bluuebunny/crossref_metadata_2025 huggingface dataset:
3024 Post Whipple's Pancreatitis: Post Procedure Inflammatory Changes Sub-Serving a Diagnostic Challenge
Authors: Nwaichi Chineme , Haque Zohaib , Elkhouly Mohamed A. , Vohra Ishaan , Attar Bashar M.
Published: October 2019

INTRODUCTION:

Making an accurate diagnosis of pancreatitis in the post-operative setting after a Whipple's procedure can be difficult. Acute pancreatitis inflammatory changes occurring in the peripancreatic area may be indistinguishable from post-operative peripancreatic inflammation hence creating a diagnostic challenge.

CASE DESCRIPTION/METHODS:

A 54-year-old woman with a past medical history of Type 2 diabetes mellitus, hypothyroidism, and pancreatic head neuroendocrine tumor status post-Whipple's procedure with a residual mild postoperative pancreatic fluid collection which was drained three years ago. She presented with epigastric pain of 5 days duration. She was hemodynamically stable, serum lipase was elevated to 2,752. Abdominal CT done 2 weeks prior to admission for cancer surveillance revealed a stent in the main pancreatic duct. Repeat abdominal CT scan demonstrated the stent and showed acute interstitial pancreatitis. MRI/MRCP done showed mildly ectatic pancreatic duct with a linear structure concerning for a retained stent. She underwent ERCP and the stent could not be visualized with no intervention performed. She was managed with intravenous fluids and analgesics for pancreatitis and subsequently had her diet advanced as tolerated.

DISCUSSION:

The true incidence of post-Whipple's pancreatitis is unknown, and there are many difficulties in making an accurate diagnosis of pancreatitis. Postoperative findings after pancreaticoduodenectomy can include inflammatory changes and fat stranding, which can make the differentiation between pancreatitis and post-operative changes challenging. Serum levels of amylase and lipase are unreliable in the postoperative period. In severe cases, an abdominal CT would be needed to make the diagnosis of postoperative pancreatitis. Post-Whipple's pancreatitis can have significant prognostic implications, including a higher risk of pancreatic fistula and a higher risk of delayed gastric emptying.
3025 Losartan-Induced Pancreatitis: A Rare Cause
Authors: Tripathi Shalini , Khuttan Akhilesh K. , Anandam Anil , Charilaou Paris , Jose Merin
Published: October 2019

INTRODUCTION:

Acute pancreatitis (AP) is an acute inflammatory state caused by multiple etiologies, the most common being gallstones, alcohol and hypertriglyceridemia. Less than <5% of pancreatitis is caused by medications and have excellent prognosis. Multiple medications have been associated with developing pancreatitis, and among these, one is losartan. So far there has been 3 case reports of losartan induced pancreatitis. Losartan is a class 1b medication associated with pancreatitis. Medications are classified into group based on number of cases reported, recurrence with re-challenge. Class 1 medications have the highest association with pancreatitis.

CASE DESCRIPTION/METHODS:

49 year old male with a past medical history of substance abuse, schizoaffective disorder, hepatitis C and hypertension presented to the hospital with epigastric abdominal pain radiating to the back for 2 days and was found to have elevated lipase of 1600 U/L with computed tomography suggestive of AP. He had no family history of pancreatitis. There was no recent alcohol use. Serum triglycerides, blood alcohol level and urine toxicology screen were negative. There was elevation in liver enzyme, Aspartate aminotransferase 148 U/L, Alanine aminotransferase 92 U/L, Alkaline phosphatase 149 U/L, total bilirubin 1.7 mg/dl. Magnetic resonance cholangiopancreatography revealed normal caliber common bile duct without filling defects. The elevated enzyme likely were due to underlying hepatitis C. Upon medication review, patient was found to be taking losartan for his hypertension since 2018. He was treated with intravenous fluids and pain control. His blood pressure medication was switched to amlodipine and was discharged after 4 days, uneventfully. Patient had a prior admission two months ago for AP while he was on losartan which was not discontinued and workup for gallstone, alcohol, hypertriglyceridemia, hypercalcemia or illicit substance use was negative.

DISCUSSION:

There have been only few case reports of losartan-induced AP. The exact mechanism of losartan causing pancreatitis is not understood. Drug induced pancreatitis is not well studied due to limited number of cases. Establishing diagnosis involves ruling out other common etiology as challenging with medication in ethically difficult. This case emphasizes the importance of reviewing the medication of patients with an unclear etiology of pancreatitis.
3037 Spontaneous Cystgastrostomy From Pancreatic Pseudocyst Erosion Into Gastric Wall Resulting in Gastrointestinal Hemorrhage
Authors: El Kurdi Bara , Babar Sumbal , Haddad Ibrahim , Aasen Tyler , El Iskandarani Mahmoud , Goenka Puneet
Published: October 2019

INTRODUCTION:

Pancreatic pseudocysts are a common complication of pancreatitis. Spontaneous erosion of a pseudocyst into adjacent organs is rare, manifesting in a variety of clinical symptoms and presentations. We present a case of spontaneous fistulization of a pancreatic pseudocyst into the stomach resulting in life-threatening bleeding.

