bluuebunny/crossref_metadata_2025 huggingface dataset:
1925 GIST Kidding: Primary Gastric Synovial Sarcoma Presenting as Hematemesis
Authors: Bialick Steven , Schwartz Stephen , Khiew Yii Chun , Budina Anna , Hartner Lee
Published: October 2019

INTRODUCTION:

Synovial sarcoma (SS) is an uncommon subtype of mesenchymal derived solid tumors that is characterized by its unique histologic pattern. It is most often found in the extremities and rarely, the digestive tract, which can lead to gastrointestinal bleeding. Gastric tumors of mesenchymal origin often have overlapping radiographic and endoscopic appearances, which presents a significant challenge in diagnosis. We report one of only 3 confirmed cases of primary gastric synovial sarcoma of the lesser curvature in a patient who presented with hematemesis.

CASE DESCRIPTION/METHODS:

A 26-year-old male presented with a two-week history of worsening abdominal pain and intermittent hematemesis. He denied any history of hematochezia, melena, early satiety, weight loss, recent NSAID use or alcohol ingestion. Exam was notable for epigastric tenderness without rebound or guarding. Labs revealed microcytic anemia and thrombocytopenia without transaminitis or elevated lipase. Abdominal CT showed an 8 cm mass along the posterior gastric body with suspicion for intratumoral hemorrhage, highly suggestive of a gastrointestinal stromal tumor (GIST) [Figure 1]. EGD revealed a large, ulcerated, non-bleeding, non-circumferential, submucosal mass on the lesser curvature of the stomach, also concerning for a GIST [Figure 2]. Endoscopic ultrasound showed neither hepatic invasion nor lymphadenopathy. Partial gastrectomy pathology supported the endoscopic biopsy results, which showed high grade, monophasic, atypical spindle cells with t(X;18)(SYT-SSX) chromosomal translocation by fluorescence in situ hybridization (FISH). Immunohistochemistry (IHC) was strongly positive for TLE1 staining, but negative for C-KIT and DOG-1, to which GISTs are immunoreactive, confirming a diagnosis of primary gastric synovial sarcoma [Figure 3]. He tolerated 6 cycles of sarcoma-directed chemotherapy without evidence of progressive disease.

DISCUSSION:

Intramural gastric spindle cell malignancies are difficult to distinguish from one another, and require different disease-tailored therapies. Though GISTs account for 90% of these tumors, other rare pathologies exist. These include synovial sarcomas, which are characterized by a variable degree of epithelial differentiation associated with a disease-specific gene translocation. In patients with hematemesis found to have endoscopic and radiographic findings suspicious for GIST, ICH and FISH analyses are crucial to differentiate between mesenchymal malignancies to guide effective therapy.
1926 Gastrointestinal Bleeding in a Patient With Latent Tuberculosis and Remote T-Cell Lymphoma
Authors: Castillo Gabriel , Bhakta Dimpal , Argyropoulos Kimon , Moen Farnoush M. , Williams Renee L.
Published: October 2019

INTRODUCTION:

Immunosuppressed patients such as those with malignancies are susceptible to reactivation of tuberculosis (TB), which can affect the gut. CMV should also be considered as a cause of colitis in these patients.

CASE DESCRIPTION/METHODS:

A 68-year-old man with a history of T-cell lymphoma of the kidney and nasal cavity and latent TB presented with weight loss and cough. He was cachectic and had diffuse rhonchi in the lung bases. CT of the chest showed areas of cavitation. Multiple sputum cultures positive for acid-fast bacilli (AFB) and a positive mycobacterium tuberculosis (MTB) PCR confirmed active TB infection. The patient developed repeated episodes of melena with a hemoglobin level of 5.0 g/dL, MCV of 71.5 fL, iron of 4.5 ug/dL, transferrin saturation of 1%. Colonoscopy revealed extensive diverticulosis in the sigmoid colon and evidence of a prior cecectomy with ulceration of the ileocolonic anastomosis. Biopsies showed dense mature lymphocytic infiltrate and granulation tissue with no evidence of T-cell lymphoma. A CT revealed a 4 cm segment of terminal ileum with mild wall thickening, mucosal hyperenhancement and thickened folds of a distal loop of jejunum. Stool AFB culture and MTB PCR were both positive, indicating a probable diagnosis of TB enteritis. A push enteroscopy showed a 60 mm infiltrative lesion with ulcerated bases and three smaller lesions of similar appearance on the anterior wall of the stomach along with jejunal ulceration. Ulcer biopsies revealed large cells with inclusions consistent with CMV enteritis. Stains for AFB were also positive. Biopsies of the stomach lesions revealed an ulcerative oxyntic mucosa with dense atypical lymphoid infiltrate. Markers were consistent with a diagnosis of Burkitt’s Lymphoma (BL). The patient was treated with TB therapy, ganciclovir, and R-CHOP.

DISCUSSION:

Immunosuppression due to this patient’s BL likely led to dissemination and reactivation of latent TB and susceptibility to infection with CMV. The stomach and bowel are the most common sites of extranodal involvement in BL. The incidence of TB in malignancy is highest in non-Hodgkin’s lymphoma like BL. Bowel involvement in TB is seen in less than 5% of cases in the United States. Common endoscopic findings include ileal or ileocecal disease, non-confluent involvement of the colon, and nodular mucosa with areas of ulceration. The diagnosis can be made by biopsy showing caseating granulomas, a positive TB culture or PCR result, or by clinical suspicion with improvement following treatment.
1927 A Puzzling Case of Rising Salicylate Levels
Authors: Lambert Karissa , Hamed Amira , Hamed Ahmed Said , Ali Eslam
Published: October 2019

INTRODUCTION:

Pharmacobezoar, with a prevalence of 0.4%, is a mass or concretion of medication found in the gastrointestinal tract, which can cause severe and life-threatening complications if not timely identified.

