bluuebunny/crossref_metadata_2025 huggingface dataset:
1409 Casting a Wide Net to Find a Rare NET: A Case of Gallbladder Large Cell Neuroendocrine Carcinoma
Authors: Law Jade , Zhornitskiy Alex , Tabibian James H. , Baltayan Armine
Published: October 2019

INTRODUCTION:

Primary neuroendocrine tumors (NETs) of the gallbladder account for <0.5% of all NETs.
1
Large-cell neuroendocrine carcinoma (LCNEC) represents an extremely rare subtype of this uncommon malignancy, and as such, clinical features, optimal treatment, and overall prognosis remains largely unknown.

CASE DESCRIPTION/METHODS:

A 58-year-old women presented to the emergency department with food intolerance due to nausea and pain at her cholecystostomy drain site. Two weeks prior, she had been admitted to an outside hospital for severe right upper quadrant (RUQ) pain without nausea, vomiting, or fever. Work-up included computed tomography (CT) of the abdomen and a RUQ ultrasound, which appeared to reveal changes of cholecystitis and cholelithiasis. Cholecystectomy was attempted, but due to an intraoperative finding of a hardened gallbladder mass, the procedure was aborted, and a surgical cholecystostomy tube was placed instead. Upon admission to our hospital, the patient had normal vital signs. Physical examination was notable for mild RUQ tenderness and a cholecystostomy drain with small amounts of dark bilious fluid. Laboratory testing was significant for total bilirubin of 3.6 mg/dL, alkaline phosphatase of 557 U/L, and AST of 57 U/L. Repeat CT of the abdomen revealed a mass in the hepatic lobe and circumferential soft tissue spanning the tract of the cholecystostomy tube. Endoscopic retrograde cholangiopancreatography (ERCP) showed an extrinsically narrowed proximal duodenum and a 1.5 cm intracholedochal tumor thrombus. Histopathology revealed high grade LCNEC with 80% Ki67 proliferative activity. Oncology was consulted, and although chemotherapy was initiated during the hospitalization, the patient expired from cardiac arrest days after discharge.

DISCUSSION:

Patients with LCNEC present with non-specific symptoms such as abdominal pain or weight loss, and imaging cannot reliably differentiate gallbladder NETs from adenocarcinoma or other pathology. Thus, many are identified incidentally peri-cholecystectomy. Treatment options include resection if distant metastases are not present; if unresectable, palliative chemotherapy and radiation may be administered. The overall prognosis of gallbladder NETs is poor, even worse than gallbladder adenocarcinoma. Early detection with aggressive surgical resection is believed to be the only potential for cure.
1410 A Rare Case of Extrahepatic Cholestasis Secondary to Acquired Immunodeficiency Syndrome (AIDS)—Related Kaposi Sarcoma
Authors: Flores Estefania , Mathew Madhu , Oramas Diana M. , Mbachi Chimezie , Desai Parth M. , Noboa Danilo , Sarda Vanessa
Published: October 2019

INTRODUCTION:

Kaposi sarcoma is an aggressive cancer seen in immunocompromised patients caused by Human Herpesvirus-8 (HHV-8) infection. Cutaneous and pulmonary complications are the most frequent, biliary tract involvement is rarely reported, typically asymptomatic but may present as cholangitis or progress to liver failure.

CASE DESCRIPTION/METHODS:

35-year-old male with HIV and CD4 count of 35 cells/uL, not on antiretroviral therapy for the past year, presented with fever, fatigue, diffuse lymphadenopathies, unintentional weight loss, generalized abdominal pain and scleral icterus for the last 2 weeks. Physical exam showed icterus, small hyperpigmented lesions throughout his trunk, a violaceous nodular enlargement of the hard palate, generalized lymphadenopathy, diffusely tender abdomen and hepatomegaly. Laboratory studies were significant for total bilirubin 23 mg/dL, direct bilirubin 16 mg/dL, ALP 288 U/L, GGT 193 U/L, AST 66 U/L, ALT 40 U/L, INR 1.3. CT of the abdomen showed hepatomegaly and an infiltrative process in the portal hepatis to the celiac area with obstruction of the biliary tract with intrahepatic biliary dilation. Endoscopic retrograde cholangiopancreatography demonstrated 3 cm stricture in the common hepatic duct, a biopsy was taken, and 2 stents were placed. Endoscopic ultrasound with biopsies taken from a stomach nodule and porta hepatis were performed as well. Pathology from porta hepatis mass showed blood clot however, HHV-8 stain from the common hepatic duct and stomach nodule biopsies was positive for Kaposi sarcoma. Doxorubicin and antiretroviral therapy were started, and patient was discharged in view of symptomatic improvement. Liver function tests normalized 8 weeks after presentation.

DISCUSSION:

Kaposi sarcoma involving the biliary tract has been associated with cholangitis and jaundice and may also be caused from extensive disease of the porta hepatis with compression of the extrahepatic biliary tree. Current first-line treatment for advanced Kaposi sarcoma is lipososomal anthracyclines (doxorubicin, daunorubicin). HHV-8 infection cannot be eradicated, but long-term remission is possible. Treatment is indicated in patients with progressive hepatic and biliary disease. Kaposi sarcoma has also been associated with AIDS (acquired immunodeficiency syndrome) cholangiopathy, a form of biliary tract inflammation with stricture formation in severely immunosuppressed HIV patients and management consists of endoscopic sphincterotomy for papillary stenosis and stenting.
1416 Rare Presentation of Large Pancreatic Mass With Chylous Ascites
Authors: Badrinath Madhuri , Mandru Rachana , Saleem Sheikh A. , Heisig David
Published: October 2019

INTRODUCTION:

Primary pancreatic lymphomas (PPL) are very rare and mimic pancreatic head cancer. We present a case of a man who presented with a pancreatic mass and chylous ascites, and was found to have PPL.