CASE DESCRIPTION/METHODS:

A 60-year-old gentleman with history of type 2 diabetes mellitus, hypertension and chronic pancreatitis with known pancreatic pseudocyst presented with multiple episodes of melena associated with fatigue, weakness and epigastric pain aggravated by food intake. He denied history of peptic ulcer disease but admitted to chronic NSAID use. Physical examination revealed a pale patient with mild generalized abdominal tenderness without signs of peritonitis. Melenic stools were noted on digital rectal exam. Labs were significant for critical normocytic anemia with Hgb 6.3 g/dL. CT scan of abdomen and pelvis showed an 11.7 × 9 cm lesion in the pancreatic body with calcified rim communicating with gastric antrum. Gastrograffin swallow showed contrast transfer from stomach into the pseudocyst. A CT-Angiogram of the abdomen and pelvis failed to reveal a source of bleeding or peripancreatic pseudoaneurysms. Patient underwent EGD which showed 1 centimeter antral fistula-opening representing a spontaneous cystogastric fistula. No ulcers were found. The patient eventually underwent surgical excision of pancreatic pseudocyst, antrectomy and Billroth-II reconstruction.

DISCUSSION:

Pseudocysts complicate 20-40% of chronic pancreatitis. They can cause pain, bowel obstruction, infection, or hemorrhage. Treatment is indicated when cysts become symptomatic or grow beyond 5 cm. However, pseudocysts often resolve by spontaneous drainage into the pancreatic ductal system. Rarely, they can rupture into the peritoneal cavity or erode into nearby hollow organs. Bleeding can be the result of pseudocyst erosion into nearby vessels or rupture of nearby pseudoaneurysms. While involvement of gastroduodenal, splenic, hepatic and inferior pancreaticoduodenal arteries has been reported, none of these sources could be identified in this case. Treatment can take the form of direct embolization or surgical hemostasis. In summary, we have presented a case of pancreatic pseudocyst with spontaneous cystogastric fistula formation accompanied by massive upper GI bleeding eventually treated by surgical excision and Billroth-II reconstruction.
3041 Eosinophilic Colitis: A Rare Entity
Authors: Madan Anand
Published: October 2019

INTRODUCTION:

Eosinophilic colitis (EC) is a rare entity characterized by abnormal infiltration of colon mucosa by eosinophils without evidence of any secondary causes. Presentation may include asymptomatic state, chronic diarrhea, abdominal pain, rectal bleed, bowel obstruction or ascites. We present two cases of EC with very different presentations requiring minimal or no therapy.

CASE DESCRIPTION/METHODS:

CASE 1: 57 year old Filipino male presented with abdominal pain and new onset ascites. Paracentesis revealed elevated SAAG suggestive of portal hypertension. Imaging studies were negative for cirrhosis. Negative liver workup for chronic liver disease. Lab studies revealed microcytic anemia and peripheral eosinophilia of 10%. No eosinophilia noted in ascitic fluid. EGD showed LA Grade C esophagitis. Colonoscopy showed multiple polyps which were removed. Pathology from polyps showed markedly increased eosinophil infiltrate in mucosa and submucosa. There was no evidence of inflammatory bowel disease, Stool studies were negative for infectious etiology. No incriminating medications were found which could lead to above finding. The patient was treated with omeprazole and diuretics with complete resolution of symptoms. CASE 2: 27 year old female presented with chronic intermittent abdominal pain, nausea and diarrhea for 2 years. Her only medications were birth control pills. She had normal blood counts, electrolytes, liver, and renal function. Stool studies were negative for any infectious etiology. She had normal fecal fat and electrolytes. EGD and colonoscopy were unremarkable. Biopsies were negative for celiac disease, Helicobacter and eosinophilic esophagitis. Random colon biopsies showed benign colon mucosa with focal infiltration of colonic mucosa with eosinophils suggestive of eosinophilic colitis. There was no peripheral eosinophilia. Patient was started on probiotics with prompt resolution of symptoms.

DISCUSSION:

EC is a rare condition, included in the group of eosinophilic gastrointestinal disorders, characterized by eosinophil infiltration of colonic mucosa in the absence of any food allergies, parasitic/helminthic infections, drugs, IBD, celiac and autoimmune diseases. The treatment options include dietary modifications, steroids, mesalamine, immunomodulatory agents, fecal microbiota transplant and surgery. The evidence for most of treatment options is limited to case reports. One of our patients required no specific therapy while other one was treated successfully with probiotics.
3045 An Unusual Episode of Acute Diverticulitis Despite Concurrent Antibiotic Therapy
Authors: Baseer Yaseen
Published: October 2019

INTRODUCTION:

Diverticulosis occurs when weak spots in the outer layer of colonic muscle weaken giving way to an inner layer of protruding pouches. The progression to diverticulitis occurs when these protruding pouches become inflamed and infected which may ultimately progress to systemic symptoms that include fever, pain, malaise, constipation and vomiting. It is estimated that 50% of the population develops diverticulosis by age 50 and 65% by age 80. Additionally, an estimated 15-20% of the population with diverticulosis will go on to develop diverticulitis. Mild cases of diverticulitis are treated with oral antibiotics and a liquid diet whereas severe cases are treated with IV antibiotics and bowel rest. Here, we present a case of a diverticulitis episode that developed while a patient was already being treated with antibiotics.

CASE DESCRIPTION/METHODS:

A 64 year old female with a history of endometrial cancer who presented to the hospital for one day history of abdominal pain associated with loose bowel movements. She stated she has had loose bowel movements since starting H. pylori antibiotics that included amoxicillin and clarithromycin 2 weeks prior to presentation. She had an esophagoduodenoscopy 3 months prior that revealed chronic gastritis without dysplasia as well as biopsy proven H. pylori. Her colonoscopy at the same time showed internal hemorrhoids and a single hyperplastic polyp. Her vital signs were unremarkable and she was afebrile. Her white blood cell count on presentation was 13.9. She had a CT scan of the abdomen and pelvis that revealed acute sigmoid diverticulitis and cholelithiasis without evidence of acute cholecystitis. She was subsequently admitted to the hospital and treated with rocephin and flagyl as well as bowel rest. Blood cultures, stool cultures and clostridium difficile cultures were negative. Patient recovered over the next couple of days with resolution of her symptoms and her WBC count.

