bluuebunny/crossref_metadata_2025 huggingface dataset:
2618 The Immigrant With Chronic Abdominal Pain: A Diagnosis of Ascaris lumbricoides
Authors: Hashmi Irma , Shor Julia
Published: October 2019

INTRODUCTION:

Ascaris lumbricoides (A. lumbricoides), a nematode affecting millions globally, is asymptomatic for years until development of high worm load when patients present with symptoms of small bowel obstruction. High suspicion is required for accurate diagnosis, especially when managing the immigrant patient. We present the case of a Pakistani immigrant who endorsed abdominal pain, lower extremity skin lesions and joint pain for several months prior to capsule endoscopy diagnosis with A. lumbricoides.

CASE DESCRIPTION/METHODS:

A 50-year-old Pakistani female with history of hypertension presented with chronic, bandlike, postprandial right upper quadrant abdominal pain associated with nausea. She also endorsed left lower extremity skin lesions and small joint pain. Basic laboratory values were normal except ALT 118. Extensive rheumatologic workup was also normal. Right upper quadrant ultrasound was benign. CT abdomen and pelvis with contrast showed irregular filling defects, with retroperitoneal and pelvic adenopathy; however, colonoscopy revealed no mass. Skin biopsy confirmed erythema nodosum (EN). A few weeks later, the patient re-presented with similar complaints and followed up in Gastroenterology clinic. EGD was without pathology, but capsule endoscopy revealed parasites in the small bowel, likely A. lumbricoides as both adult worm and blastocyst stages were seen in the small bowel. The patient was treated successfully with Albendazole.

DISCUSSION:

Infecting the pulmonary, hepatobiliary, and small intestine systems, A. lumbricoides is a common helminth infection, especially in endemic areas including the Western Pacific, South East Asia and Africa. Poor hygiene facilitates fecal-oral transmission. Humans ingest embryonated eggs, and larvae in the intestine migrate to the lungs where they are coughed up and swallowed to molt into adult form within the intestine. As the infection is largely asymptomatic, patients can carry the helminth for years. Skin manifestations, including EN, are a rare manifestation of ascariasis, with only a few case reports cited in the literature. Capsule endoscopy can be a diagnostic tool but is more expensive than stool testing. Treatment is with Albendazole. Infection with A. lumbricoides should be considered in immigrant patient populations presenting with chronic abdominal pain and atypical features such as erythema nodosum, as accurate diagnosis can lead to treatable disease.
2623 Isolated Duodenal Variceal Bleeding Secondary to Metastatic Carcinoid Tumor Obstructing the Superior Mesenteric Vein
Authors: Evans Nicole S. , Quezada Michael , Sahakian Ara , Hwang Caroline
Published: October 2019

INTRODUCTION:

Gastrointestinal bleeding secondary to duodenal varices is an uncommon finding, and is typically seen in patients with portal hypertension due to cirrhosis. We report a case of a patient without evidence of liver disease who developed significant bleeding from isolated duodenal varices caused by mesenteric venous obstruction from a carcinoid mass.

CASE DESCRIPTION/METHODS:

A 71-year-old male with a history of a metastatic mesenteric carcinoid tumor presented with recurrent gastrointestinal bleeding. He was initially diagnosed with carcinoid of the mesentery several years prior, for which he underwent resection followed by Y40 ablation of liver metastases. He had been admitted multiple times at a local hospital for recurrent gastrointestinal bleeding, for which he had undergone extensive endoscopic evaluation. He was then transferred to our facility for a higher level of care. A double balloon push enteroscopy and endoscopic ultrasound were performed with findings of a large cluster of bleeding duodenal varices in the third portion of the duodenum not amenable to endoscopic intervention. CT abdomen and pelvis with contrast and CT angiography of the abdomen showed an irregular 3 cm calcified mass at the root of the mesentery. Additionally, several branches of the superior mesenteric artery and vein (SMA and SMV) were noted to be occluded near the mass. Interventional radiology (IR) performed an IR-guided transhepatic portogram revealing obstruction of the SMV at the level of the mesenteric mass. There appeared to be a large colic branch communicating with an abnormal cluster of varices near the third portion of the duodenum. Two overlapping covered stents were placed at the large colic branch into the SMV, decompressing the varices. The patient was started on plavix, propranolol, and octreotide depot and safely discharged home without further bleeding.