CASE DESCRIPTION/METHODS:

A 69-year-old man presented with 2 months of anorexia, abdominal pain and distension. He denied fever, chills or weight loss. Abdomen was distended, soft, non-tender with shifting dullness and fluid thrill. Laboratory tests were noncontributory except for mildly elevated LDH 254 U/L. Abdominal computed tomography (CT) showed a 20 × 10 × 17 cm soft tissue mass impinging the distal duodenum, replacing the proximal pancreatic parenchyma, encasing the celiac and superior mesenteric arteries; ascites, lymphadenopathy and multiple omental nodules were seen. No cirrhosis or hepatomegaly noted. 2.5 L of grossly chylous fluid was drained with lymphocytic predominance, high triglycerides 980 mg/dL and negative cytology. Endoscopic ultrasound (EUS) showed an irregular hypoechoic mass. Fine needle aspiration (FNA) showed lymphoid cells with irregular nuclear membrane contours strongly positive for CD20, consistent with B cell lymphoma. PET-CT scan confirmed a metabolically active pancreatic mass with inguinal, aortocaval, juxtadiaphrgamatic and inframammary lymphadenopathy. Diagnostic laparoscopic biopsy confirmed diffuse B-cell lymphoma of germinal center origin positive for CD10, BCL6, BCL2 and CD45. Patient received 6 cycles of R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, prednisolone) which he tolerated well. Follow-up PET CT scan showed reduction in size of pancreatic mass and lymph nodes without areas of new/worsening lymphoma.

DISCUSSION:

PPLs comprise 0.5% of all pancreatic masses. Diagnostic criteria include dominant pancreatic mass, without superficial or mediastinal lymphadenopathy, absent hepatosplenic involvement and a normal blood leukocyte count. Clinical presentation is non-specific without classic symptoms of nodal lymphoma. Abdominal pain is the most common symptom (83%), followed by abdominal mass and weight loss. High tumor burden, β2-microglobulin levels >2 mg/l and high LDH levels are poor prognostic markers. Definitive diagnosis requires histologic confirmation, EUS-guided sampling is highly accurate. Treatment options include surgery, chemotherapy, radiation, alone or in combination. Cure rates upto 30% have been reported. Long term remission can be obtained with CHOP chemotherapy alone in majority of patients. Addition of rituximab results in overall improvement in patient survival.
1417 Gastric Outlet Obstruction Caused by Infiltrative Pancreatic Cancer Mimicking Benign Peptic Ulcer Disease
Authors: Bhardwaj Gaurav , Nawaz Waqas , Hertan Hilary
Published: October 2019

INTRODUCTION:

Gastric outlet obstruction (GOO) is a known complication of peptic ulcer disease (PUD) and pancreatic cancer. Pancreatic cancer causing GOO can sometimes be missed on endoscopic ultrasound (EUS) due to limited access, thus presenting a diagnostic challenge. We report a case of pancreatic cancer causing GOO which was missed on EUS and GOO was attributed to the duodenal ulcers.

CASE DESCRIPTION/METHODS:

A 59-year-old man with medical history of diabetes and PUD presented with epigastric pain and persistent vomiting for last 2 months associated with weight loss. He had upper endoscopy 4 weeks prior that revealed multiple ulcers in second part of the duodenum. Exam was remarkable for epigastric tenderness. Laboratory data showed hypokalemic metabolic alkalosis and acute kidney injury. Liver function tests were normal. Considering patient's clinical presentation an underlying malignancy was high on differential. CT abdomen showed GOO with duodenal narrowing and a normal pancreas. Endoscopy showed duodenal bulb stricture which could not be traversed. Biopsy showed inflamed duodenal mucosa. EUS showed no pancreatic pathology. GOO was attributed to the duodenal ulcers noted on prior endoscopy and a Roux-en-Y gastrojejunostomy was performed. He returned 12 weeks later with painless jaundice and elevated liver enzymes. MRI abdomen revealed a 2.5 cm infiltrative pancreatic head tumor extending to the pancreaticoduodenal groove resulting in dilatation of the duodenal stump and bile duct. The patient underwent Whipple's pancreaticoduodenectomy. The histopathology showed pancreatic adenocarcinoma with distal involvement of the duodenal margin.

DISCUSSION:

Pancreatic cancer is the second most common malignancy causing GOO. EUS is the most sensitive diagnostic modality for pancreatic cancer with a sensitivity of 94%. However, its accuracy can be limited in setting of duodenal stricture and infiltrating type of the pancreatic lesion. The best station to evaluate the head and genu of the pancreas is second part of the duodenum. In case of duodenal stricture, EUS cannot be stationed properly and can miss an infiltrating pancreatic head lesion causing the GOO, which can be attributed to some other co-existent etiology like PUD, especially in the setting of normal liver tests and CT abdomen. This case also highlights the utility of MRI which is more sensitive than CT in diagnosing small pancreatic lesions and sometimes might be the only revealing modality in instances where EUS is limited by duodenal stricture.
1420 No Stone Left Unturned: Use of a Novel Device for Pancreatic Calculi Extraction
Authors: Schwarzbaum David , Kim Sang
Published: October 2019

INTRODUCTION:

Pancreatic calculi are found in up to 60% of patients with chronic pancreatitis and can cause pancreatic ductal obstruction and chronic pain. Previous endoscopic methods for pancreatic stone removal include blind mechanical lithotripsy with a balloon or basket, or directly visualized laser or electrohydraulic lithotripsy (EHL). However, these techniques have variable success rates with significant complications. Here we present the first use of the SpyGlass™ Retrieval Basket for extraction of pancreatic duct stones.