DISCUSSION:

This purpose of this case is to highlight the current management and treatment options for diverticulitis. Current guidelines recommend antibiotics and bowel rest during acute episodes of diverticulitis. However, this case represents an unusual scenario where a patient develops acute diverticulitis despite concurrent treatment with antibiotics for ongoing H. pylori infection. Further randomized-controlled trials may help delineate treatment modalities for acute diverticulitis as current treatment guidelines may result in breakthrough diverticulitis episodes.
3046 C. diff Infections During Induction Chemotherapy
Authors: Chung Jae , Wazir Ali , Richter Seth , Naseer Usman , Rahman Haider , Fitzpatrick Michael
Published: October 2019

INTRODUCTION:

Patient with acute myeloid leukemia (AML) are at increased risk of developing Clostridium difficile (C. Diff) colitis due to routine use of prophylactic antibiotics, the use of chemotherapy and neutropenia. These factors also add additional challenges to successful treatment. We report a case of fulminant C. Diff pancolitis to highlight these challenges.

CASE DESCRIPTION/METHODS:

65 year old male was found to have pancytopenia on routine blood work at primary care office after experiencing 15 pound weight loss over 1 month. He had a history of rheumatoid arthritis that was well controlled on medications and had no other symptoms. His initial CBC showed a WBC 0.4 k/mm3, Hgb 6.9 g/dL, & platelets 8 k/mm3. A subsequent bone marrow biopsy showed 50% myeloblast, flow cytometry and genetic testing showed normal cytogenetics with intermediate risk & (-) FLT 3 mutation. Patient underwent 7 + 3 induction & a 5 + 2 reinduction after day 14 bone marrow showed residual disease. Patient was placed on prophylactic voriconazole, acyclovir & Levaquin but still developed fevers during neutropenic nadir. Blood cultures showed polymicrobial sepsis from a GI source (with growth of Gemella haemolysans & Rothia mucilaginosa). He developed diarrhea & NAAT tested positive for C. Diff. An abdominal X ray showed dilated large bowel loops with ileus a subsequent CT scan confirmed pancolitis (Figures 1 and 2). Patient developed septic shock. He initially responded to fluid resuscitation and was started on oral vancomycin and IV flagyl. After 4 days patient had a PEA arrest and was transferred to ICU after ROSC. Patient passed away soon after as patient family opted for comfort measures.

DISCUSSION:

Patients with acute myeloid leukemia (AML) are immunocompromised with neutropenia either due to their disease or from the effects of their chemotherapy regimen. Neutropenic patients are at risk for life threatening infections & administration of prophylactic antibiotics is common practice for induction chemotherapy. Many chemotherapy agents have antimicrobial activity altering the gut biome. Research has shown cancer patients have decreased response to therapy, increased time to resolution of diarrhea, and increased relapse rates to C. Diff associated diarrhea. The key is to diagnose & treat early. Severe disease should be distinguished early. The 2018 IDSA guidelines recommends use of algorithms and criteria to aid in this process (Figure 3). Further research is needed to outline the optimum approach to treatment in this patient group.
3048 New Onset Ascites Related to Peritoneal Carcinomatosis
Authors: Grosch Gretchen , Jadav Puja , Evans Neil
Published: October 2019

INTRODUCTION:

Peritoneal carcinomatosis (PC) is a metastatic feature in several gastrointestinal malignancies. As one of the most common presenting symptoms is new onset ascites, understanding the workup and typical findings of malignant ascites is crucial for appropriate and time sensitive diagnosis and treatment of such malignancies.

CASE DESCRIPTION/METHODS:

A 50-year-old female with past medical history significant for hypertension and alcohol abuse presented to the hospital with complaint of intermittent weakness and progressive abdominal fullness for one month. Her exam was notable for subconjunctival palor, abdominal ascites with generalized tenderness, and lower extremity edema. Labs showed leukocytosis and microcytic anemia, with hemoglobin of 5.9. CT abdomen/pelvis revealed cardiomegaly, moderate volume ascites, and diffuse body wall edema. Iron studies were obtained (low iron, low-normal ferritin) and the patient was transfused. A diagnostic paracentesis was completed with resultant SAAG of 0.6. Cytology revealed benign appearing mesothelial cells and histiocytes. Due to the patient's lack of insurance, GI was consulted for inpatient evaluation of iron deficiency. Colonoscopy showed a large (>10 cm) ulcerated lesion in the sigmoid colon with pathology consistent with moderately-differentiated adenocarcinoma. Repeat CT was obtained for staging purposes, showing diffuse peritoneal carcinomatosis, distal colon lesion, L4 vertebral sclerosis, and large volume ascites. The patient was discharged with plans to follow up with GI and oncology to discuss therapeutic options.