CASE DESCRIPTION/METHODS:

64 year old Caucasian female with a history schizoaffective disorder presented with shortness of breath and altered mental status following intentional ingestion of salicylates. Physical examination revealed tachycardia and tachypnea. She was disoriented. Laboratory examination revealed: partial pressure carbon dioxide 23 mmHg, pH 7.45, bicarbonate 9 mEq/L, anion gap 23 mEq/L, lactic acid 4.6 mmol/L, salicylate level 1143 ug/mL. Thyroid stimulating hormone, blood glucose, hepatic function, and renal function were normal. QTc not prolong on electrocardiography. Computed tomography (CT) of brain unremarkable. Patient was intubated for respiratory compromise. Bicarbonate drip, intravenous fluids with subsequent vasopressor requirement, and activated charcoal were initiated. Emergent dialysis started. Blood gas, salicylate level, and chemistry panel were frequently monitored. Despite dialysis, gastric lavage, and whole bowel irrigation, salicylate levels continued to be elevated >300 ug/mL at day 3. Given concern of salicylate-bezoar formation, abdominal CT performed and was unrevealing. Esophagogastroduodenoscopy was performed and revealed blood in entire stomach and a foreign body wrapped around pills, which was removed. Thereafter, there was a steady decline of salicylate level to undetectable. Hospital course further complicated by continued encephalopathy with unrevealing magnetic resonance imaging of brain and electroencephalography requiring ventilation support, and oliguric acute renal injury. Decision made by family to discontinue life prolonging measures, and patient expired after a 2 week hospitalization.

DISCUSSION:

A pharmacobezoar should be of concern with persistent elevation of the medication comprised. Specifically with salicylate bezoar, timely diagnosis and appropriate therapy is required to prevent potential serious complications, such as cerebral and pulmonary edema, renal failure, and death. Furthermore, psychiatric illnesses have been identified as risk factors. Recognizing risk factors and clinical findings may facilitate early diagnosis and treatment.
1931 The Use of Hemostat Spray in Refractory Rectal Cancer Bleeding
Authors: Serrao Steve , Rodrigues Medora , Imbertson Erick
Published: October 2019

INTRODUCTION:

We present a case of a patient with a history of T4b N0 M0 rectal cancer with diverting colostomy followed by radiation and chemotherapy. He presented with hemodynamically significant rectal bleeding.

CASE DESCRIPTION/METHODS:

A large four centimeter external fungating mass with fresh blood and clots noted on digital rectal exam. Patient had a similar episode of bleeding earlier for which he underwent IR embolization. The patient presented with 200–300 ml of bright red blood per rectum associated with tachycardia and hypotension, leading to ICU admission. The initial hemoglobin was noted to be 5 g/dl. He received 2 units of packed red blood cells (PRBC) with subsequent rise in hemoglobin to 7.8 g/dl. significant hematochezia continued, requiring an additional 2 units of PRBC. Endoscopic examination of rectum revealed that the cancer had circumferentially infiltrated the wall the entire remnant rectum. The rectum lacked distensibility. The floor and lateral surface of the rectum was covered in well-organized clots, fresh bleeding was noted along the walls of the rectum which looked pale, and necrotic (Figure 1). The heavy clot burden was removed with a combination of cold snare dissection and the use of a Roth net. The rectal mucosa was washed with water and two actively bleeding vessels on the floor of the rectum as well as friable tissue with active bleeding along the lateral walls were noted (Figure 2). To avoid contact with water in the instrument channel, the instrument channel of the colonoscope was flushed with 150 cc of air before Cook Hemospray catheter was introduced. Care was taken to avoid contact with the catheter and pools of blood or water in the rectum. We opted to disconnect the suction during the process of application. The Cook Hemospray device was then used with a spray catheter to apply a total of 25 sprays. Profusely bleeding sites were first prioritized after which the oozing friable mucosa were sprayed. The individual puffs of hemostat powder coalesced to achieve an even layer of powder over the entire surface of the rectal mucosa. This initial application achieved complete hemostasis from the vessels and the mucosa. We opted not to wash the powder 2 minutes after application. The final grayish white appearance resembled the lunar surface (Figure 3).

DISCUSSION:

Patient was downgraded from the ICU with a post procedure Hgb of 9.8 g/dl and no evidence of rectal bleeding or a drop in the hemoglobin for 72 hours post procedure, not needing additional PRBC transfusions.
1933 A Case of a Hidden Varix: Massive Duodenal Variceal Hemorrhage Requiring Emergent TIPS
Authors: Penninti Pranav , Valadez David , Gonzalez Lisandro , Walters Michael , Diallo Souleymane Y. , Walker John , Echavarria Juan , Brady Charles
Published: October 2019

INTRODUCTION:

Variceal hemorrhage is a potentially life-threatening cause of bleeding in cirrhotic patients. While typically associated with esophageal or gastric varices, clinically significant variceal hemorrhage may occasionally originate from the small bowel, colon, rectum or biliary tract. Duodenal variceal hemorrhage is an uncommon cause of GI tract bleeding and is associated with a mortality rate up to 40%. We present a case of severe duodenal variceal hemorrhage necessitating emergent transjugular intrahepatic portosystemic shunt (TIPS) and variceal coil embolization.

