The high volume of bilious output through the fistula precluded the use of tissue adhesives as a monotherapy. Despite the desired outcome being achieved in our case we suspect this method of closure would be less successful in fistulas complicated by chronic inflammation, infection, or malignancy.
2207 Blinatumomab-Induced Hepatic Sinusoidal Obstruction Syndrome
Authors: Tabbalat Aya , Walradt Trent , Mehta Amit , Wan David
Published: October 2019

INTRODUCTION:

Hepatic sinusoidal obstructive syndrome (SOS) occurs when sinusoidal endothelial cells are damaged leading to occlusion of hepatic venules. Causes include hematopoietic stem cell transplantation, chemotherapy, toxins, and radiation. Here, we report the case of a man with blinatumomab induced SOS.

CASE DESCRIPTION/METHODS:

A 39-year-old male with a recent history of drug induced liver injury presented with relapsed t (9;22) negative ALL and was started on blinatumomab therapy. On clinical examination, the patient was jaundiced with a distended abdomen. Prior to starting blinatumomab the patient’s aspartate aminotransferase (AST), alanine aminotransferase (ALT) and total bilirubin were 162 U/l, 71 U/L, and 12.3 mg/dL respectively. These levels rose over the next several weeks (ALT, 100 U/L; AST, 364 U/L; total bilirubin, 28.4 mg/dL). Abdominal CT showed large volume ascites, gastric varices, and hepatomegaly with numerous hypodense lesions (Figure 1). Transjugular liver biopsy (Figure 2) revealed SOS as well as cholestatic liver disease, consistent with sepsis. The patient’s condition progressed despite treatment with defibrotide, and he died of multiple organ failure 1 month after starting blinatumomab.

DISCUSSION:

Hepatic SOS occurs when hepatic terminal venules and sinusoids become obstructed. SOS is commonly seen in the setting of hematopoietic stem cell transplantation, but also occurs after chemotherapeutic agents, radiation therapy, liver tumor embolization and transplantation. The incidence of SOS varies widely between studies. Pre-existing liver disease, patients age, and prior radiation therapy are known risk factors. Clinical features of SOS include RUQ pain, jaundice, and ascites as well as elevated ALT, AST, and bilirubin. In severe disease, PT and platelet counts may also be abnormal. SOS is a clinical diagnosis, and imaging studies, such as an abdominal US, are frequently done during initial evaluation. Liver biopsy is not commonly used for diagnosis, but will show dilated and congested liver sinusoids with RBCs. Although SOS has been previously reported in the setting of chemotherapy, blinatumomab induced SOS is rare. Moreover, even though hepatotoxicity in the setting of blinatumomab has been documented, the mechanism of liver injury remains unknown. Further studies can explore whether SOS could relate directly to the method of liver injury in the setting of blinatumomab.
2211 The Ghost of TB: Danger of an Indolent Infection in the Setting of Alcoholic Hepatitis
Authors: Elkhattib Ismail , Villavicencio Jaimy , Phachu Deep , Disiena Michael , Sotil Eva
Published: October 2019

INTRODUCTION:

The benefits of corticosteroids in patients with severe alcoholic hepatitis has recently been questioned. Corticosteroids should be used with caution for a febrile patient in the setting of ETOH Hepatitis. We present a case in which steroids lead to a flare-up of an indolent infection and dissemination of tuberculosis.

CASE DESCRIPTION/METHODS:

A 23-year-old male who migrated from Mexico 8 years earlier with a past medical history of alcohol-related liver disease presented with fever, diarrhea and abdominal pain. On admission, labs were suspicious for alcoholic hepatitis (Table 1), paracentesis showed SAAG of 1.6 (Table 2) and complicated by portal HTN and SBP. He was started on Ceftriaxone and flagyl. He was started on steroids for 2 days that was replaced by pentoxifylline for the diagnosis of SBP then back to steroids after peritoneal fluid culture was negative. He continued to have a persistent fever which was attributed to severe alcoholic hepatitis for which he had a repeat paracentesis (2) that showed a lymphocytic predominance with SAAG 1.7. TB tests were ordered and showed indeterminate Quantiferon, negative AFB smear/TB PCR from paracentesis x2 and HIV was negative. Antibiotics (Zoysn) was restarted due to the persistent fever. A liver biopsy was consistent with alcoholic steatohepatitis with grade 3-4 fibrosis. Lille score was calculated at 0.010 so steroids were continued. The patient developed hemoptysis with EGD showing only grade I nonbleeding esophageal varices. Repeat CT of the lung revealed numerous new pulmonary nodules. Steroids were stopped by a rapid taper given the new pulmonary nodules. He had a diagnostic bronchoscopy and BAL grew mycobacterium TB. His ascitic fluid culture from three weeks prior eventually revealed Mycobacterium species. He was initiated on treatment for disseminated tuberculosis with RIPE therapy. The patient then developed extensive hemoptysis complicated by PEA. CPR achieved ROSC but he was made CMO and passed away.

DISCUSSION:

Tuberculous peritonitis is rare in the United States but continues to be reported to occur in certain high-risk populations. The diagnosis of this disease requires a high clinical index of suspicion especially in the presence of ascites with a lymphocyte predominance and serum-ascitic albumin gradient of <1.1 mg/dl. Microbiological or pathological confirmation remains the gold standard for diagnosis. Ascitic fluid cultures have a low yield, but peritoneoscopy with biopsy or cultures frequently confirms the diagnosis.
2229 Peripheral Eosinophilia; An Unusual Presentation of Autoimmune Hepatitis
Authors: Akanbi Olalekan , Kato Hirotaka , Tripathi Nishant , Singh Tushi , Karri Kishore , Thakur Kshitij
Published: October 2019

INTRODUCTION:

Autoimmune hepatitis (AIH) is a chronic inflammatory condition of the liver characterized by elevated hepatocellular enzymes, autoantibodies, immunoglobulins, periportal inflammation and rapid improvement with steroids. Associated peripheral eosinophilia has been rarely reported. We report a case of AIH presenting with eosinophilia.

CASE DESCRIPTION/METHODS:

A 48-year-old Caucasian male with a past medical history of splenectomy a year ago following a motor vehicle accident presented to the emergency department with a 2-week history of diarrhea, malaise, anorexia, chills and dark urine. He also observed yellowish discoloration of his eyes 5 days prior to presentation. No history of over-the-counter medications, supplements, alcohol or drug use. Vital signs were normal while physical exam was only notable for scleral icterus. Labs on admission showed: WBC 21.9K/mL (35% eosinophils), AST 820U/L, ALT 350U/L, ALP 204U/L, total bilirubin 13mg/dl (conjugated bilirubin 8.7mg/dl), INR 1.8. Due to concerns for acute liver injury, evaluation by CT abdomen and MRCP revealed nodular contours of the liver suggestive of chronic hepatic parenchymal disease, no evidence of biliary ductal pathology. He was managed conservatively with fluids while further extensive work-up to determine etiology of liver injury and eosinophilia such as acute hepatitis panel, CMV PCR, EBV IgM, alpha-1 antitrypsin, ceruloplasmin, mycoplasma IgM, stool studies for infection and parasites, strongyloides, histoplasma antigen were negative. IgG (2084mg/dl) and IgA (732mg/dl) were elevated as ANA and smooth muscle antibody were positive. As liver enzymes, eosinophilia and INR continued to rise, a liver biopsy was performed which showed extensive bridging fibrosis, ballooning degeneration of hepatocytes, mild fatty change, mixed inflammatory infiltration with lymphocytes, plasma cells, eosinophils and occasional neutrophils in the portal areas, prominent interface changes all consistent with autoimmune hepatitis. No evidence of ductopenia, periductal fibrosis or granulomas was seen. He was started on steroids with immediate resolution of eosinophilia and improvement of symptoms and labs.