DISCUSSION:

Peritoneal carcinomatosis is defined as the dissemination of cancer cells throughout the periteoneum. About 8% of patients with colorectal cancer present with PC; most commonly with nonspecific symptoms such as fatigue, abdominal pain/fullness, and bowel obstruction. Since new onset ascites is common to PC, it is important to identify malignant ascitic fluid. Malignant ascites related to peritoneal carcinomatosis is mainly caused by subphrenic vessel obstruction and accounts for 7% of ascites cases. A diagnostic paracentesis is indicated, with typical fluid findings of WBC >500, SAAG <1.1, and total protein >2.5. Fluid cytology is important, however sensitivity is affected by the number and quality of specimens used, making the overall sensitivity only about 60-70%. After a diagnosis of malignant ascites is made, the patient should be counseled and referred for evaluation of available therapeutic options.
3056 A Case of NSAID-Induced Collagenous Colitis
Authors: Farhoud Adel , Al-Obaid Lolwa , Gleason Daniel , Hasan Imran
Published: October 2019

INTRODUCTION:

Collagenous colitis is a disorder of chronic watery diarrhea. It has 2 main histologic forms. It is characterized by normal appearance of the colon on colonoscopy but abnormal histology. It is more likely to occur in elderly women and smokers and has been associated with certain medications such as NSAIDs, PPIs, Antipsychotics. Our case report demonstrates the importance of medication reconciliation when working patients up for diarrhea, and supports the fact that medications, such as those mentioned above can cause recurrence of symptoms, even after treatment.

CASE DESCRIPTION/METHODS:

A 68 year old female patient with a PMH notable for hypertension, GERD, and asthma was diagnosed with diarrhea-predominant IBS in 2015 treated with Rifaximin in the past. In 2015, she began to have 4-6 episodes of brown watery diarrhea daily, from a normal baseline. She underwent colonoscopy at the time, which was normal. She was treated with a 10 day course of Rifaximin with resolution of symptoms. 3 years later, she began to have diarrhea and abdominal cramping for which she made dietary changes with no improvement. She completed another 10 day course of Rifaximin with persistent symptoms. She was admitted to LHMC for weakness and diarrhea because of her inability to tolerate oral intake. Colonoscopy on 11/28 demonstrated ulceration in the hepatic and splenic flexures concerning for ischemic injury versus inflammatory bowel disease. Biopsies were consistent with collagenous colitis although there was neutrophilic cystitis concerning for a superimposed drug induced of infectious process. She was started on Budesonide with improvement in her symptoms before she returned 2 weeks later with diarrhea. Medication reconciliation demonstrated patient had been placed on Omeprazole and NSAID. This was discontinued however her symptoms persisted and she underwent repeat colonoscopy. Biopsies were consistent with Collagenous colitis.

DISCUSSION:

Collagenous colitis is a chronic inflammatory disease of colon. Presents with insidious onset of chronic watery non bloody diarrhea. Pathogenesis remains unclear. It has been associated with multiple medication classes, including medications that this patient was on. She had been treated with Budesonide with resolution of her symptoms, however re-initiation of both PPI and NSAID may have caused recurrence of her symptoms. Our case highlights the importance of vigorous history, chart and medication review when investigating a patient with diarrhea of unknown etiology.
3066 Recurrent Streptococcus bovis Bacteremia in the Absence of Colonic Neoplasm
Authors: Ramachandran Rajarajeshwari , Jani Niraj
Published: October 2019

INTRODUCTION:

Associations between Streptococcus bovis (S. bovis) bacteremia and colorectal cancers and colonic adenomas have been reported in the medical literature since the 1970's. We are reporting an extremely rare case of recurrent Streptococcus bovis biotype II bacteremia in the absence of colonic neoplasm.

CASE DESCRIPTION/METHODS:

53-year-old man with diffuse large B-cell lymphoma – in remission (treated with chemotherapy and autologous stem cell transplantation), nesidioblastosis (treated with partial pancreatectomy/splenectomy) and hypertension was admitted to the hospital with severe sepsis. Of note, one month prior to his presentation, he was admitted to the hospital for S. bovis bacteremia. Examination: temperature 37.8°C, HR 104/minute, respiratory rate 28/minute, BP 101/51 mmHg and Spo2 98% on 4 liters nasal cannula. Laboratory data: white cell count 32.83 × 103/μL, hemoglobin 13.0 g/dL, platelets 210 × 103/μL, sodium 139 mEq/L, potassium 3.2 mEq/L, chloride 95 mEq/L, bicarbonate 22.6 mEq/L, creatinine 1.3 mg/dL, AST 124 IU/L, ALT 152 IU/L, alkaline phosphatase 139 IU/L, total bilirubin 0.3 mg/dL, lactic acid 6.6 mmol/L. Blood culture – positive for S. bovis. Infective endocarditis was ruled out by an echocardiogram. Patient was given intravenous antibiotic therapy and follow up blood cultures did not demonstrate any growth. Due to the association between S. bovis bacteremia and colonic malignancy, colonoscopy was performed. Patient was found to have a small, hyperplastic polyp in the cecum and diverticulosis involving the ascending, sigmoid and descending colon.

