bluuebunny/crossref_metadata_2025 huggingface dataset:
1538 An Unusual Presentation of Ischemic Colitis
Authors: Davis Nathan , Govil Yogesh
Published: October 2019

INTRODUCTION:

We present an unusual physical exam finding in ischemic colitis.

CASE DESCRIPTION/METHODS:

A 44 year old male with no known medical history presented to emergency department with complaint of abdominal pain and flu-like symptoms for 10 days. He had associated bloating and constipation which was minimally relieved with over the counter laxatives. There was no report of hematochezia or melena. Computed tomography of the abdomen and pelvis was notable for severe contiguous wall thickening and pericolonic fat stranding in the descending colon, sigmoid colon, and rectum. These findings were suspicious for either infectious or inflammatory colitis. There were no abnormalities in the mesenteric vasculature. The patient was discharged on an empiric course of ciprofloxacin and metronidazole, and was seen in the office two days later for follow up. On physical examination, there was an unusual finding of a tender, non-pulsating palpable mass over the left hemi-abdomen without rebound, guarding or rigidity. The patient's antibiotics were discontinued due to low suspicion for an infection. Given the finding of abdominal mass on exam, he was referred for urgent colonoscopy out of concern for colon cancer or lymphoma. On colonoscopic examination, findings were notable for altered vascularity, edema, erythema and linear erosions throughout the rectum, sigmoid colon and descending colon which were consistent with colitis. Biopsies from these sites showed edema and superficial prominence of capillary-sized vessels. The patient was given a diagnosis of colonic ischemia and he was provided with appropriate treatment. One week later on telephonic follow up, the patient reported resolution of his symptoms with plan for repeat computed tomography of the abdomen.

DISCUSSION:

This patient presented with an unusual finding of a palpable mass to his left hemi-abdomen in the setting of colonic ischemia. Abdominal masses on exam are most frequently due to hernias, neoplasms, infectious collections and hematomas. However, the diagnosis of colonic ischemia generally relies on history, imaging and colonoscopy. The available literature on physical exam is generally non-specific and limited to abdominal tenderness. This patient had the characteristic findings of colonic ischemia including edema, linear erosions and segmental erythema to support a diagnosis of colonic ischemia. It is suspected that his abdominal mass represented the affected colonic segments which makes this a rather unique finding for this disease.
1540 Colorectal Cancer: An Uncommon Cause for Restrictive Lung Disease
Authors: Mizrahi Joseph , Namn Yunseok , Buscaglia Jonathan M.
Published: October 2019

INTRODUCTION:

Colorectal cancer (CRC) often presents with gastrointestinal complaints such as changes in bowel habits or rectal bleeding. We present here an unusual case of CRC diagnosed in the setting of respiratory distress.

CASE DESCRIPTION/METHODS:

A 78-year-old female with no prior history of lung disease but a long smoking history presented with acute dyspnea, with an oxygen saturation of 86%. The physical exam revealed bilateral wheezing and a soft non-distended abdomen. There were no biochemical lab abnormalities and her chest radiograph demonstrated an elevated right hemidiaphragm, a chronic finding for the patient (Figure 1). Given her longstanding smoking history, she was started on steroids and nebulizers for a suspected COPD exacerbation. However, her respiratory status worsened and she was upgraded to the medical intensive care unit. A pulmonary function test was subsequently performed which showed a reduced FEV1 (0.48) and FVC (0.63), but a normal FEV1/FVC ratio (77%) – denoting a restrictive lung disease pattern, inconsistent with the original diagnosis of a COPD exacerbation. This prompted further imaging which revealed a severely dilated colon (maximum dilation of 8.4 cm) with a transition point at the proximal sigmoid colon (Figure 2). As the patient previously never had a colonoscopy, one was performed which revealed a 3 cm, circumferential, fungating, nearly lumen obstructing mass 30 cm from the anal verge, concerning for adenocarcinoma (Figure 3). A colonic stent was therefore placed with improvement in the patient's work of breathing. Biopsies later confirmed adenocarcinoma for which she underwent a left hemicolectomy.

DISCUSSION:

CRC is rarely diagnosed as a result of non-gastrointestinal related symptoms. In this case, the patient presented with wheezing and dyspnea as a result of a large colonic mass causing upstream dilation and severe compressive atelectasis. Based on the patient's smoking history and wheezing on exam, the physicians anchored on the diagnosis of a COPD exacerbation despite the lack of a COPD history or radiographic findings to suggest an obstructive pulmonary pathology. Anchoring bias is a common source of diagnostic error among physicians and it is important to always establish a broad differential diagnosis – especially when patients fail the first line of treatment. In addition, this case underscores the importance of CRC screening in patients, as she herself had no prior screening and unfortunately developed CRC.
1544 Klippel-Trenaunay-Weber: Rare Congenital Syndrome Causing Persistent Rectal Bleeding
Authors: Kataria Archish , Patel Harsh D. , Wright Randy P.
Published: October 2019

INTRODUCTION:

Klippel-Trenaunay Weber syndrome (KTS) is a rare congenital disorder characterized by a triad of cutaneous capillary malformation (port-wine stain), venous malformations and limb hypertrophy. Diffuse vascular malformations of the gut in KTS can lead to gastrointestinal (GI) bleeding ranging from minor to life threatening hemorrhage necessitating surgical intervention. We describe a case of persistent rectal bleeding and iron dependent anemia in a patient with KTS.