DISCUSSION:

With this report, we hope to draw awareness to this unusual presentation of AIH. As eosinophilia resolved rapidly with treatment of liver disease, AIH should be strongly considered in patients with elevated liver enzymes and peripheral eosinophilia especially in the absence of other predisposing conditions for eosinophilia.
2233 Emergent Living Donor Liver Transplantation for Fulminant Hepatic Failure Secondary to Wilson’s Disease
Authors: Kumar Shiva
Published: October 2019

INTRODUCTION:

Liver transplantation (LT) is indicated for patients with Wilson’s disease (WD) who present with either fulminant hepatic failure (FHF) or end-stage liver disease. However, there is very limited information regarding emergent LDLT in adult patients with WD presenting with FHF. Here we report a case of FHF due to decompensated WD in an adult treated with emergent LDLT.

CASE DESCRIPTION/METHODS:

A 25-year-old female with no prior medical history presented with jaundice and fatigue. At presentation, lab tests showed: Br 14.8 mg/dL, ALT 42 U/L, AST 165 U/L, ALP 65 IU/L, INR 3.2. Serum ceruloplasmin level was low: 70 (Range 190-390) and 24 hour urine copper was markedly elevated at 7269 μg /24 Hr (Range 5–50). Subsequent clinical course was characterized by progressive encephalopathy and coagulopathy. Lab tests 4 days later revealed: Br 36.42, ALT 30, ALT 217, ALP 30, Cr 2.75 mg/dL, INR 5.8 (MELD > 40). She was diagnosed with FHF due to WD and underwent emergent LDLT utilizing a left lobe graft from her 33-year-old brother, who had a normal screening ceruloplasmin. Explant revealed a cirrhotic liver with necrosis, cholestasis and positive copper immunostain (Figures 1 and 2). Quantitative hepatic copper content was 2119 mcg/g (Range 10−35). Recipient genetic testing revealed c.2930C>T p. (Thr977Met) variant in homozygosity in the ATP7B gene. Donor was heterozygous. The patient gradually improved and continues to do well 8 months later with normal ceruloplasmin and 24 hour urinary copper excretion.

DISCUSSION:

WD is an autosomal recessive disorder of copper metabolism caused by a mutation in the ATP7B gene on chromosome 13. It affects one in 30 000 individuals with a reported carrier frequency of one in 90. LT is the only effective option in WD presenting with FHF and corrects the underlying hepatic metabolic defect. The overwhelming majority of reported cases of emergent LT for FHF secondary to WD in adults utilized deceased donor LT, with a few reported cases of LDLT in children. Given the narrow window of opportunity for LT in FHF and concerns related to heterozygosity in donors, emergent LDLT is rarely performed in this setting. In recipients with cirrhosis secondary to WD, LT using heterozygous donors for the WD gene has been shown to have outcomes comparable to that from a deceased, unrelated donor. Given the scarcity of deceased donor organs, LDLT may be a viable option for patients with decompensated WD presenting with FHF, even if the donor could potentially be heterozygous for the WD mutation.
2246 Rifampin-Induced Decompensation of Cirrhosis: A Tuberculosis Dilemma
Authors: Kolli Sindhura , Aamar Ali , Etienne Denzil
Published: October 2019

INTRODUCTION:

Tuberculosis (TB) is highly prevalent in cirrhotic patients. Due to the underlying depressed immune system and damaged hepatocytes, the metabolism of anti-tuberculous drugs can be variable, given 3 out of the 4 drugs are potentially hepatotoxic. Currently, there are no established guidelines for treatment and monitoring of TB patients with cirrhosis. We present a case of hepatic decompensation in a patient with underlying cirrhosis who was started on anti-tuberculous drugs.