DISCUSSION:

S. bovis is a rare cause of bacteremia accounting for <1% of blood culture isolates. It has a high mortality rate of 26-70% and has been associated with colorectal malignancy, endocarditis, and hepatic dysfunction. There are two S. bovis biotypes (I and II) and the prevalence of colorectal neoplasm in patients with S. bovis biotype II bacteremia (23%) is substantially lower than biotype I (70%). Our patient had S. bovis biotype II bacteremia and did not have evidence of malignancy/adenoma(s) in the colonoscopy. To our knowledge this is the first case of recurrent S. bovis bacteremia reported in the medical literature in the absence of both colorectal cancer and colonic adenoma.
3068 Ischemic Colitis With Unresolved Ileus
Authors: Murthi Mukunthan , Chamarti Karthik , Murali Rangan
Published: October 2019

INTRODUCTION:

Ischemic colitis (IC) is the most common form of ischemic injury to the gastrointestinal tract. This can result in inflammation and superficial injury to full thickness necrosis of colon. Most of the non-gangrenous IC resolve spontaneously while gangrenous IC requires operative intervention and is associated with high morbidity and mortality. Almost 90% of the cases of IC are in patients over 60 years of age. Ileus is a common finding in patients with IC and usually self-limiting except in cases where necrosis is present. We present a rare case of unresolved ileus resulting from non-gangrenous ischemic colitis.

CASE DESCRIPTION/METHODS:

A 90-year-old female with past medical history of Hodgkin's lymphoma in remission for the past five years, presented with nausea, vomiting and non-bloody watery diarrhea for the past four days. She visited the Emergency Department on the first day where she tested positive for E.coli urinary tract infection and was treated with ceftriaxone and nitrofurantoin. Over the last day, she did not have any bowel movements but continued to have right lower quadrant abdominal pain, abdominal distension, and nausea. Her WBC count was 34,000 cells/mm3 and C. difficile testing was negative. CT scan showed distended small bowel loops without transition point and decompressed colon, indicating ileus. She was put on NPO and nasogastric suction and started on broad-spectrum antibiotics. After four days, she continued to have distended abdomen with sluggish bowel sounds. Repeat CT scan of the abdomen showed no changes. She was eventually taken to the OR for exploratory laparotomy. Intraoperative findings showed edematous and thickened right colon with small bowel distension. Subsequent colonoscopy showed significant ischaemic changes in the right colon and the pathology result was consistent with ischaemic colitis with no signs of necrosis. She was started on TPN. Even after our best efforts, her condition continued to deteriorate and she developed sepsis and passed away on the tenth day.

DISCUSSION:

Ileus in the setting of non-gangrenous ischemic colitis is usually self-limiting. Protracted ileus is observed in cases with necrosis of the colon. Even with no evidence of necrotic disease, our patient's ileus failed to resolve after prolonged medical management. Our patient had multiple indicators of poor prognosis, including old age, isolated right-sided colon involvement, and absence of hematochezia, which could have contributed to her condition.
3069 CMV Colitis Presenting as Chronic Non-Remitting Diarrhea and Anemia
Authors: Bsrat Makda , Kassim Gassan , Rastogi Neelesh , Rogers Steven
Published: October 2019

INTRODUCTION:

Cytomegalovirus (CMV) is a common infection in immunocompromised patients including solid organ transplant patients. CMV infection of the GI tract can present in various ways. We present a case of chronic diarrhea of one-year duration associated with anemia.

CASE DESCRIPTION/METHODS:

A 56 year old female with a past medical history of hypertension, end stage renal disease with renal transplant in 2004 (maintained on cyclosporine, mycophenolate mofetil and prednisone) presented to the emergency room with generalized weakness of 4-days duration. The patient further endorsed significant weight loss and gradually progressive watery diarrhea that initially was postprandial and had been present for about one year. The symptoms persisted despite treatment with anti-diarrheal agents. The patient was also found to have anemia that began around a similar time as the diarrhea, and required multiple admissions for blood transfusions. She denied melena, hematochezia, fevers or chills. During prior admissions, fecal occult blood tests were negative and stool studies were unrevealing. On admission, the patient was found to have hemoglobin (Hgb) of 5.4 g/dL, acute kidney injury and metabolic acidosis. Fecal occult blood test was positive. Colonoscopy revealed diffuse pan colonic erythematous inflamed mucosa with rectal sparing and no evidence of punched-out ulcers (see Figures 1 and 2). Qualitative CMV polymerase chain reaction study was positive. Hematoxylin and Eosin stained biopsies were inconclusive for inclusion bodies. Immunohistochemical staining for CMV was positive for scattered reactive cells. CMV colitis was diagnosed. Patient was treated with oral valganciclovir leading to complete symptom resolution, improvement of anemia and weight gain.

DISCUSSION:

CMV colitis in immunocompromised patients typically presents with diarrhea associated with abdominal pain, fever, leukopenia and frank hematochezia. This case represents an unusual disease manifestation with an atypical timeline of disease duration, lack of aforementioned symptoms and non-characteristic endoscopic findings, making the diagnosis challenging. Furthermore, delayed CMV infection in organ transplant patients is quite unusual, as most typically, CMV infection presents shortly after initiation of immunosuppressive therapy.
3072 A Unique Cause of Ischemic Colitis: Docetaxel Chemotherapy
Authors: Syed Azfar , Francis Jonathan P.
Published: October 2019

INTRODUCTION:

Ischemic Colitis (IC) is the most common form of intestinal ischemic disorders. This disease process typically affects older adults and is the result of non-occlusive hypoperfusion, which can be precipitated by a multitude of risk factors. Patients usually present with lower abdominal pain and hematochezia. A colonoscopy with biopsies is the gold standard for diagnosis. Increasingly, medications have been associated with contributing to this disease process. Here, we report a unique case of IC attributed to Docetaxel, a taxane class chemotherapeutic agent.