CASE DESCRIPTION/METHODS:

A 32-year-old female with previous diagnosis of KTS was seen for recurrent hematochezia and iron deficiency anemia. A recent colonoscopy demonstrated non-bleeding arteriovenous malformations (Figure 1), presumed to be the source for the recurrent rectal bleeding episodes. On exam, she appeared pale, had a right hip deep purple telangiectasia, right posterior thigh palpable mass without visible varicosities and no limb hypertrophy. Her laboratory tests revealed: Hb: 9 g/dl, mean corpuscular volume: 75.0 fl, ferritin: 3 ng/ml and serum iron: 22 mcg/dl. CT abdomen/pelvis showed diffuse thickening of the rectum and sigmoid colon with scattered mural calcifications. A repeat colonoscopy demonstrated non-bleeding large circumferential vascular malformation extending from the dentate line to about 20 cm in the rectum (Figure 2) and multiple soft, pale lymphatic blebs in the colon and rectum (Figure 3). Her iron deficiency anemia from chronic blood loss was treated with oral and IV iron therapy. Despite conservative therapy, patient continues to bleed intermittently but has decided against surgical intervention at this time.

DISCUSSION:

GI hemorrhage occurring in association with KTS is an uncommon cause of rectal bleeding but is the most common symptom and potentially life-threatening emergency of KTS involving the gut. Investigation should begin with visualization of the entire GI tract for localization and extension of the disease. Angiography remains the gold standard and carries the advantage of allowing therapeutic interventions to control bleeding. The management of GI vascular malformations in KTS depends on the frequency and severity of blood loss requiring transfusions. Conservative management and iron supplements may be sufficient in the patient who presents with occasional non-debilitating bleeding. Transfusion dependency and life-threatening bleeding episodes necessitate definitive surgical therapy which involves resection of the diseased bowel.
1555 Intestinal Spirochetosis: A Call to Unravel the “Spiral” of Undetermined Significance
Authors: Cancio Anthony T. , Cruz Crystale J.
Published: October 2019

INTRODUCTION:

Intestinal Spirochetosis (IS) is a rare incidental finding on routine biopsies of the colon, thought to be a commensal organism more prevalent among those with HIV, immunocompromised, or those in developing countries. Anecdotally, it does not seem to be widely known among practicing gastroenterologists, and in those who have encountered it, their management has varied widely. The classic histologic finding is a fringe-like attachment of densely packed filamentous spirochetes on the surface epithelium of the large intestine. Identification can be done with H&E staining, but confirmation requires Warthin-Starry staining. Although clinical presentation varies, often patients are asymptomatic and have an endoscopically normal appearance.

CASE DESCRIPTION/METHODS:

In this case report, we present a 37 year old otherwise healthy homosexual female with intermittent hematochezia and RLQ pain and a family history remarkable for polyps in her sister (36), and father who was diagnosed with colon cancer in his 50s. Colonoscopy was remarkable for punctate ulcers on her IC valve and cecum, with biopsy findings of “chronic inflammation and architectural distortion” suspicious for Crohn's. She was started on Apriso BID, and on second read, the pathologist stated, ‘of note, we also identify organisms morphologically consistent with intestinal spirochetosis (Brachyspira), confirmed with a Warthin Starry stain, with an appropriately positive control. Intestinal spirochetosis usually is an incidental finding and the organisms are generally not considered pathogenic'. Consideration was given to treat the patient with a course of Flagyl, however, the patient was no longer symptomatic and on repeat colonoscopy the ulcers had resolved. Biopsies taken of the involved area again demonstrated Spirochetosis.

DISCUSSION:

While often regarded as a clinically insignificant finding, not enough is known about IS to make firm conclusions about the relevance of this organism. IS has been associated with IBS in a general population in Sweden1, and a retrospective case-control study in Japan demonstrated a strong association between IS and Sessile Serrated Adenomas/Polyps2. This case sheds light on the fact there is a lack of awareness and understanding of this organism among all involved sub-specialties. Further studies on this potentially pathogenic organism need to be carried out.
1557 Not Your Average Colon Cancer: Diffuse Large B-Cell Lymphoma in a Terminal Ileum Mass and Colon Polyp
Authors: Gordon Benjamin , Wan David
Published: October 2019

INTRODUCTION:

Although the GI tract is a common site of extranodal non-Hodgkin lymphoma, primary ileocolonic lymphoma is rare among GI malignancies. Here, we report the case of a man presenting with abdominal pain diagnosed with diffuse large B-cell lymphoma (DLBCL) in his terminal ileum and sigmoid colon on colonoscopy.

CASE DESCRIPTION/METHODS:

A 72 year-old male with type 2 diabetes mellitus and recurrent UTIs presented with several weeks of abdominal pain and rectal bleeding. A colonoscopy 7 years prior showed diverticulosis. He had a 10 pack-year smoking history (quit 35 years prior). Family history was notable for a father with prostate cancer. Exam showed abdominal tenderness in the right lower quadrant. Laboratory work-up was only notable for ESR 25 and CRP 1.1. CT abdomen/pelvis demonstrated wall thickening in the cecum/ascending colon with surrounding inflammatory change and reactive adenopathy. Colonoscopy showed an ulcerated 2.0 × 1.8 cm mass in the terminal ileum, involving one-third of the lumen circumference (Figure 1). A 1.0 cm semi-pedunculated polyp was found in the sigmoid colon (Figure 2). Pathology of the ileal mass was consistent with DLBCL, non-germinal center B cell origin; pathology of the sigmoid polyp was tubular adenoma with large atypical lymphoid submucosal cells, suggestive of lymphatic involvement.