CASE DESCRIPTION/METHODS:

A 65-year-old male with compensated alcoholic cirrhosis and chronic recurrent pancreatitis was referred for evaluation of a diffusely dilated pancreatic duct (PD) seen on MRI. The patient underwent an endoscopic ultrasound (EUS) which showed a tortuous main PD dilated to 8.6 mm. Two hyperechoic foci up to 10 mm were found in the main PD suggestive of calculi. The patient underwent endoscopic retrograde cholangiopancreatography (ERCP). Pancreatogram revealed a dilated and beaded main PD with stones in the head and neck portion of the main PD. A pancreatic sphincterotomy was performed; and the main PD was dilated and swept with a Hurricane balloon removing one stone and debris. Complete ductal clearance could not be achieved using mechanical lithotripsy with a balloon, so the patient returned for a subsequent ERCP. We then used SpyGlass™ for direct pancreatoscopy, which revealed multiple large calculi in the genu of the main PD. The SpyGlass™ Retrieval Basket was advanced through the SpyScope™ and used to manipulate, dislodge and remove the PD stones. Six stones were extracted from the duct. The patient had mild post-ERCP pain, which was treated with oral medications.

DISCUSSION:

The Spyglass™ Retrieval Basket is a device developed for directly visualized stone extraction through the SpyGlass™ system. In contrast to EHL or laser lithotripsy it does not require fragmentation of stones, which may reduce the risk of post-procedural pancreatitis and perforation. This is the first use of the SpyGlass™ Retrieval Basket to extract stones from the pancreatic duct.
1432 Pancreatic Acinar Cell Carcinoma With Lipase Hypersecretion Syndrome
Authors: Edwards Marcellus , Ayoola Rotimi , Hassan Muhammad Masood , Naab Tammey , Laiyemo Adeyinka
Published: October 2019

INTRODUCTION:

Pancreatic acinar cell carcinoma (PACC) is a rare, highly aggressive, malignant, exocrine-functioning neoplasm. Acinar cells are the most common cells (82%) in the pancreas but accounts for only 1-2% of primary pancreatic neoplasms. In 10-15% of these cases patients can develop lipase hypersecretion paraneoplastic syndrome (LHS) characterized by subcutaneous fat necrosis, polyarthralgia and peripheral eosinophilia.

CASE DESCRIPTION/METHODS:

A 69-year-old man with history of hepatitis C virus, hypertension, gout, peripheral artery disease and prostate cancer presented with a 1-month history of painful nodules on his bilateral lower extremities (LE). He described progressively worsening joint pain, bilateral LE swelling and purulent drainage from the right LE nodule. Examination revealed hepatomegaly, a 3 × 3 cm nodule on the anteromedial surface of the right LE with purulent drainage, and multiple small, hyperpigmented nodules on bilateral LE. Labs were significant for a white blood cell count of 17.3, hemoglobin of 8.7, normal eosinophil count, albumin of 2.9 g/dL, lipase 5444 IU/L, CA 19-9 44 U/mL and an AFP of 1.8 ng/mL. Computerized tomography revealed an 8.7 × 6.2 × 5.7 cm pancreatic mass encroaching on the 2nd part of the duodenum. Multiple hypoattenuated lesions were seen within the liver largest measuring 4.7 × 5.6 × 7.2 cm with metastatic invasion into the portal vein and superior mesenteric vein. Patient underwent wound debridement. An esophagoduodenoscopy revealed a 5 cm duodenal mass with ulceration extending from the duodenal bulb towards the 2nd portion of the duodenum. Lastly, he underwent an interventional radiology guided liver biopsy. Biopsy of the liver and duodenum both were consistent with PACC. Biopsies from the right leg revealed pancreatic panniculitis. Multi-drug resistant sepsis and recurrent upper gastrointestinal bleeding requiring arterial embolization complicated the hospital course. The patient was placed on comfort care and passed.

DISCUSSION:

LHS typically presents in advanced disease and is considered a negative prognostic factor. In LHS, PACC overproduces zymogen granules containing lipase, which cause inflammatory and fat necrosis in peripheral tissue through hematogenous spread. Immunochemistry staining is usually positive for trypsin, chymotrypsin and lipase. No standard therapy for PACC has been made but 5-fluorouracil is considered to be effective, and surgical intervention is recommended if possible.
1438 A Starry Sky Liver: Klebsiella Pneumoniae Septic Shock Caused by Infected Multiple Biliary Hamartomas
Authors: Neubert Zachary , Mirhosseni Nader , Lawson Robert D.
Published: October 2019

INTRODUCTION:

Biliary hamartomas or von Meyenburg complexes are an exceedingly rare benign cystic disease of the liver. They are diagnosed radiographically due to a distinct appearance. We present an unusual case of a patient presenting with septic shock from multiple infected biliary hamartoma cysts.