CASE DESCRIPTION/METHODS:

A 76-year-old Caucasian female with a history of multi-focal intraductal carcinoma (Stage IIA), hypertension, and diverticulosis presented to the emergency room (ER) with complaints of lower back and abdominal pain. She had begun therapy with Docetaxel and Cyclophosphamide 8 days prior to presentation. In the ER, she was afebrile, neutropenic (ANC 400), and hypotensive requiring supportive care including antibiotics, fluids and a very brief course of norepinephrine. She was subsequently admitted to the intensive care unit where her neutropenia was noted to have resolved and antibiotics were discontinued in setting of negative cultures. On hospital day 3, she complained of continued abdominal pain and hematochezia with CT imaging that demonstrated bowel wall thickening and mild inflammatory changes in the sigmoid/descending colon. Subsequently, a colonoscopy was performed and showed circumferential, violaceous mucosa consistent with IC. Antibiotics were restarted and the patient was treated supportively with complete resolution of symptoms. Following hospital discharge, she was evaluated by her oncologist who discontinued her Docetaxel and initiated therapy with Paclitaxel. No recurrence of her symptoms have been noted and repeat cross sectional imaging demonstrated resolution of colonic thickening in the previously noted watershed distribution.

DISCUSSION:

IC is a rare but serious complication that has been described in patients receiving Docetaxel. Among the 6 reported cases, symptoms occur within 10 days of Docetaxel administration. Patients present with abdominal pain and hematochezia in the setting of neutropenia with or without fever. This type of IC is often severe, with spontaneous perforation, bowel necrosis, and a reported mortality rate of 40-50%. Although underreported, Docetaxel use is a risk factor for developing IC, one deserving of more clinical awareness.
3073 Eosinophilic Gastroenteritis and Eosinophilic Proctocolitis With a Large Rectal Sessile Serrated Adenoma: A Rare Association
Authors: Nagaraj Savitha V. , Aamar Ali , Reddy Madhavi
Published: October 2019

INTRODUCTION:

Eosinophilic Gastrointestinal Disorders (EGID) are a group of rare disorders characterized by eosinophilic infiltration of the gastrointestinal tract. Eosinophilic gastroenteritis (EGE), eosinophilic colitis (EC) and eosinophilic proctitis (EP) are different types of EGID. We report a case of rare association of EGID and a large sessile serrated adenoma in a middle-aged Hispanic female.

CASE DESCRIPTION/METHODS:

A 49-year-old Hispanic female presented with epigastric discomfort, nausea and hematochezia. The symptoms were insidious in onset and evolved over the span of 3 years. Upper GI Endoscopy showed mild diffuse erythematous mucosa in the antrum and body of the stomach. Colonoscopy showed a few superficial ulcers in the terminal ileum, two polyps in the transverse colon and a large laterally spreading polypoid lesion in the rectum with adjacent multiple small polypoid lesions (Figures 1 and 2). Histological assessment of the gastric biopsy specimen revealed chronic active gastritis, numerous H. pylori, in addition to very high number of eosinophils in the lamina propria. Biopsies of ileum, colon and the rectum also revealed very high number of eosinophils in the lamina propria. Stool for ova and parasite examinations were negative and no peripheral eosinophilia was noted. Patient did not have any food or environmental allergies. Other disorders that could contribute to eosinophil infiltration of the GI tract were ruled out. Hematochezia was likely due to eosinophilic proctitis and rectal polypoid lesion. Although exact eosinophilic count in the biopsy specimen of the stomach, small bowel and the colon was not reported, the clinical presentation and histology was likely consistent with EGID. Patient was treated for H. Pylori infection. Endoscopic submucosal dissection of the rectal polypoid lesion was performed (Figure 3). Pathology revealed sessile serrated adenoma.

DISCUSSION:

Eosinophilic gastrointestinal disorders are a group of rare gastrointestinal diseases with non-specific symptoms and clinical presentation. Diagnosis of EGE, EC and EP involves evaluating for presence of gastrointestinal symptoms, histopathology finding of eosinophilic infiltration of the GI tract and ruling out secondary causes of eosinophilia. Endoscopic examination may reveal patchy erythema, loss of vascularity and lymphonodular hyperplasia mostly localized to the rectum. The authors report this rare case of possible association of EGID and sessile serrated adenoma.
3076 Post Colonoscopy Diverticulitis in a 50-Year-Old Woman Undergoing Surveillance Colonoscopy
Authors: Mahoro Giselle , Copland Andrew , Frye Jeanetta
Published: October 2019

INTRODUCTION:

Colonoscopy is used as a diagnostic and therapeutic tool to treat a wide range of gastrointestinal disorders. Acute diverticulitis after colonoscopy is a rare but potentially serious complication. The incidence of acute diverticulitis after colonoscopy is reported to be 0.084%. Since this is a rare entity, there is limited data regarding the risk, prevention and management of acute diverticulitis after colonoscopy.

CASE DESCRIPTION/METHODS:

A 50 year old woman with a history of adenomatous polyp with villous component detected 4 years prior presented for surveillance colonoscopy. She did not have any abdominal pain. Her labs from a year prior showed WBC 6.86 k/uL. Colonoscopy was notable for pan-colonic diverticulitis (Figure 1), most prominent in sigmoid colon. There was a 2 mm sessile polyp in recto-sigmoid colon that was removed with cold biopsy forceps. The procedure was otherwise uncomplicated. She presented to the emergency department (ED) 3 days later with left lower quadrant pain (LLQ) and fever up to 101 Fahrenheit. The pain started 2 days after she underwent colonoscopy. She did not have nausea, vomiting or rectal bleeding. In the ED, she was afebrile with moderate LLQ tenderness without rebound or guarding. Labs showed WBC 15.41 k/uL (72.5% segmented neutrophils), BUN 11 mg/dL, Cr 1.0 mg/dL. CT of the abdomen and pelvis had findings concerning for acute sigmoid colon diverticulitis without abscess (Figure 2). The patient was discharged from the ED on moxifloxacin and metronidazole.