DISCUSSION:

The ileocolonic area is the least common site of primary GI lymphoma, accounting for only 0.3-0.5% of malignancies found there. Most patients present with abdominal pain, lower GI bleeding, or weight loss. GI lymphoma is more common in men, age 60-70s. Other risk factors are immunosuppression, chronic viral illness, H. Pylori, IBD, and Celiac disease. CT is the mainstay in diagnostic imaging. However, radiographic and endoscopic appearance cannot differentiate GI lymphoma from other malignancy; biopsy is the only way to confirm diagnosis. DLBCL is the most common subtype, with mantle cell and follicular lymphoma less prevalent. There is no standard treatment, although surgery is generally performed given risk of spontaneous perforation. Chemotherapy is often offered alone or adjuvantly as disease usually extends beyond local fields. Though our case has some typical features of GI lymphoma, ileocolonic involvement is very uncommon, and occurrence in multiple areas is rare, found in less than 10% of primary GI lymphomas. Thus, this case is unique, as the patient had an ileal mass as the primary site of DLBCL with a polyp in the sigmoid, suggesting lymphatic spread.
1560 Sessile Serrated Polyposis Syndrome (SPS) and Sessile Serrated Polyps (SSPs): Features, Variations in Detection Rate, and the Associated Risk of Both Synchronous and Metachronous Neoplasia
Authors: Alansari Tarek H. , Alansari Ahmed , Khan Gulam
Published: October 2019

INTRODUCTION:

Colorectal cancer (CRC) is the second most common cancer worldwide, accounting for 8% of all cancer related deaths. Sessile serrated polyposis syndrome (SPS) is a genetically inherited disease. The actual prevalence is unknown but is estimated to be 1 in 2000 to 3000

CASE DESCRIPTION/METHODS:

63 year old female with no family history of colon cancer, presented for a diagnostic colonoscopy after a positive fecal occult blood test (FOBT). FOBT was done for screening purposes. Patient had a negative FOBT X 3 a year ago. Colonoscopy showed 10 polyps. All polyps were resected with different techniques based on size, features and location. All polyps came back as sessile serrated polyps. 6 polyps showed features of cytologic dysplasia. 5 were proximal to the Sigmoid colon (1 was >20 mm in size and 3 were >10 mm in size).

DISCUSSION:

Based on a growing body of data, sessile serrated polyps (SSPs) have a higher prevalence than previously thought. Whether sporadic or part of the sessile serrated polyposis syndrome (SPS), SSPs are associated with increased risk of synchronous and metachronous neoplasia. A recent study looked at the synchronous burden of large (≥ 20  mm) SSPs in patients without SPS. The study found that 67/146 patients (45.9 %) had SPS, 53/146 (36.3 %) had a solitary SSP, and 26/146 (17.8 %) were categorized as oligo-SSP. Dysplasia in large SSPs was frequent in all groups (41.1 % overall). SPS was recognized by referring endoscopists in only 9.0 % of cases. Patients meeting the World Health Organization criteria who elect long-term endoscopic surveillance should receive annual colonoscopy after the diagnosis is established. Surgery is indicated when CRC is diagnosed or the number of polyps makes endoscopic control unfeasible. White-light endoscopy is considered the gold standard for detection and removal of colorectal lesions to prevent CRC development. However, detection of small adenomas (<5 mm) and SSPs is difficult as conventional endoscopy relies on the experience of the endoscopist. As a result, the reported adenoma detection miss rate for the general population is relatively high (27%). This underscores the necessity of improving endoscopic detection strategies. In a randomized controlled trial, 86 patients with SPS underwent tandem high-definition (HD) colonoscopies from February 2015 through July 2016 at 7 centers in Spain. It was found that panchromoendoscopy increases detection of polyps (mostly of small serrated lesions) and should be considered in patients with SPS.
1567 A Case of Gastrointestinal Amyloid Causing Colocolic Intussusception in an Adult
Authors: Laszkowska Monika , Garcia-Carrasquillo Reuben
Published: October 2019

INTRODUCTION:

Intussusception is very rare in the adult population. It is typically associated with a pathologic lead point, most commonly a malignant lesion. To our knowledge, colocolic intussusception due to gastrointestinal amyloidosis has not been reported.

CASE DESCRIPTION/METHODS:

This is a case of a 57-year-old man with kappa light-chain (AL) amyloidosis with biopsy-proven myocardial involvement who was initially admitted for congestive heart failure exacerbation and was being managed with ionotrope-assisted diuresis. Five days into his hospitalization, he developed sudden onset abdominal cramping, nausea, non-bloody vomiting, and melena. Physical exam revealed no abdominal tenderness and maroon stool in the rectal vault. Laboratory testing was notable for a hemoglobin decline from 10.2 g/dL to 7.7 g/dL over the course of one day. A CT of the abdomen and pelvis showed a 6 cm segment of distal transverse colon with irregular mural thickening and an apple core lesion, initially concerning for malignancy. A colonoscopy was done, and a protruding, large mass with dusky mucosa was identified in the transverse colon concerning for intussusception. Re-review of CT imaging did suggest a region consistent with intussusception. The patient underwent a laparoscopic extended right colectomy to remove a hemorrhagic transverse colon mass. Pathology of the excised segment showed two foci of hemorrhagic infarction, including a large polypoid lesion, associated with severe perivascular amyloidosis.