CASE DESCRIPTION/METHODS:

A 52-y/o caucasian female presented to the emergency department with 20 pounds of unintentional weight loss over 3 months, painless jaundice, rigors and worsening altered mental status. Medical history included: Down's syndrome with progressive dementia, depression, and hypothyroidism. Physical exam notable for hypotension, fever, and tachycardia. Laboratory evaluation illustrated a leukocytosis of 10.9, total bilirubin of 7.6, direct bilirubin 6.1, alkaline phosphatase 926, ALT 44, AST 71, INR 2.3. An abdominal ultrasound revealed numerous hepatic cysts without cholelithiasis. MRCP confirmed innumerable uniform hepatic cysts without connection to the biliary tree consistent with multiple biliary hamartomas. The hepatic cysts lacked mural nodules. She was treated for presumed septic shock from ascending cholangitis with empiric IV antibiotics and vasopressors. With continued supportive care, her liver enzymes and coagulopathy normalized. Blood cultures grew Klebsiella pneumoniae. Her septic shock resulted from cholangitis due to infected biliary hamartomas. She discharged after 7 days in healthy condition.

DISCUSSION:

Multiple biliary hamartomas (MBH) are rare, benign lesions of the liver. They occur roughly 0.6-2.8% of the general population. Multiple biliary hamartomas are thought to arise from ductal plate malformations involving the small interlobular bile ducts. The cysts are typically uniform in size and most are asymptomatic found incidentally on imaging. MBH are associated with autosomal polycystic kidney disease, hepatic fibrosis, and polycystic liver disease. Gold standard for diagnosis of MBH is MRCP. It depicts striking stereotypical multiple T2 hyper-intense cystic lesions distributed homogeneously within the liver without communication to the bile ducts. Differential diagnosis for this imaging appearance includes metastasis, simple liver cysts, liver cancer, biliary adenomas, and Caroli's disease. Albeit unclear, MBH may be a risk factor for cholangiocarcinoma. This case highlights a peculiar case of biliary septic shock caused by infected liver biliary hamartomas.
1442 Acute Pancreatitis Induced by a Migrated Percutaneous Endoscopic Gastrostomy Tube: A Case Report
Authors: Hawa Fadi , Marii Anas , Al-Sous Ola
Published: October 2019

INTRODUCTION:

Percutaneous Endoscopic Gastrostomy (PEG) tube placement is a widely used and effective method to provide enteral feeding in critically ill patients. However, it could cause major complications leading to significant morbidity. This case reports a rare late complication of a migrated PEG-tube to the duodenum causing obstruction of the biliary tree and resulting in acute pancreatitis.

CASE DESCRIPTION/METHODS:

A 50-year-old male with complicated tonsillar squamous cell carcinoma requiring tracheostomy and PEG-tube placement, suffered a traumatic brain injury resulting in paraplegia. Two months later, while at an in-patient rehabilitation unit, patient developed sudden onset epigastric abdominal pain. Physical examination was significant for diffuse abdominal tenderness. PEG-tube was noted in place. Laboratory studies showed elevated lipase (781 U/L) but otherwise normal liver enzymes without a cholestatic pattern. Abdominal Computed Tomography (CT) scan showed acute pancreatitis with a portion of the PEG tube in the duodenum abutting the Ampulla of Vater, and causing biliary obstruction. Patient was started on conservative management, and his PEG-tube was exchanged at the bedside. Subsequently, patient had rapid improvement of his symptoms and his lipase levels normalized within two days.

DISCUSSION:

The exact incidence of PEG-tube migration to the duodenum remains unclear; there are thirteen case reports of PEG tube migration induced acute pancreatitis reported in the literature. It is hypothesized that tube migration to the duodenum is caused by the peristaltic movement of the intestines. This results in disruption of the biliary flow and serves as a predisposing factor to acute pancreatitis. The increasing number of cases reporting this adverse event suggests that acute pancreatitis might be one of the late complications of PEG tube placement that carries significant morbidity. Despite inability to prove causality, the rapid improvement in patient's clinical status and laboratory findings after PEG tube exchange, supports the aforementioned hypothesis. Awareness of such complication and its possible consequences including acute pancreatitis can ensure early recognition and timely treatment of such adverse event.
1444 Spontaneous Asymptomatic Intraperitoneal Rupture of a Pancreatic Pseudocyst Prior to Attempted Endoscopic Drainage
Authors: Sadowski Brett , Tritsch Adam , Young Patrick
Published: October 2019

INTRODUCTION:

Pancreatic pseudocysts are inflammatory fluid collections occurring after an episode of acute pancreatitis. Drainage of large pseudocysts is indicated in symptomatic patients at least 4 weeks after an acute episode in order for encapsulation. Prior to stent placement, some advocate for contrast-enhanced imaging to evaluate for a pseudoaneurysm formation. We present a case of symptomatic patient who was scheduled for cystgastrostomy but was found to have had spontaneous intraperitoneal rupture of her pseudocyst, leaving her symptom free.

CASE DESCRIPTION/METHODS:

A 63-year-old female smoker with a history of ileal Crohn's disease in clinical remission, chronic pancreatitis as well as cholelithiasis was admitted of progressive epigastric and right upper quadrant pain, early satiety, nausea and weight loss three months following an episode of acute pancreatitis. CT performed during hospitalization demonstrated a 15 × 10 × 9 cm pseudocyst in the tail of the pancreas leading to gastric compression, having grown from 4.9 × 5.1 × 2.8 cm within a week of her index presentation. The patient was discharged with close follow up and was evaluated with physical exam within 5 days, at which time endoscopic cystgastrostomy was scheduled for early in the next week. She completed an abdominal CT scan the morning of her procedure noting that over the weekend, her symptoms had substantially improved. Her CT demonstrated a 95% reduction in cyst volume with new perihepatic ascites but she remained clinical asymptomatic. Her procedure was canceled and she was subsequently underwent a cholecystectomy.