DISCUSSION:

The American Society for Gastrointestinal Endoscopy (ASGE) lists diverticulitis as a miscellaneous complication, however, there is limited data regarding the risk of developing diverticulitis after colonoscopy. In a retrospective cohort of 236, 377 patients who underwent colonoscopy, 68 patients (0.029%) developed post-colonoscopy diverticulitis. The mean time to develop diverticulitis after colonoscopy was 12 ± 8 days. 34 patients (50%) had a history of diverticulitis prior to colonoscopy and 30 patients (44%) required hospitalization. Prospective studies are now needed to evaluate the risk, mechanism and prevention of colonoscopy induced diverticulitis. If significant diverticula are noted on colonoscopy, post-colonoscopy diverticulitis should be discussed as a potential complication, and it should be considered in a patient who presents with fever and abdominal pain after undergoing colonoscopy.
3077 Inverted Appendix Caused by Inversion-Ligation Appendectomy: An Unusual Case of Cecal Mass
Authors: Moosvi Zain , Sowa Piotr , Samarasena Jason , Albers Gregory
Published: October 2019

INTRODUCTION:

Polypoid lesions involving the cecum and more specifically the appendiceal orifice (AO) can be a diagnostic dilemma. The thin walled cecum poses risk of perforation, therefore resection should be avoided for benign lesions. Invasive adenocarcinoma or adenocarcinoma is situ arising from the appendiceal lumen or AO are rare with less than 250 reports. Other lesions include appendiceal endometriosis, juvenile polyps, adenomatous polyps, and appendiceal inversion.

CASE DESCRIPTION/METHODS:

A 68-year-old female with a past medical history of fibroids s/p hysterectomy and prophylactic appendectomy over 30 years ago presents for first time screening colonoscopy. She denies history of rectal bleeding, constipation, weight loss or family history of colon cancer. An elongated tubular lesion was identified in the cecum (Figures 1 and 2). During inspection, the lesion appeared to arise from the AO. Due to risk of perforation, the polypoid lesion was not removed and multiple biopsies were obtained. The patient had 4 additional polyps, ranging from 4-10 mm, that were removed during the procedure. Pathology report of the cecal mass showed normal colonic mucosa with mild inflammation.

DISCUSSION:

Inversion of appendiceal base is an expected occurrence after inversion-ligation appendectomy. This surgical procedure has been performed historically as an incidental appendectomy, which avoids the transection of the appendiceal lumen and decreasing risk of bacterial peritonitis. The majority of these cases result in atrophy of the appendiceal stump causing scar tissue formation in the AO. However, few autopsy reports show a retained polypoid appendiceal stump that occasionally increases in size. A few reports have described appendiceal inversion resembling a neoplastic polyp during routine colonoscopy. Many of these patients have undergone inversion-ligation appendectomy. The risk of perforation and major bleeding is dramatically increased if endoscopic resection is attempted. We recommend a conservative approach with biopsy to assess for dysplasia or malignancy. If endoscopic resection is attempted, complications can be minimized with the utilization of endoloop or endoscopic clips.
3080 Intestinal Endometriosis: A Case of Mistaken Identity
Authors: Shrimanker Isha , Thein Kyaw , Goel Siddharth , Singh Pratiksha , Charan Mohan , Nookala Vinod
Published: October 2019

INTRODUCTION:

Intestinal involvement is seen in 3-30% of the cases of endometriosis with the rectum and sigmoid colon being frequently affected (75-90%) followed by distal ileum (2–16%) and appendix (3–18%). In addition to the classic triad of pelvic disease, the presentation may vary from being asymptomatic to rectal bleeding, bowel obstruction and rarely perforation. In the majority of the cases, the mucosa is spared with involvement limited to serosa and muscularis propria. The median age of diagnosis is 34-40 years, but reports of diagnosis in the peri- and post-menopausal women are known to exist in literature.

CASE DESCRIPTION/METHODS:

A 55-year-old Caucasian female presented with intermittent bleeding per rectum and abdominal pain for a period of two months with a history of irritable bowel syndrome and anemia. She denied any weight loss or loss of appetite. The examination was unremarkable except for pallor and tenderness in the lower quadrant and laboratory investigations revealed microcytic anemia. Colonoscopy was significant for a 1.5 cm mass in the sigmoid colon. Biopsy of the mass showed endometrial foci and stroma with signs of transmural involvement but was negative for signs of malignancy. The patient was managed with hormonal suppression therapy leading to resolution of abdominal symptoms.

DISCUSSION:

Intestinal endometriosis mimics a broad spectrum of diseases; inflammatory bowel disease neoplasms, colitis, diverticular disease, and infection. The clinical picture along with its overlapping clinical, endoscopic and radiological findings add to the diagnostic conundrum. It is essential to differentiate it from colon adenocarcinoma, the third most common type of cancer in women, to avoid unwarranted diagnostic and therapeutic interventions. The literature regarding standardized workup and treatment is limited and continues to be a topic of research.
3082 Overdosing From Down Under: An Atypical Route of Methamphetamine Use Resulting in Bowel Ischemia
Authors: Narasimha Shruthi , Rios de Choudens Fabiola
Published: October 2019

INTRODUCTION:

Methamphetamines are sympathomimetic medications that cause a surge in catecholamines, which leads to a significant abuse potential. The National Survey on Drug Use and Health reported in 2017 that 5.4% of the population, which at that time made up over 14.7 million people have used methamphetamines at least once in their lives. The usual routes of administration include oral, nasal or intravenous. However, novel anal routes are being seen in current literature and clinicians should be aware so they can notice the severe and potentially life threatening side effects.