DISCUSSION:

AL amyloidosis rarely involves the gastrointestinal tract, and intussusception secondary to amyloidosis is extremely rare. It has been described as a possible complication in the small bowel, but to our knowledge this is the first report of amyloid causing colocolic intussusception.
1602 Mantle Cell Lymphoma Presenting as Intussuscepting Colon Mass
Authors: Smith Brandon , Reilly Kyle , Baker Elena , Deeken Amy H. , Dan Adrian
Published: October 2019

INTRODUCTION:

Mantle Cell Lymphoma (MCL) is a non-Hodgkin lymphoma accounting for 2.5% of lymphoid neoplasms in the United States. Primary gastrointestinal (GI) lymphomas account for 1-4% of all GI malignancies, with few reports of primary mantle cell lymphoma presenting as a single colonic mass and none to our knowledge with colon-colonic intussusception as the presenting finding. Accurate and timely diagnosis is imperative because MCL has rapid progression and early chemotherapeutic intervention results in improved patient outcomes.

CASE DESCRIPTION/METHODS:

A 61-year-old male presented with 1 month history of nonspecific right sided abdominal pain. Computed Tomography (CT) of the abdomen identified an intussuscepting mass of the proximal ascending colon and an additional 8mm hepatic lesion. Colonoscopy identified a large mass in the corresponding area of colon identified on CT. Histology and immunohistochemistry of biopsied specimen diagnosed MCL. Planned surgical intervention was deferred and the patient was referred for oncologic evaluation and treatment.

DISCUSSION:

We report the first case to our knowledge of MCL presenting as colon-colonic intussusception and discuss the work-up of this rare lymphoma that clinicians may be required to diagnose and manage. This report serves as a reminder to maintain a broad differential inclusive of uncommon diseases and unanticipated pathology. Practicing with a thorough understanding of medical principles and clinical acumen is essential for optimal patient care and, as demonstrated in this case, preventing a potentially unnecessary surgical intervention thus delaying appropriate chemotherapy.
1603 Abdominal Pain in a Patient With Marfan Syndrome
Authors: Itani Wafic , Tageldin Omar , Mansoor Muhammad Sohail , Parsa Nour , Alexandre Cassidy
Published: October 2019

INTRODUCTION:

Marfan syndrome is an inherited systemic disease affecting the aorta and multiple organ systems. Aortic dissection is the leading cause of mortality in Marfan syndrome. We describe a case of person well known to have Marfan syndrome, who had abdominal pain and diarrhea and eventually turned out to have type B aortic dissection.

CASE DESCRIPTION/METHODS:

This is a 33-year-old female known to have Marfan syndrome presenting with one week of dark diarrhea and nausea. Patient also had prior to presentation one day of crampy, sharp lower back and abdominal pain. CT scan abdomen and pelvis with IV and oral contrast done showed mild bowel wall thickening involving the ascending colon. Patient underwent EGD and colonoscopy were unremarkable. After the colonoscopy, she developed extreme abdominal pain in her lower quadrants radiating to the back. CT angiogram chest abdomen pelvis showed intact vasculature, but showed interval development of a moderate amount of new proteinaceous fluid seen within the pelvis, the hepatic and the splenic flexure. Patient underwent emergent open laparotomy for a concern of colonic perforation post colonoscopy. Patient was found to have partial bowel obstruction with a band of adhesion that came across the transverse colon. She underwent lysis of adhesions. Her abdominal persisted after the surgery, but was manageable with pain medications, so she was discharged home. Two days later, she presented with severe chest pain radiating to the back. Due to the high level of suspicion, she underwent CT angiogram chest abdomen pelvis showing aortic dissection arising just distal to the origin of the left subclavian artery and extending inferiorly along the abdominal aorta to the level of the right common iliac artery. Patient underwent emergent endovascular repair of the descending aortic dissection. Patient did well post operatively and was discharged home.

DISCUSSION:

Aortic dissection is a well known complication of Marfan syndrome, but only 10% of aortic dissections occur distal to the left subclavian. New abdominal pain in patients with Marfan should raise suspicion for aortic dissection, especially when the pain radiates to the back. Free fluid in the abdomen post colonoscopy should not be only seen as colonic perforation, but also a sign of vascular complication in patients with Marfan. Even when CT scan was negative a few days ago, repeating CT scans in the appropriate clinical setting can be life-saving.
1608 Double Trouble: A Rare Case of Recurrent Ischemic Colitis Due to Pseudoephedrine
Authors: Shehata Alexandre , Mallipudi Rajiv , Khan Qamar , Itidiare Michael , Alquran Lance , Matin Sirawar , Nathan Swami
Published: October 2019

INTRODUCTION:

There are 10 reported cases of ischemic colitis due to pseudoephedrine. We present the first case of recurrent ischemic colitis due to pseudoephedrine.