DISCUSSION:

Size alone does not mandate drainage, though larger cysts are more likely to be symptomatic, making treatment indicated. Though guidelines regarding the management of pseudocysts recommend peri-procedural imaging prior to drainage, there is variability in clinical practice. In our case, given the high pre-test probability for pseudocyst (and not a cystic neoplasm), imaging was obtained to rule out a pseudoaneurysm in an effort to reduce a risk of bleeding. Instead, it showed a spontaneous rupture of the pseudocyst, which occurs in <3% of cases, with theoretical mechanisms including minor abdominal trauma, increased intra-abdominal pressure or cyst wall digestion by proteolytic enzymes. Case reports of spontaneous rupture into the stomach and portal vein have been reported. Unlike prior cases of intraperitoneal rupture, our patient remained asymptomatic without evidence of peritonitis.
1445 Spontaneous Isolated Celiac Artery Dissection: A Rare Cause for Acute Pancreatitis
Authors: Cheung Maggie , Marella Dean , Dhar Kalyani , Patel Manish S.
Published: October 2019

INTRODUCTION:

Spontaneous celiac artery dissection is a rare event. Due to similar presenting symptoms of abdominal pain, diagnosis of celiac artery dissection as a cause of acute pancreatitis can be easily missed.

CASE DESCRIPTION/METHODS:

A 51-year-old man with a history of cholecystectomy presented with severe epigastric pain radiating to bilateral upper quadrants. He denied nausea, vomiting, diarrhea and fevers. Physical exam was notable for epigastric, LUQ, and RUQ tenderness. Labs revealed lipase 35 U/L. CT A/P showed peripancreatic inflammatory changes with hyperdense peripancreatic fluid, concerning for hemorrhagic pancreatitis. Typical etiologies for acute pancreatitis were absent, including alcohol and gallstones, and IgG4 was negative, suggesting this was not autoimmune pancreatitis. MRCP was performed and identified a dissection of the celiac axis extending to the splenic artery. CT angiography confirmed celiac artery dissection and re-demonstrated peripancreatic fat stranding. Patient received aggressive IV fluids for the first 24 hours with improvement in pain. Vascular surgery recommended starting aspirin 81 mg daily without any surgical intervention and the patient was discharged home with close follow-up.

DISCUSSION:

Though our patient had a normal lipase, he had severe epigastric pain and peripancreatic stranding on imaging, satisfying 2 of the 3 criteria for acute pancreatitis. In the absence of other causes, imaging identified celiac artery dissection as the etiology of his pancreatitis. Of the visceral artery dissections, celiac artery dissection represent only 4% of cases, and only 5 reported cases have identified spontaneous celiac artery dissection as a cause of pancreatitis. In the setting of a dissection, the pancreas likely experienced an ischemia-reperfusion injury, where there was transient hypoperfusion from the celiac trunk, followed by reperfusion from collaterals from the superior mesenteric artery, resulting in exposure to oxygen-free radicals and cellular processes leading to inflammation. There is no standardized treatment, but conservative management with antiplatelet and/or anti-coagulation is pursued in mild cases of pancreatitis. Surgery is reserved for severe cases involving bowel ischemia, vessel rupture, or continued abdominal pain. This case highlights a rare presentation of acute pancreatitis secondary to a spontaneous isolated celiac artery dissection.
1452 Unusual Complication Following Screening Colonoscopy
Authors: Dirweesh Ahmed , Shamsi Nabiha , Freeman Martin , Trikudanathan Guru
Published: October 2019

INTRODUCTION:

Colonoscopy in general can be a challenging procedure as the colon is often quite mobile and tortuous. While abdominal pain is relatively common during and after the procedure, evaluation is always required to rule out serious causes such as colonic perforation and organ injury.

CASE DESCRIPTION/METHODS:

A 62-year-old female with a history of a left nephrectomy (23 years ago) underwent a screening colonoscopy (performed with good bowel preparation, under conscious sedation, and the whole colon was described as significantly redundant, tortuous and endoscopically normal) at the referring facility. She developed worsening left sided abdominal pain, nausea and vomiting three days after the procedure (managed at several occasions with bowel rest and antibiotics for presumed enteritis/diverticulitis). CT scan, 3 months following colonoscopy showed a complex irregular collection involving pancreatic tail and splenic flexure with adjacent partially rim-enhancing fluid collection abutting the greater curvature of the stomach. A CT guided percutaneous aspiration of fluid collection showed a markedly elevated lipase and amylase. This was concerning for pancreatic duct (PD) leak. She underwent an ERCP and placement of 3 Fr by 13 cm single pigtailed Advantix stent and 5 Fr by 3 cm Geenen stent for a confirmed PD leak. Although no definite fistulous communication to colon was seen on the fluoroscopic images, an immediate post ERCP non-contrast CT scan revealed contrast in the left colon concerning for a colo-pancreatic fistula. Her clinical symptoms resolved immediately following procedure. A follow up ERCP after 4 weeks confirmed no further PD leak.