CASE DESCRIPTION/METHODS:

A 58-year-old female with a history of cryptogenic cirrhosis decompensated by ascites presented to the ER with melena and dull, generalized abdominal pain over 2 days. Vital signs were notable for tachycardia to 114 bpm and she was normotensive. Her abdomen was non-tender to palpation and rectal exam was notable for melenic stools. Her hemoglobin was 9.5 g/dL on presentation. She continued to have melena over the course of the day with associated tachycardia and a decrease in hemoglobin to 5.6 g/dL. She was transferred to the intensive care unit where she underwent an upper endoscopy revealing small esophageal varices with no stigmata of bleeding and a normal duodenum. However, she continued to have melena unresponsive to blood product resuscitation leading to profound hypotension. A stat CT Angiogram showed intraluminal hyperdensities within the second portion of the duodenum due to hemorrhage from adjacent varices. Interventional Radiology was consulted and performed a right hepatic vein to right portal vein TIPS. They also performed fluoroscopic guided coil embolization of large duodenal varices arising from the main portal vein. The patient’s hemoglobin stabilized and she had no further bleeding during the course of her hospitalization.

DISCUSSION:

Duodenal variceal hemorrhage is a rare and life-threatening manifestation of portal hypertension. Due to the rarity of the condition, there are no established guidelines regarding treatment. Endoscopic therapy aimed at achieving hemostasis, such as sclerotherapy and clipping have shown limited success in case reports. TIPS, as seen in this case, is a viable treatment option. Our case illustrates the importance of considering ectopic varices in cirrhotic bleeders. Moreover, it highlights the importance of utilizing angiographic evaluation for patients in whom the source of bleeding is not identified on endoscopy.
1941 Meckel’s Diverticulum in an Adult Presenting as Acute Gastrointestinal Bleeding
Authors: Palmer Quinton D. , Pandey Yadav , Goel Akshay , Kumar Ujjwal , Tharian Benjamin , Johnson Kemmian D. , Nadeem Urooba , Wadhwa Vibhor , Wang Xiaofei , Corley Kevin
Published: October 2019

INTRODUCTION:

Meckel’s diverticulum (MD) is the most common congenital anomaly of the gastrointestinal (GI) tract. MD develops as incomplete obliteration of the vitelline duct forms a true diverticulum in the small intestine. It often presents in children as painless rectal bleeding, while adults are often asymptomatic. We are presenting an unusual case of MD in an adult with acute, frank GI bleeding.

CASE DESCRIPTION/METHODS:

A 35-year-old male presented with one day of bright red blood per rectum (BRBPR), LLQ abdominal discomfort followed by a near syncopal episode. Vital signs were stable on arrival. Physical exam significant for pallor and bright red blood in the rectal vault. Initial hemoglobin was 11.6 g/dl and hematocrit 33.5%. Computed tomography angiogram (CTA) abdomen and pelvis was negative for active bleed. Initial colonoscopy showed gross blood throughout colon without an identifiable source of bleeding. Esophagogastroduodenoscopy was also negative. Patient continued to have episodes of BRBPR with progression to hemorrhagic shock. Hemoglobin and hematocrit the next day decreased to 6.1 g/dl and 17.9%, respectively. However, repeat CTA was negative for active bleeding. Repeat colonoscopy showed blood in the terminal ileum. Technetium 99m pertechnetate scintigraphy demonstrated a focal area of ectopic gastric mucosa in the distal ileum. Laparoscopic small bowel resection was performed with symptom resolution.

DISCUSSION:

While uncommon in adults, MD should be included on the differential diagnosis of adults with obscure GI bleeding. GI bleeding in MD develops as ileal mucosa is exposed to acid secretion from ectopic gastric mucosa resulting in ulceration in 11.8% of symptomatic adults. Adults often present with melena; hence it is unusual for an adult to present with frank BRBPR. Technetium 99m pertechnetate scintigraphy, also known as Meckel’s scan, is regarded as the modality of choice for diagnosis in the pediatric population, due to its sensitivity of 85%, specificity of 95%, and overall diagnostic accuracy of 90%. Meckel’s scan is less reliable in adults with a sensitivity of 62.5%, specificity of 9% and diagnostic accuracy of 46%. One study illustrated that balloon assisted enteroscopy provided the highest accuracy for diagnosis of bleeding MD in adults and should be considered the preferred modality for preoperative diagnosis. Despite its rarity, awareness and understanding of MD in adults as well as its complications is imperative and may improve patient outcomes.
1954 Hyperplastic Polyp: A Rare Case of Recurrent Iron Deficiency Anemia
Authors: Rashid Mamoon Ur , Sarvepalli Deepika , Ullah Waqas , Zafar Hammad , Hussain Ishtiaq , Hasan Badar , Ur Rehman FNU Asad , Hurairah Abu
Published: October 2019

INTRODUCTION:

Hyperplastic polyps are the most common polyps accounting for 17% of all the gastric polyps. Most polyps are asymptomatic but may present with anemia, bleeding or gastric outlet obstruction. Here, we are reporting a case of large benign hyperplastic polyp presenting with iron deficiency anemia.

CASE DESCRIPTION/METHODS:

A 69-year-old male with a history of chronic back and neck pain and GERD was evaluated for chronic iron-deficiency anemia, treated multiple times with oral and IV iron supplements. The patient had been taking NSAIDs for chronic pain. On labs, patient hemoglobin of 9 with a low iron profile. The patient was scheduled for screening colonoscopy and EGD to further investigate anemia. On EGD patient had a large polypoid lesion about 25 mm in size in the prepyloric antrum extending into the duodenal bulb, likely cause of iron-deficiency anemia. There was also a small superficial clean-based ulcer on the antral lesion. Colonoscopy showed small internal hemorrhoids. Patient was discharged home on PPI and counseled to stop NSAIDs. Pathology report of the biopsies showed fragments of a benign hyperplastic polyp, negative for H pylori. The patient was afterward referred to interventional endoscopist for EUS and polyp excision.