CASE DESCRIPTION/METHODS:

A 64-year-old female with past medical history of hypertension, seasonal allergies presented to the ED with two days of worsening severe left lower quadrant pain and hematochezia. Her medications included rosuvastatin, HCTZ, and fexofenadine hydrochloride/pseudoephedrine hydrochloride (Allegra-D). On admission she was afebrile and normotensive. Physical exam showed mild tenderness in the left lower quadrant, no rebound tenderness, rigidity or peritoneal signs. Hemoglobin was 14.9 g/dL with leukocytosis at 15,100/µl. A CMP, hepatic panel, and pancreatic enzymes were unremarkable. A CT scan revealed diffuse edema with surrounding infiltration of fat in the bowel in the region of the splenic flexure and proximal descending colon, consistent with ischemic colitis. Patient was made NPO and started on IV fluids and antibiotics. Her bleeding subsided. It was suspected that the pseudoephedrine in the Allegra-D may have induced vasoconstriction of the bowel. Allegra-D was discontinued and she improved with conservative care and discharged four days later. She was advised to avoid vasoconstrictors such as pseudoephedrine and switched from Allegra-D to Allegra. Unfortunately, seven years later the patient presented again with similar complaints of abdominal pain and hematochezia. She reported taking Claritin-D (loratadine and pseudoephedrine) for allergies. A CT angiogram displayed normal vasculature. A colonoscopy showed ulcers in the sigmoid area with denuded mucosa with sharp margins. Biopsy revealed colonic inflammation, regenerative changes of the crypt with mucin depletion, and the presence of a fibrin thrombus. These findings were consistent with ischemic colitis. The patient had a score of 11 on the Naranjo Scale suggesting that the ischemic colitis was caused by an adverse drug reaction. She was switched from Claritin-D to regular Claritin and symptoms resolved without hospitalization.

DISCUSSION:

It is unprecedented for a patient to have unintentional pseudoephedrine induced ischemic colitis on two separate occasions. The minute nuances in branding can mislead patients into thinking that a medication does not contain certain agents – in this case pseudoephedrine – and lead to adverse health outcomes. It is our duty to carefully reconcile these medications, and educate patients in order to prevent such adverse events.
1630 Rectal Duplication in a Middle-Aged Adult Presenting With Constipation and Abdominal Mass After Hysterectomy
Authors: Sirimongkolkasem Jarongkorn , Tantiphlachiva Kasaya , Sanpavat Anapat , Patcharatrakul Tanisa , Gonlachanvit Sutep
Published: October 2019

INTRODUCTION:

Alimentary tract duplications are rare congenital malformation that usually presented since childhood.

CASE DESCRIPTION/METHODS:

A 43–year-old female presented with constipation and progressive enlargement of abdominal mass for 4 years. Her constipation symptoms started after she underwent hysterectomy for myoma uteri. She had straining and fecal soiling that was refractory to laxatives. Physical examination revealed a 25-cm non-tender hard mass at mid-lower abdomen. Digital rectal examination showed anal wink, normal sphincter tone, and empty rectum. Paradoxical anal sphincter contraction was presented while pushing. Other physical findings were unremarkable. CT abdomen showed marked dilatation of rectosigmoid colon with feces content with an abrupt change of caliber at upper rectum. Small bowel was not dilated. Barium enema study was shown in Figure 1. Colonoscopy showed a 1.5-cm opening of a large blind pouch at 10 cm above anal verge. Anorectal manometry revealed dyssynergic defecation type II with rectal hyposensitivity with delayed balloon expulsion time. The patient underwent a complete transabdominal resection of the duplication with temporary loop sigmoid colostomy. Gross findings showed a large uniloculated cyst (Figure 2). Pathological findings showed a cystic lesion lined by complete colonic wall (Figure 3).

DISCUSSION:

Rectal duplications are rare congenital anomalies (1/200,000 live births) and seventy percent of them are diagnosed before the age of two. They can be classified as type I (cystic) and type II (tubular) with or without communication to rectum or perineum. The wall of the duplications is typically lined with complete rectal wall. Surgical removal is indicated as it prevents septic and carcinogenic complications [1]. Our patient’s symptoms interestingly occurred late in adulthood after surgery. Removal of uterus and myoma uteri might change the angle of the duplication’s opening. Also, the presence of dyssynergic defecation might contribute and cause gradual accumulation of fecal content inside. Three months post-operative anorectal manometry still showed dyssynergia but improved rectal sensitivity. At present, our patient has bowel movement every 1-2 days per colostomy with minimal usage of laxative and is currently undergoing biofeedback training before colostomy closure.
1638 Post-Colonoscopy Diverticulitis: A Rare Complication
Authors: Mohan Neena , Goldstein Jack
Published: October 2019

INTRODUCTION:

Post-colonoscopy diverticulitis is a rare but potentially significant complication. We report a case of colonoscopy-induced diverticulitis in a patient with no prior history of diverticulitis.

CASE DESCRIPTION/METHODS:

A 59-year-old female with a past medical history of hypertension, hypothyroidism and gastroesophageal reflux disease presented for a screening colonoscopy. Colonoscopy findings included a few small and large-mouthed diverticula in the sigmoid colon, a 4mm sessile polyp in the sigmoid colon removed with cold biopsy forceps, and non-bleeding grade I internal hemorrhoids. Pathology of the polyp returned as tubular adenoma. Two days post-procedure, she reported worsening lower abdominal pain as well as nausea and was recommended to go to the emergency room. On arrival, she was afebrile and hemodynamically stable. She was noted to have tenderness to palpation along her lower abdomen, greatest in the left lower quadrant. She denied fevers, chills or rectal bleeding. Labs were significant for a white blood cell count of 11.63 × 103/μL (reference range 4.5-11 × 103/μL). CT abdomen/pelvis with IV contrast showed inflamed diverticulum within the sigmoid colon with surrounding inflammatory changes, consistent with uncomplicated sigmoid diverticulitis. She was discharged home with a 10 day course of ciprofloxacin and metronidazole, and was doing well at her follow up visit.