DISCUSSION:

This patient's presentation is most consistent with chronic PD leak. The likely explanatory mechanisms include traction on fibrous surgical adhesions between the splenic flexure and distal pancreas, direct blunt trauma by passage of the colonoscope through the splenic flexure, and external abdominal pressure around the left colon. This case illustrates that it is possible for a patient with pre-existing risk factors to develop a significant pancreatic injury following colonoscopy. Careful review of patient's surgical history at time of informed consent is essential to identify those at risk and to take preventive measures including avoiding and reducing endoscope looping, avoiding excessive force and minimizing air insufflation.
1460 An Unusual Histopathology of Colonic Polyps
Authors: Vohra Ishaan , Almoghrabi Anas , Katiyar Vatsala , Randhawa Tejinder , Palacios Pedro , Kotwal Vikram , Attar Bashar M.
Published: October 2019

INTRODUCTION:

Sarcoidosis is a multi-system disorder most commonly known to involve lungs, eyes, skin and joints. Colonic involvement either in isolation or as a part of systemic disease has been reported in less than 20 cases. Here, we describe a patient who presented with abdominal pain, constipation, and weight loss and was found to have colonic sarcoidosis.

CASE DESCRIPTION/METHODS:

A 38-year-old woman presented with chronic left lower quadrant abdominal pain, constipation, and unintentional weight loss for a few months. Her past medical history significant for treated latent tuberculosis and uterine fibroids. She denied fever, diarrhea, melena or hematochezia. Physical exam revealed tenderness in the left lower quadrant and periumbilical region. Laboratory work up showed hemoglobin of 9.6 (11.7-14.9 g/dL). Her ACE levels were elevated at 120 (8-52 U/L). Chest xray showed scattered pulmonary nodules and bilateral hilar lymphadenopathy. CT scan demonstrated extensive porta hepatis, mesenteric, portocaval, retroperitoneal, and inguinal lymphadenopathy. Biopsy of inguinal lymph node showed granulomatous lymphadenitis but no malignancy. Acid fast bacilli and fungal stains were both negative. Further, colonoscopy revealed multiple sessile polyps in descending colon ranging between 2-8 mm (Figure 1), removed with excisional biopsy. Biopsy from the colon polyps revealed numerous non-caseating granulomas (Figure 2). She was diagnosed with multi-system symptomatic sarcoidosis and was started on prednisone with improvement of her symptoms.

DISCUSSION:

Gastrointestinal tract involvement by sarcoidosis is seen in less than 1% of cases, with stomach being the most commonly affected organ. Colonic sarcoidosis is extremely rare and has variable clinical presentation but abdominal pain is most commonly described. Endoscopic appearance is very nonspecific and includes polyps, mass like lesions, erosions, ulcers and focal nodularity. Diagnosis requires demonstration of non necrotizing granulomas in the involved organ, evidence of sarcoidosis in at least one other organ system and exclusion of other granulomatous disorders such as tuberculosis, fungal infections, inflammatory bowel disease and malignancy. While no therapy is warranted for inactive disease, steroids are the initial treatment of choice in symptomatic patients.
1470 Pylephlebitis: An Unusual Presentation of Metastatic Colon Cancer
Authors: Madhani Kamraan , Aamar Ali
Published: October 2019

INTRODUCTION:

Pylephlebitis occurs in the setting of abdominal inflammatory processes and commonly begins with thrombophlebitis of mesenteric veins draining areas of infection. If unrecognized, it can carry a 30-day mortality as high as 32%.
1
Common etiologies include pancreatitis and diverticulitis, whereas no cases associated with metastatic colon cancer had been reported.
2,3
Thus, a high index of suspicion is necessary to make a timely diagnosis of a rare condition.

CASE DESCRIPTION/METHODS:

A 64-year-old man presented with 3-week history of constipation and fever of 103° F. Physical exam revealed scleral icterus, and tenderness to palpation of the abdomen. Lab studies were significant for leukocytosis of 21,000 cells/mL. Blood cultures remained negative. Abdominal CT revealed widespread tumor in the liver and thrombosis of the superior mesenteric vein (SMV) extending into the portal vein, causing edema in the colonic mesentery (Figure 1). Presence of gas within the clot in the SMV was noted. Core biopsy of a liver mass revealed adenocarcinoma. Colonoscopy revealed a cecal mass, confirmed to be colonic adenocarcinoma (Figures 2 and 3). The patient was started on antibiotics for suspected pylephlebitis, later transitioned to oral Ciprofloxacin and Metronidazole, for 4 weeks. Intravenous heparin was changed to Enoxaparin.

DISCUSSION:

Without the development pylephlebitis, our patient's colon cancer likely would have spread beyond the liver. While bacteremia was not detected, it is not reported with 100% frequency.
1
The presence of gas within the clot along with fever and leukocytosis raised suspicion for infection of the venous clot. Therapy includes antibiotics for up to 6 weeks with consideration for anticoagulation. While the routine use of anticoagulation for pylephlebitis remains controversial, given the risk of thrombus extension causing mesenteric ischemia, the benefits outweighed the risks. Pylephlebitis due to metastatic colon cancer is a rare etiology, and should be considered in patients presenting without commonly reported risk factors.
1475 Plasmablastic Lymphoma Presenting as Ileocolic Intussusception
Authors: Selby Alexandra
Published: October 2019

INTRODUCTION:

Plasmablastic lymphoma (PBL) is an exceedingly rare yet aggressive subtype of diffuse large B cell lymphoma that is most often identified in HIV-infected individuals. PBL is detected with the highest incidence in the oral cavity, with only 12% of cases being documented in the gastrointestinal tract. Even rarer are cases of PBL manifesting as intussusception, a phenomenon observed almost exclusively in children. To the author's knowledge, only two case reports of plasmablastic lymphoma presenting as intussusception (ileoileal and colonic) have been documented in the American literature since 2015. Herein the first case of PBL manifesting as ileocolonic intussusception in an immunocompromised adult is presented.