DISCUSSION:

A hyperplastic gastric polyp is usually an incidental finding on upper endoscopy. With a prevalence of 6.35%, they are seen equally in elderly males and females in their 60s–70s. Hyperplastic polyps are believed to occur as a result of the reactive and inflammatory hyperproliferation of gastric foveolar cells, and Helicobacter pylori are believed to be the precursor. Diagnosis is usually made based on the results of endoscopy and subsequent biopsy of the suspicious area for the histological exam. On endoscopy, they appear as an area of hyperemia with a smooth dome-shaped surface, mostly in the antral area. As the size increases, they become pedunculated and the surface gets eroded resulting in chronic blood loss and anemia. Rarely, gastric outlet obstruction occurs when the large polyps prolapse though the pylorus. Since large polyps (>2 cm) are associated with carcinoma in 0.6%–2% cases, it is important for the pathologist to look carefully for any dysplastic foci and carcinomatous changes in the tissue specimen. Once the diagnosis of hyperplastic polyp is confirmed, treatment consists of endoscopic resection of any polyp measuring >1 cm in size and eradication of H.pylori, when present.
1955 An Ulcerated Lipoma as the Cause of Obscure Gastrointestinal Bleeding
Authors: Vitolo Melissa , Coben Robert
Published: October 2019

INTRODUCTION:

GI bleeding remains one of the most common reasons for GI consultation, with top causes including peptic ulcer disease, erosive disease, angiodysplastic lesions, varices, Mallory Weiss tears, dieulafoy lesions, and malignancy. Obscure GI bleeding (OGIB), defined as recurrent or persistent bleeding or anemia despite negative endoscopic evaluation, makes up 5% of all GI bleed cases. Approximately 75% of OGIB are found to have small bowel lesions. We outline a case of a rare cause of OGIB.

CASE DESCRIPTION/METHODS:

A 78-year-old female with history of HTN, HLD, CAD, STEMI s/p DES placement, biliary colic s/p cholecystectomy, is referred to GI clinic for symptomatic anemia. She was found to have a hemoglobin of 8 g/dL from baseline 11–12 g/dL. She had been on dual antiplatelet therapy with ticagrelor until 3 months ago, now on aspirin 81 mg. Anemia workup revealed iron deficiency. CT scan negative. Started on po iron with improvement in symptoms. Denied abdominal pain, weight loss, or overt bleeding. No NSAID use. No prior endoscopy or colonoscopy. No family history of GI malignancy. An upper endoscopy and colonoscopy were done. There was antral erythema, otherwise normal EGD. Duodenal and gastric biopsies were negative. Colonoscopy only notable for extensive diverticulosis and a small tubular adenoma. Capsule endoscopy identified active bleeding in the proximal small bowel and a potential submucosal mass. Push enteroscopy revealed a long polypoid lesion extending from the third to fourth portion of the duodenum, approximately 15 mm in width and at least 100 mm in length with visible ulcerated tip. Mucosa was otherwise normal. Endoloop was applied and tissue removed with a hot snare. Pathology resulted in a submucosal lipoma. She was followed with serial blood counts and continued on iron therapy. She is doing well with continued GI follow up.

DISCUSSION:

This case of an ulcerated lipoma as the cause of an OGIB is among a handful of other case reports and seem to be similarly found in patients on antiplatelet or anticoagulation therapy. Other cases have undergone surgical resection for symptomatic lipomas, however our case suggests that perhaps in those that are able to stop antiplatelet therapy and have a lesion within reach of an enteroscope, resection of the ulcerated portion may be sufficient treatment and may avoid invasive surgery.
1960 Life-Threatening Gastrointestinal Bleeding Secondary to Kaposi’s Sarcoma of the Duodenum
Authors: Ibrahim Hanan , Ghanimeh Mouhanna Abu , Al Saheli Zaid
Published: October 2019

INTRODUCTION:

Kaposi’s sarcoma is common in patients with AIDS. Gastrointestinal involvement is not uncommon. However, a life-threatening bleeding is rare.

CASE DESCRIPTION/METHODS:

A 58-year-old bisexual male with a history of AIDS presented to the clinic with progressive dyspnea, dizziness and unintentional weight loss. He was found to be tachycardic and hypotensive. Physical exam revealed a non-tender, non-pruritic, dark purple skin lesions over his body, face and scalp. The patient was admitted for further evaluation. His initial labs revealed a Hb of 6.2 g/dl and a CD4 count of 120 cells/µL. CT scan of the abdomen and pelvis showed multiple enlarged lymph nodes in the peri aortic, right external iliac and porta-cava areas. He was initiated on HAART and a skin biopsy was performed. While inpatient, Hb dropped to 5.8 g/dl, which responded appropriately to 2 units of pRBCs. However, Hb dropped again and the patient started to have melena and hematochezia for which he was transferred to the ICU for close observation and resuscitation. A continuous infusion of pantoprazole 8 mg/hour was initiated. An EGD and colonoscopy were performed after resuscitation. The EGD showed erosive esophagitis, multiple non-bleeding gastric ulcers with a flat pigmented spot and non-bleeding duodenal erosions. The stomach and duodenum were biopsied. The colonoscopy showed old clotted blood in the entire examined colon. The patient underwent a second look EGD due to persistent melena and Hb drop which showed clotted blood in the gastric fundus, as well as a large, cratered gastric body ulcer, along the greater curve with adherent clot. Most of the clot was removed without bleeding or high-risk stigmata. Over the next few hours, the patient became hemodynamically unstable with increasing amounts melena. The interventional radiology team was consulted, and an urgent selective embolization was performed to the right gastroepiploic artery which was coursing through the ulcer. The patient stabilized and was eventually discharged with a plan of outpatient follow up. The biopsies from skin, stomach and duodenum showed proliferating spindle cells forming slit-like vascular channels within the lamina propria. HHV-8 immunostaining was positive.