CASE DESCRIPTION/METHODS:

The case involves a 29-year-old male with history of benzodiazepine and methamphetamine use who came to the hospital with complaints of rectal pain and hematochezia. He reported continued daily intravenous drug use but also divulged that he had been inserting methamphetamines rectally for the past 5 days. He reported that recently, the bag burst and caused him significant hemorroidal irritation and bleeding. Most of the drugs passed rectally per the patient and the bleeding was improving by the time of admission. Vitals were stable and labs were significant for mild leukocytosis, mild normocytic anemia, and a urine drug test showed elevated amphetamines and benzodiazepines. Due to the continued hematochezia, gastroenterology was consulted and a flexible sigmoidoscopy showed distal ischemic changes in the rectum and an anal ulcer that showed chronic inflammation on biopsy. Through the hospital course, his symptoms improved and he was eventually discharged after extensive education and two weeks of rectal mesalamine.

DISCUSSION:

This case highlights two important points. The first deals with the unusual route of administration, which is helpful to know so that providers can address proper removal of the source. Methamphetamines have rapid gastrointestinal absorption, so it would be important to evacuate the rectal area to prevent further intoxication. The second key aspect of this case deals with the resulting side effect of bowel ischemia. A handful of case reports describe this adverse effect and patients range from having fatal to self-limited outcomes. However, these cases do not all address the route of drug ingestion but direct anal exposure would likely increase the risk of bowel ischemia due to the local vasocontrictive mechanism. Thus, it is vital to initially ask how patients administered the methamphetamines and evaluate the patient's clinical course for bowel injury secondary to ischemia.
3088 Zenker's Full Thickness Diverticulotomy Combined With Botox Injection
Authors: Dawood Enad , Sharma Bashar , Deskmukh Ameya , Nieto Jose
Published: October 2019

INTRODUCTION:

We present a case of an 88 year old gentleman with a history of dysphagia and a recent episode of aspiration pneumonia. A routine swallow evaluation showed a defect in the cricopharyngeal region. A follow up esophagram revealed a large Zenker's diverticulum. We present a case of full thickness endoscopic Zenkers diverticulotom followed by Botox injection post diverticulotomy and resolution of symptoms on one month follow up.

CASE DESCRIPTION/METHODS:

The endoscope was introduced into the esophagus, a wire was passed, then a nasogastric tube was passed into the stomach via the wire, this was used to identify the esophageal lumen. Using a hybrid I knife The diverticulotomy was started. Complete dissection and myotomy of the diverticulum was completed. 10 cc of 100 units of botox were then injected to the proximal esophageal muscle and a diverticular ricopharyngeal muscle. In order to assess for perforation, a upper esophagram was preformed that showed no evidence of leak and the patient was discharged. 30 day follow up showed a completely resolved Zenkers diverticulum and an asymptomatic patient from dysphagia and no evidence of recurrent aspiration pneumonia.

DISCUSSION:

Zenker's diverticulum can be repaired with a variety of surgical and procedural options. However, endoscopic intervention has been shown to reduce operative time and to simplify management in postoperative care. We introduce a novel approach using Botox injections following Zenker's full thickness diverticulotomy to correct a diverticular pouch and relax the surrounding musculature. The video case report showcases the practicality and effectiveness of the procedure.

Watch the video: http://bit.ly/2M2fgMv
3097 Reduction of a Hiatal Hernia Using Osteopathic Treatment
Authors: Peck Meredith T. , Volokitin Mikhail , Sonpal Niket
Published: October 2019

INTRODUCTION:

Hiatal hernia describes superior herniation of abdominal contents through the diaphragm. This type of herniation occurs when the esophageal hiatus weakens and the positively pressurized abdominal cavity forces contents into the negatively pressurized thoracic cavity. Risk factors include conditions that either increase intra-abdominal pressure (e.g., obesity) or weaken the hiatus and associated structures (e.g., fibromuscular degeneration associated with normal aging). Multiple types and classifications of hiatal hernias encumber assessments of disease prevalence; however, hiatal hernias are broadly classified as either sliding or paraesophageal. While many sliding hernias are asymptomatic, patients may experience reflux-like symptoms due to weakening of the lower esophageal sphincter. Paraesophageal hernias are more serious and can lead to volvulus, bleeding, and respiratory compromise. Surgical repair of the hernia is indicated in symptomatic patients refractory to conservative management and to manage complications; however, surgical intervention is a risk factor for more serious complications such as stenosis and perforation.

CASE DESCRIPTION/METHODS:

Here we present a case of a 71-year-old female with reflux symptoms diagnosed with a 3 cm hiatal hernia on esaphagogastroduodenoscopy (EGD). After four osteopathic manipulative treatments (OMT), follow-up EGD showed no evidence of hernia or gastritis and the patient reported complete relief of symptoms.

DISCUSSION:

To our knowledge, this is the first case confirmed by EGD to show a complete reduction of a 3 cm hiatal hernia with OMT being the sole treatment modality. This case demonstrates that hiatal hernias can be managed using OMT, without the use of medications or the need for surgical intervention.