DISCUSSION:

Although colonoscopy-induced diverticulitis is a rare finding, it is important to consider it as a complication in patients with symptoms after colonoscopy. Potential causes of post-colonoscopy diverticulitis include barotrauma, multiple attempts for intubation, and direct pressure of the scope. Another possible cause is reactivation of silent diverticulitis, with air insufflation unsealing micro-perforations in diverticula. Prior history of diverticulitis is associated with incomplete colonoscopy and can be a risk factor for developing diverticulitis; this is likely due to deformed colonic architecture from prior severe inflammation. Our patient had no prior history of diverticulitis, and presented with diverticulitis two days after her first colonoscopy. More research needs to be done on the risk of post-colonoscopy diverticulitis in those without a prior history of diverticulitis, as the prevalence of this complication is likely higher than reported.
1646 Primary Colorectal Diffuse Large B-Cell Lymphoma: A Rare Presentation of a Rare Colonic Neoplasm
Authors: Mellor Thomas , Fawley Ryan
Published: October 2019

INTRODUCTION:

Diffuse Large B Cell Lymphoma (DLBCL) is the most common subtype of non-Hodgkin lymphoma accounting for 25% of cases. Of those, only one third are found to have a primary extranodal source. While this is known to arise from the stomach, a colorectal primary site is exceedingly unique. We present the case of primary colonic DLBCL diagnosed in a patient admitted for hematochezia.

CASE DESCRIPTION/METHODS:

An 85-year-old female with coronary artery disease on aspirin and diverticulosis presented to the emergency room with acute hematochezia and left lower quadrant (LLQ) abdominal pain. She was hemodynamically stable with reproducible LLQ tenderness and rectal exam confirming bright red blood. Labs were pertinent for leukocytosis and hemoglobin of 12.1 g/dL down from a baseline of 14.4 g/dL. Contrasted abdominal CT revealed a 4.1 cm soft tissue mass in the ascending colon with extravasation of contrast consistent with active bleeding. Due to concern for a malignant bleeding etiology, interventional radiology performed CT angiography, but were unable to identify an active arterial source. The patient continued with hematochezia and was taken for urgent colonoscopy. Within the ascending colon, a 5cm non-obstructing, fibrous mass with central ulceration was identified and biopsied. Colorectal surgery was consulted; due to concern for recurrent bleeding a right hemicolectomy was performed the following day. Final pathologic diagnosis revealed primary colonic DLBCL with local lymph node involvement. PET/CT showed complete resection of disease and, through multidisciplinary shared decision making, further treatment or surveillance was not pursued. At follow up the patient is doing well without recurrent symptoms.

DISCUSSION:

Primary colorectal DLBCL accounts for less than 0.3% of all cancers involving the large intestine. While data is limited, the majority of patients are male between the 5th and 7th decades of life. Symptoms are nonspecific with few cases discovered due to overt bleeding. Endoscopic appearance is variable including mucosal nodularity, ulceration or a mass with or without ulceration, which can mimic adenocarcinoma. Due to the abundance of lymphoid tissue, most lesions involve the cecum and ileocecal valve. Diagnosis of primary colonic DLBCL can include local lymph node involvement, but distant nodal disease must be excluded. The mainstay of treatment is surgical resection with adjuvant chemotherapy, however, due to patient age and preference a conservative strategy was pursued.
1657 Acute Drop in Hemoglobin Requiring Transfusion an Odd Presentation of Metastatic Breast Cancer to the Colon in Form of Colon Polyps
Authors: Harris Elizabeth , Boktor Moheb , Burstein Ezra , Hammer Suntrea
Published: October 2019

INTRODUCTION:

Breast cancer (BC) is the leading cancer and second most common cause of cancer deaths in women. It can present with metastases to other organs. However, BC metastases to the colon are uncommon. Lobular carcinoma, comprising 10% of BC, is most commonly spread to gastrointestinal tract (GIT). We present a case of a patient whose recurrent metastatic lobular adenocarcinoma presented as colon polyps.

CASE DESCRIPTION/METHODS:

A 59-year-old female was diagnosed in 2006 with stage IIIC grade 1 estrogen (ER+), progesterone receptor positive (PR+), and HER-2/neu negative (Her2-) invasive lobular BC of left breast and treated with left modified radical mastectomy, chemo and radiation therapy to left chest wall. She was in remission since 2007 and on maintenance hormonal therapy. She presented in late 2018 with shortness of breath and fatigue secondary to anemia. She had a history of roux and Y gastric bypass. She was admitted to the hospital with symptomatic anemia, drop in HGB 8.3 to 5.5 though she received blood transfusion a week prior. A full hematologic workup was unrevealing including bone marrow biopsy. She required multiple transfusions and hospitalization in 2019. CT scan of abdomen and pelvis revealed no abnormality in the colon. She underwent EGD and colonoscopy. EGD revealed esophagitis and prior gastric bypass without evidence of bleeding. Colonoscopy revealed numerous polyps throughout colon, all removed. Pathology on these polyps showed metastases of ER+, PR+, HER2- BC. She underwent re-staging with biopsy of a para-aortic lymph node and skeletal survey, both of which showed metastatic disease. After colonoscopy with polypectomy her anemia improved. She has subsequently been started on palliative chemotherapy.