DISCUSSION:

Involvement of the GI tract by Kaposi’s sarcoma is usually asymptomatic but hemorrhages, even though uncommon, have been reported. An adequate endoscopic sampling is crucial to avoid false negative results. However, severe bleeding may occur due to the hypervascularity of the lesion.
1963 Non-Cirrhotic Hepatocellular Carcinoma Presenting as Bleeding Rectal Varices
Authors: Magee Jared S. , Francis Jonathan P.
Published: October 2019

INTRODUCTION:

Anorectal sources account for 15–20% of hospital admissions for acute lower gastrointestinal bleeding (LGIB). Rectal varices are common in patients with portal hypertension, however, clinically significant bleeding occurs in only 0.5–5%. Management of rectal varices is described in several case reports but no standardized therapy exists due to the low incidence. Here we describe a case rectal varices treated by collateral vein embolization during an initial presentation for noncirrhotic hepatocellular carcinoma.

CASE DESCRIPTION/METHODS:

A 69-year-old African American male presented for weakness in the setting of 3 days of hematochezia. Medical history was notable for prostate cancer status post radiation therapy, prior hepatitis B exposure and hepatitis C status post Harvoni with sustained virologic response. Physical examination was notable for normal vital signs and gross blood on glove during rectal exam. Labs revealed a hemoglobin of 11.6 g/dl, and BUN of 18.0 mg/dl. CT abdomen was performed and notable for asymmetric rectal wall thickening, an ill-defined mass at the hepatic dome and expansion of the portal veins. He was admitted for colonoscopy in the setting of hematochezia. Liver MRI was completed, showing an abnormal heterogeneous right hepatic lobe with extensive portal vein thrombus and a 1.1 cm exophytic nodular LI-RADS 5 lesion. Tumor markers were notable for a normal CEA, and an Alpha-1-fetoprotein of >55,000 ng/ml. Colonoscopy was performed to evaluate the rectal findings on CT, revealing large rectal varices with a prominent nipple sign. Interventional radiology (IR) was consulted for embolization of a venous shunt draining bilateral hemorrhoidal veins and obtained a liver biopsy, resulting in grade II-III Hepatocellular carcinoma (HCC). Patient would ultimately fail sorafenib and lenvatinib therapy due to liver toxicity and continued tumor growth without recurrence of LGIB.

DISCUSSION:

HCC in the absence of cirrhosis has been documented in several patient populations to include chronic hepatitis B and more recently NASH. Portal vein thrombosis (PVT) is common in HCC with an incidence of 34–50%, and frequently leads to varix formation. Rectal varices are less common than esophageal and gastric varices, however can still result in life threatening hemorrhage. Given the low incidence, there are no established guidelines to define management strategies for bleeding rectal varices. Currently long term management is directed by physician expertise and available services.
1967 Unexplained Massive Recurrent Upper GI Bleeding: A Case of Missed Connection
Authors: Qamar Khola , Tiwari Abhinav
Published: October 2019

INTRODUCTION:

Erosion of an aortic prosthetic graft into the surrounding gastrointestinal structures leads to formation of Aortoenteric fistula (AEF). It occurs after months to years after aortic surgery and may be related to graft infection and can result in torrential Gl bleeding. Here we present a case of recurrent GI bleeding, the cause of which initially remained obscure despite repeated endoscopies.

CASE DESCRIPTION/METHODS:

61 y old male with PMH of peripheral vascular disease and femoropopliteal bypass on ASA and Eliquis presented with 3 days of passing black-tarry stools and dizziness. Initial hemoglobin was 7 gm/dL (normal baseline). Urgent EGD up to 2nd part of duodenum revealed clot in the stomach without any lesion or source of bleeding. EGD was repeated the next day due to ongoing melena, which again was nonrevealing. CTA also did not show any active bleeding. Eliquis was discontinued and the patient was discharged. 2 days later, he presented with ongoing melena and dizziness. EGD, however, this time revealed aortic graft eroding into 3rd part of the duodenal wall. He was transferred to a tertiary care center for repair of the fistula.

DISCUSSION:

AEF is an uncommon but life-threatening complication of aortic reconstructive surgery. Due to the anatomic proximity, most cases involve the duodenum, with the proximal suture line of an aortic prosthesis. It is imperative to inquire about the history of aortic reconstruction patients presenting with Upper GI bleeding, as these patients are considered to have an AEF until proven otherwise. In our case, the remote history of aortic reconstructive surgery was not put in the clinical perspective and aortic graft was overlooked on the CT scan. Both MRI and CT can fail to diagnose AEF and EGD has 50% sensitivity. Endoscopy should include the fourth portion of the duodenum. Prompt recognition and repair of fistula in highly critical for patient survival.
1968 Where Did the Problem Stem From? An Unusual Case of Hematemesis and Hematuria
Authors: Bhardwaj Meera , Hong Simon , Berkowitz Daniel
Published: October 2019

INTRODUCTION:

Accidental foreign body ingestion is a common problem encountered in emergency departments. Most of the time foreign bodies pass through the GI tract without any sequela; however, perforation can occur in up to 1% of cases. Here we discuss a case of a perforated viscus presenting with hematemesis and hematuria.