CASE DESCRIPTION/METHODS:

A 62-year-old African American female with a history of hepatitis C cirrhosis presented with altered mental status. She was on rifampin, isoniazid (INH), pyrazinamide and ethambutol for active TB. Labs showed elevated bilirubin, liver enzymes and INR and hypoalbuminemia. US abdomen showed ascites and cirrhosis. Patient was diagnosed with hepatic encephalopathy in the setting of decompensated cirrhosis secondary to rifampin use. Autoimmune workup was negative except for a weakly positive ANA. Rifampin and INH were discontinued resulting in improved clinical status and lab abnormalities. Treatment for her tuberculosis was restarted with one drug at a time with ethambutol, INH, and moxifloxacin with weekly monitoring of LFTs for a total of 18 months.

DISCUSSION:

Routine treatment for TB is a 4-drug regimen consisting of INH, rifampin, pyrazinamide and ethambutol. INH and rifampin are the most potent anti-TB drugs, but they both have transient hepatotoxic effect. A true hepatotoxic effect from either drug is idiosyncratic in nature and more common in those with underlying hepatic dysfunction. Monitoring with weekly LFTs for the initial 2 months is recommended. Rifampin can cause centrilobular necrosis within hepatocytes and competes with bilirubin for clearance leading to cholestasis. It increases the hepatotoxicity of other anti-TB drugs. In those cases, all 4 drugs should be stopped immediately to see if there is a reversal of transaminase levels. Once AST/ALT/bilirubin have returned to baseline, drugs should be reintroduced one at a time consecutively at lower doses for hepatic adaptation while withholding the offending agent. If the rechallenge is not tolerated in the setting of worsening cirrhosis, an urgent liver transplant must be considered. Intermittent short course drug regimens are being studied to diminish the effects of worsening hepatotoxicity in patients with underlying cirrhosis.
2291 Drug-Induced Autoimmune Hepatitis Secondary to Infliximab
Authors: Reinhart Evan , Diocares Juan , Powell Priscilla R. , Jeffries Mark A.
Published: October 2019

INTRODUCTION:

The increased utilization of Infliximab therapy has produced a small number of reported cases associating Infliximab with varying patterns of drug-induced liver injury. We present a rare case report of drug-induced autoimmune hepatitis that embodies a realistic presentation of a potentially underreported liver injury pattern that can occur following the induction of Infliximab therapy.

CASE DESCRIPTION/METHODS:

A 36 yo female with a PMHx significant for Crohn’s Disease, HTN and chronic alcohol abuse was admitted for generalized body aches, right upper quadrant abdominal pain, and shortness of breath. The patient described a recent increase to her alcohol consumption from 48 to 120 oz of beer daily for the last two weeks. The patient otherwise denied: smoking tobacco, illicit drugs, and naturopathic or over the counter medications. Physical examination revealed jaundice and tenderness to the RUQ of the patient’s abdomen. No evidence of ascites, palmar erythema, spider angiomata or protein malnutrition were present. Lab Findings revealed: AST/ALT: 1135/175, T. Bili: 10.9, AP: 230, Albumin: 2.7, Platelets: 233, INR: 1.1. The patient’s lab findings and subjective history validated continued concern for alcoholic hepatitis. Viral hepatitis serologies and autoimmune markers were collected and produced negative results except for a positive Anti-Nuclear Ab; ANA Titer: 1:2560. A RUQ Ultrasound with Doppler revealed hepatomegaly without signs of cirrhosis. Histopathologic results from biopsy revealed florid lymphoplasmacytic portal inflammation, stage 2-3 with periportal/bridging fibrosis and was without steatosis or steatohepatitis; findings consistent with the diagnosis of autoimmune hepatitis and drug induced liver injury.

DISCUSSION:

A detailed review of the patient’s medications revealed Infliximab infusions were initiated 5 months prior ,with the most recent being 3 weeks before presentation. The patient had no new medication exposures. Despite an initial concern for alcoholic hepatitis, the patient’s biopsy results showed no evidence of an alcoholic liver injury pattern. The positive ANA, histopathology, favorable response to infliximab withdrawal followed by steroid induced immunosuppression was consistent with the diagnosis of drug-induced autoimmune hepatitis (DIAIH). This case suggests patients receiving Infliximab therapy with elevations in liver function tests require thorough evaluation and strong consideration of biopsy for appropriate diagnosis.