DISCUSSION:

This is a unique case of metastatic BC with severe anemia due to colonic metastases. To our knowledge, only a handful of case reports exist describing similar presentations. BC rarely metastasizes to GIT and when it does it spreads to the stomach as linitis plastica. Metastases of BC to the colon are less common, although there is a case reports metastatic BC being diagnosed based on a single colon polyp and colonic obstruction due to large metastatic masses. Our case highlights the importance of screening for GIT metastases that may not occur until many years after the initial BC diagnosis. Moreover, given the propensity of lobular BC to metastasize to GIT, more frequent screening endoscopies may be beneficial to these patients.
1658 Colonic Metastatic Disease Masquerading as Immune Checkpoint Inhibitor-Mediated Colitis
Authors: Hastie Elizabeth , Rubin Joshua
Published: October 2019

INTRODUCTION:

The use of immune-checkpoint inhibitors (ICIs) in the treatment of advanced cancer has increased exceptionally since ipilimumab was first approved for melanoma in 2011. As the prevalence of patients being treated with ICIs rises so too have their immune related adverse events (irAEs). Clinicians are now faced with the challenge of accurately and promptly recognizing irAEs. With immune-mediated diarrhea and colitis being two of the most common irAEs, an algorithm for their treatment has already been established; however, it is important for clinicians to maintain a broad differential diagnosis when caring for a patient on an ICI with colitis symptoms.

CASE DESCRIPTION/METHODS:

A 48-year-old woman with a history of metastatic, refractory, triple negative, BRCA positive breast cancer was started on pembrolizumab four years after being diagnosed with breast cancer. 18 months after initiating treatment with pembrolizumab, she developed loose, watery stools. Cross sectional imaging revealed mild, circumferential wall thickening of the proximal ascending colon. A gastrointestinal pathogen nucleic acid detection test was negative, and she was started on a two-week course of budesonide for presumed immune checkpoint inhibitor-mediated colitis (IMC). Her symptoms progressed with bright red blood per rectum and abdominal cramping. Treatment for IMC was escalated with a prednisone taper followed by infliximab infusion. 6 weeks after being treated for IMC, her hemoglobin was 7.6 and ferritin 4. She was referred to gastroenterology for iron deficiency anemia. Repeat abdominal CT revealed increased colonic wall thickening. Colonoscopy revealed an obstructing, ulcerated mass in the ascending colon. Pathology identified poorly differentiated adenocarcinoma consistent with a breast cancer metastasis. She underwent right hemicolectomy 6 months after the initial CT showed colonic thickening.

DISCUSSION:

Pembrolizumab is one of many ICIs that have been developed for the treatment of advanced-stage malignancies. The gastrointestinal side effects of this class of medications pose a challenge for physicians as IMC is nearly indistinguishable from many other etiologies of diarrhea clinically, and the onset of gastrointestinal symptoms ranges widely from 1 to 32 weeks after starting the medication. As the use of ICIs becomes more widespread, quick and accurate differentiation of an irAE from other life threatening pathology is of vital importance, and early colonoscopy should be considered to rule out metastatic disease.
1671 Neuroendocrine Tumours of the Anal Canal: A Catastrophic Culprit
Authors: Aujla Amreet K. , Desai Aakash , Delasos Lukas , Hong Timothy
Published: October 2019

INTRODUCTION:

Neuroendocrine (NE) tumors within the gastrointestinal (GI) tract are a rare type of GI malignancy with an estimated incidence of 2.5–5 per 100,000 people per year. 45% NE tumors arise in the small intestine, with the incidence decreasing throughout distal portions of the GI tract. Anal NE tumors represent 1% of all malignancies of the anal canal and are found incidentally on endoscopy. The rarity of this disease has led to a lack of sufficient data available to help guide therapy. Thus, the prognosis associated with NE tumors has remained poor throughout all stages of the disease. We present a case of anal NE carcinoma with disease recurrence after multiple lines of systemic treatment and salvage immunotherapy.

CASE DESCRIPTION/METHODS:

A 58-year-old female presented with complaints of constipation and mild rectal bleeding. She underwent a colonoscopy that revealed a 2 cm mass about 1 cm from the anal verge. Biopsy of the anal mass demonstrated high-grade NE carcinoma with small cell features. Staging computed tomography (CT) scan showed no metastases. Magnetic resonance imaging (MRI) of the brain was negative for metastasis. She underwent 4 cycles with cisplatin and etoposide as well as prophylactic cranial irradiation. Follow up CT scan showed an adequate response to initial therapy. However, three months later, repeat imaging showed new left retroperitoneal lymphadenopathy with biopsy revealing recurrent NE carcinoma. She again underwent therapy with cisplatin and etoposide as well as radiation therapy to the area of local recurrence. Repeat imaging showed absence of disease recurrence. The patient remained disease free for the next six months, until follow up imaging revealed a new left adrenal mass and retroperitoneal nodule. MRI of the brain showed brain metastasis. She began therapy with topotecan and cranial radiation, but due to a mixed response to treatment she was transitioned to temozolomide. Therapy continued but ended soon after progression of disease was noted. As a last attempt, she underwent immunotherapy with pembrolizumab but was transitioned to hospice care after the onset of rapid clinical progression of her disease.