CASE DESCRIPTION/METHODS:

A 61 year old woman with type 2 diabetes presented to the emergency room with new onset abdominal pain, hematemesis and hematuria an hour after eating dinner at home. A CT scan was obtained on admission and was notable for periduodenal lymphadenopathy, thickening of the duodenal wall, and dense material in the right renal calyx. Upper endoscopy showed a clot in the duodenal sweep, which was unroofed to reveal a sharp foreign body that was embedded in the small bowel wall and protruded 1.5 cm into the lumen. The foreign body was removed with a snare and the mucosal defect was closed with an endoclip. On gross examination, the foreign body measured 6 cm in total length and had a dried stem-like appearance. A CT scan was repeated to evaluate for suspected perforation, which demonstrated gas around the first and second portions of the duodenum and right-sided hydroureter. The patient was managed conservatively with antibiotics, with resolution of abdominal pain. However, due to persistent hematuria, patient underwent a renal angiogram, which showed a right renal artery aneurysm for which the patient required angioembolization, cystoscopy for evacuation of clots in the bladder, and right uretral stent placement. The patient did not have any further hematemesis or hematuria, and pathology of the foreign body returned as plant-based material suspected to be a dried stem.

DISCUSSION:

In cases of GI foreign bodies, the culprit sharp objects are often chicken or fish bones, paper clips, or dental tools. In this patient, we report a case of plant matter causing viscus perforation through the duodenum and into the right kidney, presenting as simultaneous hematemesis and hematuria. Plant matter may not appear on radiographic images and might be missed on preliminary radiographic evaluations. Furthermore, this case highlights the anatomic proximity of the duodenum to the right kidney, specifically the renal calyx. Simultaneous presentation of abdominal and urologic symptoms may suggest a duodenal source. This should cue endoscopists to pay extra attention to the duodenal sweep, which can be overlooked during endoscopy.
1986 An Unusual Case of Massive Duodenal Diverticulum Bleeding: A Challenging Treatment Approach
Authors: Chaar Abdelkader , Shiari Aryan , Zamora-Sifuentes José , Bill Katherine , Barawi Mohammed
Published: October 2019

INTRODUCTION:

Duodenal diverticula are relatively common findings in the small bowel with reported prevalence ranging between 0.6–22%. The vast majority of them are asymptomatic and found incidentally. We present an unusual case of hemorrhagic shock resulting from bleeding duodenal diverticula.

CASE DESCRIPTION/METHODS:

A 46-year-old male with history of alcohol abuse presented with 1-day history of multiple episodes of hematochezia and dark tarry emesis. He had associated lightheadedness, dyspnea, diaphoresis along with 1 episode of syncope. He did not use any medications on regular basis. His heart rate was 125 beats/minute and blood pressure 99/53 mmHg. Labs included hemoglobin (Hgb) of 4.5 gm/dL, platelets 75000/mcL, creatinine 1.81 mg/dL and lactic acid 4.4 mmol/L. Patient was subsequently intubated for airway protection due to recurrent episodes of hematemesis. An esophagogastroduodenoscopy (EGD) showed 3 large diverticula in the second portion of duodenum with active bleeding noted from a non-periampullary proximal diverticulum (Figure 1). Hemostasis was achieved with epinephrine injection followed by Hemospray. A follow up arterial angiogram was unremarkable. Patient experienced recurrent bleeding within 48 hours requiring 2 additional EGDs with therapeutic interventions (epinephrine, ablation and endoclips). Repeat angiography was done due to persistent drop in Hgb. This time, an area of irregularity in one of the gastroduodenal artery branches was identified adjacent to the previously placed endoclips. Coil embolization was performed successfully with excellent results. Patient’s condition eventually stabilized without any recurrent bleed. Upon follow up, his Hgb was 10.7 gm/dL 3 weeks after discharge.

DISCUSSION:

The majority of duodenal diverticula are asymptomatic. About 1% result in complications requiring definite endoscopic or surgical intervention. Potentially fatal bleeding represents minimal proportion of these complications and its management can be challenging. Our case demonstrates an extreme example of massive gastrointestinal bleeding that was difficult to control despite multiple endoscopic interventions. Initial angiography was not successful to identify the bleeding. Applying endoclips helped to subsequently localize and control the source of bleeding in the second angiogram. Using this approach can be an invaluable asset in such conditions.
1987 A Rare Cause of Massive Upper Gastrointestinal Bleeding
Authors: Gajjar Bhavesh A. , Aasen Tyler , Goenka Puneet
Published: October 2019

INTRODUCTION:

Pseudoaneurysm (PA) is a rare, life-threatening complication of pancreatitis. Spontaneous PA rupture can cause massive bleeding, and up to 60% of massive bleeding following pancreatitis is due to rupture of PA. PA rupture may be lethal and in cases of diagnostic delayed mortality can be as high as 60 %. There are no known risk factors for PA rupture. We are presenting a case of gastrointestinal (GI) bleeding due to the ruptured splenic artery pseudoaneurysm. We believe this was a delayed complication of AXIOS stent which is a lumen-apposing metal stent (LAMS) used for cystogastrostomy.