CASE DESCRIPTION/METHODS:

A 49-year-old man with a past medical history significant for AIDS (CD4+ 128) on intermittent HAART therapy presented with a 1-week history of sharp, bilateral lower quadrant pain and worsening abdominal distension. Admission labs revealed a mild transaminitis (AST 104 U/L, ALT 61 U/L) and lactic acidosis (2.8 mmol/L) but were otherwise unremarkable. His abdominal exam was notable for bilateral lower quadrant tenderness and marked abdominal distention. CT abdomen/pelvis with IV contrast demonstrated moderate-to-severe ascites as well as marked thickening of the terminal ileum, cecum and ascending colon with hyperemia and surrounding infiltration of fat concerning for short segment ileocolic intussusception. The patient was evaluated by general surgery and later deemed not to be a surgical candidate after several days of appearing non-obstructed. The patient subsequently underwent diagnostic and therapeutic paracentesis, with cytology consistent with plasmablastic neoplasm. Colonoscopy revealed a large, hard, partially obstructing mass in the ascending colon, with biopsy results most consistent with plasmablastic lymphoma. HHV-8 and EBV were negative on pathology. The patient was initiated on EPOCH chemotherapy by hematology/oncology and continues on therapy at the time of publication.

DISCUSSION:

The aforementioned case demonstrates the first known case report of PBL presenting as ileocolonic intussusception in recent review of the American literature. Taken in conjunction with other case reports documenting the association of PBL with intussusception, this case underscores that practitioners must be cognizant to include PBL in the differential diagnosis of intussusception in the immunocompromised adult so as to help expedite appropriate initiation of chemotherapy.
1477 A Rare Case of Successful Endoscopic Decompression of Ileal-Pouch Volvulus
Authors: Cavaliere Kimberly , Trindade Arvind , Kuntzen Christain
Published: October 2019

INTRODUCTION:

Ileal-pouch anal anastomosis is a common surgery to restore bowel continence after total proctocolectomy. Obstruction is the most common late complication and occurs in up to 25% of cases. However, Ileal-pouch volvulus is an exceedingly rare complication of this procedure with only 16 published cases. All but one were treated with emergent surgical intervention. We present the second case of successful endoscopic decompression and the first reported in a patient with familial adenomatous polyposis (FAP).

CASE DESCRIPTION/METHODS:

A 33-year-old female with FAP status-post total proctocolectomy with ileoanal anastomosis and J-pouch formation complicated by history of ventral hernia repair and pouchitis presented with one week of severe left sided abdominal pain and emesis. On the day of presentation she noted new onset of abdominal distension causing her to present to the emergency room. The patients work up was notable for urosepsis, leukocytosis, AKI, hyperkalemia and a metabolic acidosis. A CT showed dilated small bowel loops swirled around a transition point in the left lower quadrant. A barium enema confirmed the diagnosis with barium that did not pass the distal rectum but was not therapeutic. Flexible sigmoidoscopy was then performed and showed twisted bowel with stenosis at 20 cm proximal to the anus. The endoscope was gently advanced with minimal CO2 insufflation and the stenosis re-opened, revealing dark gray, edematous mucosa with black spots. Proximally and distally, the mucosa appeared healthy. A colonic decompression tube was inserted to prevent future volvulus. The patient underwent exploratory laparotomy seven days later. No volvulus or bowel ischemia was found at that time and the pouch appeared viable. Extensive lysis of adhesions in the right upper quadrant and reduction of an internal hernia were performed. A small segment of small bowel was resected due to serosal injury. The patient then completed a course of antibiotics and was discharged home.

DISCUSSION:

This is a unique case of an extremely rare complication of an Ileal-pouch anal anastomosis. Additional abdominal surgeries, pouchitis and sepsis have been described as risk factors for pouch complications, all of which occurred in our patient and may have contributed to this rare presentation. Endoscopic decompression, if done expeditiously, may prevent loss of the pouch and need for surgical repair. This demonstrates the need for high clinical suspicion and awareness of this rare complication.
1478 Small Cell Carcinoma of the Cecum: A Rare Entity
Authors: Gladys-Oryhon Jordan , Umar Shifa , Cole Rita , Farah Katie
Published: October 2019

INTRODUCTION:

Small-cell carcinoma of the colon (SmCC) is a very rare disease and is difficult to achieve long-term survival due to its aggressive behavior. Distant metastases are often found at the time of diagnosis of tumor. High recurrence rates contribute to poor survival with a median survival of 10.5 months. The World Health Organisation (WHO) in 2010 classified SmCC as a subgroup of neuroendocrine carcinoma (NEC) which accounts for approximately 0.6 percent of all colorectal cancers. Peak incidence of these tumours is in the sixth and seventh decades of life. The limited information on colorectal small cell carcinoma in the literature shows that these tumors have similar demographic features to colorectal adenocarcinomas with the exception of being more common in females. Of note, cecal small cell carcinoma is even more rare.

CASE DESCRIPTION/METHODS:

A 51-year-old female with no significant past medical history presented with a 2 year history of iron deficiency anemia and PICA. She had experienced 3 weeks of RUQ pain, abdominal distension, and fatigue. Colonoscopy revealed a 15 cm infiltrative mass in the cecum. Pathology showed invasive poorly differentiated grade 3 small cell carcinoma of the colon (Figure 1). Immunostains + CAM, synaptophysin, MAP-2, and CDX2. CTscan showed diffuse liver metastasis. PET scan showed diffuse brain metastasis. Chemotherapy with cisplatin and etoposide was instituted. Her course was complicated by confusion, lethargy, pulmonary embolus, recurrent ascites, and sepsis. She passed away 8 months after diagnosis.