DISCUSSION:

There remains a lack of treatment options beyond standard chemotherapy for this disease. Although she had an initial response to treatment, prognosis for anal NE carcinoma remains grim. This case illustrates the difficulty in management of this disease. Novel approaches in treatment are much needed.
1675 A Rare Case of Rectal Adenocarcinoma With Isolated, Asynchronous Metastasis to the Temporal Bone
Authors: Gajula Prianka , Mahmood Ali
Published: October 2019

INTRODUCTION:

Metastatic disease only to the bone without other organ involvement in colorectal cancer patients is extremely rare. Isolated, asynchronous metastasis to the temporal bone, without involvement of the liver or lung is an even further deviation from the traditional presentation. We present the case of a 56-year-old lady with a history of rectal cancer in remission presenting with hearing loss, facial swelling, and facial droop.

CASE DESCRIPTION/METHODS:

The patient presented with a stage 3C rectal cancer pT3N2bM0 and received adjuvant chemotherapy based on her pathology. The disease was in complete remission, without evidence of any CT, PET, or endoscopic findings of disease recurrence. Three years after her initial diagnosis, the patient began to develop swelling, with associated myalgia and hearing loss on the ipsilateral side. CT and MRI imaging revealed a mass in the right temporal bone, eroding into the bony architecture with peri-orbital and temporal swelling, with inflammatory changes of the right mandibular process. A subsequent biopsy of the cranial mass was consistent with metastatic rectal adenocarcinoma. Repeat imaging had not shown any evidence of abdominal or chest disease.

DISCUSSION:

More than 90% of colorectal carcinomas are adenocarcinomas originating from epithelial cells of the colorectal mucosa. Approximately 10% of all colorectal carcinomas are mucinous carcinomas. The metastatic pattern of colorectal carcinomas is well known. In a study using more than 49,000 patients with colorectal cancer, it was found that the most common sites of metastasis involved the thoracic organs, the liver, the nervous system, and the peritoneum. Literature review reveals an overall incidence of 5–11% of bony metastasis. This figure includes both isolated skeletal metastases and those with coinciding liver and lung spread. Isolated skeletal metastases are even more infrequently seen, occurring at an estimated frequency of 1–2%. Asynchronous and isolated metastasis to the temporal bone is rare. Assi R, Mukherji D, Haydar A, Saroufim M, Temraz S, Shamseddine A. Metastatic colorectal cancer presenting with bone marrow metastasis: a case series and review of literature. J Gastrointest Oncol. 2016;7(2):284–297.
1692 Retrieval of Impacted Extraction Balloon: A Rare Complication of ERCP for Choledocholithiasis
Authors: Ali Saad Emhmed , Frandah Wesam , Mardini Houssam , Gabr Moamen
Published: October 2019

INTRODUCTION:

ERCP is an essential tool in the management of biliary disorders. A large variety of rare ERCP related complications have been reported such as an impacting a retrieval basket, and colonic perforation. We report an unusual complication of ERCP with a retained balloon and a successful endoscopic removal at subsequent ERCP.

CASE DESCRIPTION/METHODS:

A 61-year-old man was transferred from a local hospital after undergoing an ERCP for choledocholithiasis. The ERCP balloon became lodged in the bile duct during stone extraction. The endoscopist tried to retrieve the balloon by pulling on the external part of the balloon catheter, but the catheter broke. He aborted the procedure and removed the ERCP scope by cutting the balloon catheter from outside and pulled the scope out. The patient was left intubated with the balloon catheter in his mouth and was transferred to our facility. Upon arrival, the patient was taken for ERCP. A fluoroscopic film showed the extraction balloon in the right upper quadrant of the abdomen (Figure 1). The duodenoscope was introduced through the mouth next to the balloon catheter. The impacted balloon was seen emerging from the major papilla (Figure 2). It was compressing the upper ampulla, duodenum, and stomach leading to linear pressure erosions (Figure 2). We used the Spyglass direct visualization system ((Boston Scientific, Marlborough, Mass, USA) to visualize the balloon impaction site, which was obstructed by the balloon catheter and the stone (Figure 3). The bile duct was then cannulated using a 0.025-inch × 270 cm angled ERCP guidewire (Olympus VisiGlide) through a 3.9 Autotome sphincterotome (Boston Scientific). The CBD was moderately and diffusely dilated. The impacted balloon catheter was pulled using the external part of the catheter, and it was successfully removed. We placed one fully covered self-expandable metal stent (FCSEMS) (Wallflex, Boston Scientific)10 mm by 4 cm with one 7 Fr by 10 cm double pigtail plastic stent into the CBD to maintain adequate drainage. The ERCP was accomplished without difficulty. The patient was extubated, liver function test improved. He was discharged home in a stable condition. He will have repeated ERCP in 8 weeks to remove the stents.

DISCUSSION:

Retaining ERCP balloon during stone extraction is extremely rare because it is easy to deflate and remove. Up to our knowledge, it has not been reported in the literature. We have demonstrated a successful retrieval of retained ERCP balloon during stone extraction.

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