CASE DESCRIPTION/METHODS:

A 30-year-old male with a history of walled off necrosis secondary to alcohol-induced pancreatitis presented with massive hematemesis and lightheadedness. He had undergone cystogastrostomy with LAMS placement three weeks prior. He was taking ibuprofen 800 mg daily. On presentation was in hypovolemic shock. CT scan did not reveal any findings suggestive of bleeding. Esophagogastroduodenoscopy showed bleeding from the LAMS with large clot formation in the stent. The bleeding worsened after attempting to dislodge the clot and did not stop after epinephrine injection. After stabilizing the patient, he underwent CT angiography. It showed a PA arising from the distal splenic artery, directly posterior to the LAMS (Figure 1). The patient was sent for conventional angiography, and multiple coils were placed in the splenic artery near the PA (Figures 2 and 3). He did not have further bleeding. He continued to improve during the hospitalization and was eventually discharged. The LAMS was successfully removed approximately one month after discharge with near resolution of the walled-off necrosis.

DISCUSSION:

Ruptured PA is a life-threatening complication of pancreatitis. Delayed diagnosis has a mortality of 25 to 60 %. Timely diagnosis and treatment can reduce mortality to less than15%. 4 to 10 % of patients with chronic pancreatitis may be at risk of bleeding due to PA. LAMS has been widely used for endoscopic cystogastrostomy. LAMS due to bi-flanged design stays in the place and achieves the better success of draining a pseudocyst. There are few reported cases of delayed bleeding due to ruptured PA due to LAMS. The provider should have a high suspicion of a ruptured PA once other causes of bleeding are ruled out by an EGD. An urgent CT angiography is the diagnostic test of choice. Embolization of bleeding pseudoaneurysm is the first line of therapy even in critical conditions.
1992 Hematochezia? Think Histoplasmosis
Authors: Higley Cory , Cherian Nuval , Steinberg Joshua , Jennings Joseph J. , Lewis James
Published: October 2019

INTRODUCTION:

Histoplasmosis is the most common mycosis in North America, responsible for more hospitalizations and deaths than any other endemic mycosis in the United States. While it most commonly presents with pulmonary manifestations, we present a case of a 68-year-old female with history of renal transplantation who was transferred to our tertiary-care hospital with hematochezia, abdominal cramping, and emesis.

CASE DESCRIPTION/METHODS:

A 68-year-old female with history of renal transplant on immunosuppressive medications was transferred to our tertiary-care hospital with hematochezia. Prior to arrival at our hospital, she was transfused with 2 units of packed red blood cells for a hemoglobin of 5.3 g/dL. A diagnostic nasogastric lavage was negative. She underwent a colonoscopy which did not reveal active bleeding, however the mucosa throughout the entire colon was abnormal, described as nodular with focal areas of blanching and hemorrhagic appearance. The gross appearance was concerning for lymphoma, specifically posttransplant lymphoproliferative disease given her transplant history. As a result, she was transferred to our facility for further management. Chest CT revealed mesenteric and mediastinal lymphadenopathy as well as scattered calcified and noncalcified pulmonary micronodules. She had no pulmonary symptoms. Additional work up revealed a positive Histoplasma galactomannan urinary antigen. Additional staining of colonic biopsies revealed numerous histiocytes in the lamina propria with small round intracytoplasmic yeast microorganisms (GMS and PAS positive and mucicarmine negative) confirming the diagnosis of disseminated histoplasmosis. Patient was treated initially with a two-week course of amphotericin B before being transitioned to oral itraconazole.

DISCUSSION:

Disseminated histoplasmosis is most common in patients with a history of organ transplant, HIV or immunosuppressive medication regimen. T cell dysfunction accounts for a 10-fold higher risk for dissemination of histoplasmosis with nearly 1 in 2000 acute histoplasmosis infections becoming disseminated. Early diagnosis is the key to effective treatment. A simple urinary test can rule out the diagnosis and should be among one of the first steps in the workup of such patients. We propose clinicians maintain a high index of suspicion and that histoplasmosis be considered in patients with history of immunosuppression who present with acute onset bloody diarrhea with negative work-up for another intra-abdominal pathology.
1993 Diagnosis and Management of Porto-Porto Varices in a Patient With Prior Orthotopic Liver Transplant
Authors: Drosdak Alyssa , Hill Eddie , Ismail Mayada , Al-Natour Mohammed , Post Anthony
Published: October 2019

INTRODUCTION:

Gastrointestinal variceal bleeding is a frequent complication in patients with liver disease. Small bowel varices represent a less common source of bleeding, and are often challenging to manage due to their location. We describe a case of bleeding small bowel porto-porto varices in a young patient status-post orthotopic liver transplant.

CASE DESCRIPTION/METHODS:

An 18-year-old-female patient presented with melanotic stools and a presyncopal episode. Her medical history was significant for iron deficiency anemia and biliary atresia. Associated surgical history included hepatoportoenterostomy in infancy and orthotopic liver transplantation at age two. Admission labs were significant for hemoglobin (Hgb) of 4.0 g/dL. Hepatic enzymes, INR and platelets were within normal limits. Initial colonoscopy and EGD were revealing for hematin in the cecum and colon. CT enterography showed smaller collateral veins draining into a large superior mesenteric collateral vein. This finding was confirmed by triple phase CT angiography, which also demonstrated chronic occlusion of the portal vein. The collaterals provided bypass of the thrombosed portal vein, and also included jejunal submucosal porto-porto varices. As the patient’s hemoglobin continued to drop despite blood transfusions, recanalization of the portal vein was attempted by Interventional Radiology (IR). The portal vein was stented, resulting in reduced flow through collateral vessels. The patient was taken back to the IR suite three days later as she had recurrent melena and Hgb drop. The stent had thrombosed, and a combination of chemical and mechanical thrombolysis was used to restore flow. Coil embolization of three collateral vessels from the SMV was also performed. A contrasted CT scan of the abdomen three days later revealed a patent stent with significant improvement in jejunal porto-porto varices. At her last clinic appointment two months after discharge, the patient denied further bleeding.