DISCUSSION:

The available literature consists mainly of series of case reports or small case series that provide guidance for optimal therapy to prolong survival. Prognosis is very poor and is secondary to the tumor's aggressive biology, the presence of metastatic disease at the time of diagnosis, and poor response to chemo/radiotherapy. Seventy percent of patients present with metastases at the time of diagnosis. The reported 6 months, 3 year and 5 year survival rates of 58%, 13%, and 6%, respectively, with a median survival of 10.4 months. There is no agreed standard treatment approach for colorectal SmCC at the present time. Combination of surgery, chemotherapy and radiotherapy is the standard at this time but overall prognosis is poor. It is of utmost importance to perform colonoscopic evaluation if patients have any alarm features such as iron deficiency anemia, unexplained abdominal pain, and altered bowel habits so that diagnosis can be made earlier.
1482 Chalk Eating: A Culturally-Accepted Form of Pica in Georgia?
Authors: Uy Pearl Princess , Crisona Frank , Sridhar Subbaramiah
Published: October 2019

INTRODUCTION:

Pica is the persistent intake of nonnutritive and nonfood substances seen commonly in children, pregnant women, institutionalized persons, patients with developmental disabilities and iron deficiency. Kaolin ingestion in the form of chalk, white dirt or white clay, is a lesser known form of pica but a common occurrence in Central Georgia. We present a case of a young black female from Georgia who presented with a partial bowel obstruction from eating chalk.

CASE DESCRIPTION/METHODS:

A 35-year-old black female from Augusta Georgia with iron deficiency anemia and depression presented with worsening abdominal pain, distention and constipation with the last bowel movement 2 weeks prior to presentation. She ate 5 lbs of chalk with each meal for the previous 10 years, like her mother. Her cravings for chalk increased with worsening anemia. Physical exam was pertinent for abdominal distention and tenderness. Laboratory tests revealed iron deficiency anemia but normal calcium and vitamin D level. The abdominal x-ray showed radiopaque material opacifying the lumen of the colon with nonobstructive bowel gas pattern. Flexible sigmoidoscopy was performed for mechanical disimpaction using endoscopic accessories was unsuccessful. Gastrograffin enema was then performed twice with resulting bowel movements. The patient received intravenous iron therapy and was evaluated by psychiatry. She was discharged home on iron supplements and laxatives.

DISCUSSION:

Kaolin is a soft white clay and an important ingredient in making porcelain, paper and rubber. It is not absorbed systemically but acts locally in the intestines where it adsorbs toxins and is used as an anti-diarrheal agent. The prevalence of kaolin ingestion especially among black female residents in Central Georgia represents a cultural-bound syndrome shared by family members or friends such as in our patient. Although our patient had iron deficiency anemia which could be associated with pica, the cultural practice of eating chalk is widely accepted in their community and believed that ingesting chalk helps with nausea, indigestion, and even constipation! Complications from this form of pica include anemia, malnutrition, constipation, intestinal obstruction, and even colon perforation. Management include medical, endoscopic or surgical removal of these substances and most importantly cognitive behavioral treatment. It is important to have a high index of suspicion for pica when multiple opacities are noted in the colon especially among residents of Georgia.
1485 Rectal Foreign Body: A Novel Minimally Invasive Extraction Technique With Blakemore Tube
Authors: Ali Ijlal Akbar , Hayat Maham , Kanagala Rajesh
Published: October 2019

INTRODUCTION:

Rectal foreign bodies often pose a challenging diagnostic and management. They are usually classified as sharp or blunt and sexual or non-sexual. A few novel techniques described in literature to aid with extraction include Foley catheter, Blakemore tube, obstetrical forceps and vacuum extractor. We describe such a case of rectal foreign body extraction with Blakemore tube and flexible sigmoidoscopy, which saved the patient from an open surgical approach.

CASE DESCRIPTION/METHODS:

A middle-aged male presented to the Emergency room with complaint of inability to pass a rectal foreign body (cucumber) he had inserted into his rectum. He reported doing this on a regular basis and would usually remove them by bearing down. He did endorse any vomiting or abdominal pain and had been passing gas. A CT scan noted an elongated 23.5 × 4.9 × 4.7 cm foreign body in the rectosigmoid area with no bowel wall thickening or perforation with distal tip was 8.8 cm from the anal verge. Initial attempts at manual extraction by surgeon with exam under anesthesia were unsuccessful. An adult upper endoscope was inserted and used to guide a Blakemore tube under direct visualization beyond the proximal edge of the foreign body. The gastric balloon was inflated to 60 cc with saline and endoscope was withdrawn. Traction was applied by pulling the Blakemore and distal edge of cucumber was manually grasped and removed by the surgeon. Endoscopic re-inspection of the rectosigmoid colon confirmed no deep mucosal injury.

DISCUSSION:

This case demonstrates a few important principals which one should be cognizant of when managing large rectal foreign bodies. The most important factor in successful extraction is patient relaxation. Objects located more proximally in the rectum or the distal sigmoid colon may need a combined approach between gastroenterology and general surgery. A combined approach is also safer and minimally invasive, and able to save patient from an unneeded laparotomy. It is also important to re-evaluate the bowel mucosa for inadvertent injuries and perforations after successful removal of foreign body.