DISCUSSION:

This case illustrates the diagnostic and therapeutic challenges in patients with small bowel varies. This case is noteworthy as it highlights a type of collateralization, porto-porto varices, which have not been well described. Furthermore, this case occurred in a population not frequently studied: patients who previously underwent orthotopic liver transplant for biliary atresia. Recognition and appropriate treatment of associated liver conditions is crucial to increasing survival in this group.
1994 Spontaneous Intramural Intestinal Hematoma: An Increasing Phenomenon?
Authors: Florian Rosemarie , Jackson Christian
Published: October 2019

INTRODUCTION:

The development of small bowel intramural hematomas is a rare process that is often seen in the young, precipitated by abdominal trauma. Non-traumatic, spontaneous, small bowel intramural hematomas are an even rarer entity, seen in the elderly and is associated with the overuse of anticoagulants.

CASE DESCRIPTION/METHODS:

93 y/o male with past medical history of paroxysmal atrial fibrillation, deep vein thrombosis and pulmonary embolism, on anticoagulation, and diabetes mellitus type 2. He presented to the ED with abdominal pain, constipation, nausea and hematemesis with intermittent melena for 1 week. Anticoagulation was switched to edoxaban from warfarin given his unstable INR levels. Last dose of warfarin was 1 week prior to presentation. Patient denied prior abdominal trauma or NSAID use. On arrival, he had mild tachycardia and normotension. On exam, he had diffuse abdominal pain with mild rebound, no guarding. Labs were significant for coagulopathy INR > 5.5, prothrombin time (PT) > 95s, partial thromboplastin (PTT) time of 121s with stable thrombocytopenia Plt 126 (BILL/L) and hemoglobin Hgb 16.2 (g/dL). CT abdomen pelvis with contrast revealed circumferential wall thickening in the distal duodenum and proximal jejunum with no obstruction. Anticoagulation was held and he received IV fluids, fresh frozen plasma, prothrombin complex concentrate and vitamin K for coagulopathy and started on a protonix gtt. EGD revealed diffuse submucosal hematomas in the jejunum without ulcerations, confirming diagnosis of intestinal intramural hematomas. After medical management symptoms improved and he was discharged without anticoagulation.

DISCUSSION:

Spontaneous small bowel intramural hematomas are not often seen in patients admitted for acute abdominal pain. Although rare, intramural hematomas can have a devastating outcome. In this case, the patient was taking both warfarin and edoxaban, as evidenced by the lab findings. This likely doubled his risk for developing an intramural hematoma. Early imaging resulted in early diagnosis and prompt medical intervention. Prior cases have reported complications of obstruction, acute peritonitis, perforation, and hemorrhage shock. These lesions mostly affect the jejunum in 71.6% and duodenum in 29.8%. Thus, patients who present with non-specific abdominal pain and are on anticoagulant therapy, consider spontaneous intestinal intramural hematoma as a potential etiology. Early intervention may decrease complications and need of surgical intervention.
1999 Jejunal GIST: An Unusual Cause of Acute Massive Gastrointestinal Bleeding
Authors: Liu Yingheng , Shah Suraj , Weisberg Ilan
Published: October 2019

INTRODUCTION:

Gastrointestinal stromal tumors (GISTs) are rare, making up 0.1–3% of all gastrointestinal (GI) tumors. While most commonly found in the stomach, GISTs in jejunum are among the rarest subtypes. The majority of GISTs present with occult GI hemorrhage. Here we present a case of massive GI bleeding due to a jejunal GIST in a young woman with BRCA2 gene mutation.

CASE DESCRIPTION/METHODS:

A 30-year-old woman presented with 1 day of melena and symptomatic anemia. Medical history was notable for BRCA2 gene mutation. Family history was significant for colon cancer in her maternal grandfather and breast cancer in her maternal aunt. On admission, there was melena in the rectal vault and her abdomen was soft, non-tender with no palpable masses. She was anemic with hemoglobin 6.8 g/dL. Emergent EGD revealed no blood or source of bleeding identified. After a rapid bowel preparation, an urgent colonoscopy showed melena in the entire colon and examined terminal ileum, however no culprit lesion was identified. Patient was hemodynamically unstable subsequently so an urgent computed tomography angiogram was performed and revealed active GI bleeding from the jejunal artery. A 3.1 × 2.2 cm mass with peripheral hemorrhage in the left upper quadrant was seen. The patient then underwent emergent embolization of two jejunal branches. An exploratory laparotomy was subsequently performed with resection of a proximal jejunal mass. Histology confirmed a spindle-cell GIST with positive staining for c-kit (CD117). Given the size, low-grade, and mitotic rate of 1/50 high-power field, no adjuvant therapy was needed. Magnetic resonance imaging surveillance was recommended.

DISCUSSION:

Bleeding jejunal GIST is a rare cause of acute massive GI bleeding. GISTs can be particularly difficult to diagnose because of their endoscopic inaccessibility. The majority of GISTs are thought to be a result of activating mutations of proto-oncogenes c-KIT (CD117) or PDGFR-alpha. These then increase tyrosine kinase receptor activity and result in the proliferation of stem cells. No reports yet suggest a direct association between a BRCA2 germline mutation and small bowel neoplasms. This case highlights a dramatic presentation of massive hemorrhage from a GIST, especially when confined to the small bowel. Further studies are needed to establish whether an association exists between BRCA mutations and GIST as well as other small bowel neoplasms.