DISCUSSION:

Duodenal varices are an uncommon but potentially serious complication of portal hypertension, and are most often seen as a sequelae of liver disease. The development of duodenal varices as a result of venous obstruction secondary to a desmoplastic reaction induced by a carcinoid tumor has seldom been reported in the literature. This case illustrates a noteworthy example of bleeding ectopic varices in a patient without liver disease, a rare cause of obscure gastrointestinal bleeding.
2631 Angiotensin Converting Enzyme Inhibitor-Induced Isolated Angioedema of Small Bowel
Authors: Adusumilli Radha Kishan , Patel Manishkumar , Hong Gloria , Kulairi Zain I.
Published: October 2019

INTRODUCTION:

Angiotensin-converting enzyme inhibitors (ACEi) are generally known to cause angioedema, with the face, tongue, and pharynx primarily involved. ACEi-induced small bowel angioedema is relatively rare occurring in 0.1 to 0.7% patients on ACEi.

CASE DESCRIPTION/METHODS:

Our case report is about a 34-year-old woman who was recently started on lisinopril and diagnosed with angioedema of the stomach and duodenum. The patient presented to our hospital with a 3-week history of nausea and a 2-day history of worsening epigastric pain. She also had one episode of non-bilious emesis and one episode of watery diarrhea. Her home medications included lisinopril 20 mg daily for hypertension, which she started taking 3 weeks ago. She was hemodynamically stable and physical examination revealed mild epigastric tenderness with no organomegaly, guarding or rebound tenderness. Laboratory values were significant for leukocytosis of 12,000, and normal complement and lipase levels. Abdominal computed tomography (CT) scan showed signs of findings of acute severe enteritis involving the duodenum and proximal jejunum, with no pancreatitis. Endoscopy revealed edema of the duodenum. Given the high suspicion for ACEi induced angioedema of the small bowel, her lisinopril was discontinued and the patient showed complete symptom resolution within 24 hours.

DISCUSSION:

ACEi-induced angioedema of the small bowel is a rare clinical presentation, however, it is an important differential diagnosis to consider when a patient taking an ACEi presents with nausea and abdominal pain. It is important to highlight angioedema of the small bowel can occur at any time after a patient starts taking an ACEi. Although ACEi-induced small bowel angioedema is relatively rare, its recognition is important as ACEi use is high and misdiagnosis can lead to frequent hospital visits and unnecessary surgery. The first line treatment being discontinuation of ACEi, there are other pharmacological options including icaibant, ecallantide which have unproven efficacy from the current trails. Fresh frozen plasma has shown to have success in cases where nothing has worked. The usual dose being used to treat are 2 to 4 units of fresh frozen plasma.
2634 Small Bowel Lymphoma Presenting With Perforation: A Case Report
Authors: Karim Syed S. , Singh Davinder , Bhatt Ruchi , Prasa Jarin , Rizvon Kaleem , Mustacchia Paul , Esackimuthu Venkatesh S.
Published: October 2019

INTRODUCTION:

Lymphoma account for only 1 to 4 % of neoplasms in the gastrointestinal tract (GIT), with the stomach being the most common location (68 to 75%) and the small bowel as the second most common (30 %). Among the possible presentations of GIT lymphomas, small bowel perforation is one of the most lethal and rare. Here we present a case of a patient that had a perforated jejunum secondary to lymphoma.

CASE DESCRIPTION/METHODS:

57 year old female with history of diabetes, presented with 2 days of severe abdominal pain and vomiting. Physical exam revealed peritoneal signs and absent bowel sounds. CT showed multifocal small bowel thickening, pneumoperitoneum and extraluminal contrast indicating perforation. The patient was rushed to have explorative laparotomy which revealed multiple masses along the small bowel and had resection of a perforated jejunum. Pathology revealed lymphoma. Immunohistochemical staining was positive for CD20 and CD5, and was negative for Bcl-6 and CD10. FISH analysis was negative for translocation t(11,14), t(14,18), and MYC. The patient’s wounds healed and she was eventually treated with cyclophosphamide, doxorubicin, vincristine, prednisone (CHOP) along with rituximab for 6 cycles and Intrathecal (IT) chemotherapy.

DISCUSSION:

The WHO classify small bowel lymphomas (SBL) into B-cell subtypes (90 % of cases), T-Cell subtypes and Hodgkins Lymphoma.The most common symptoms are abdominal pain (70% of cases), ileus, and weight loss. Perforation was only found in approximately 16% of cases. CT may show polypoid lesions, multiple masses, and small bowel thickening. Usually, SBL is surgically resected for both diagnosis and treatment. Historically, endoscopy has been difficult because of the location. However, with the advent of capsule endoscopy and double balloon techniques, endoscopy can potentially avoid invasive surgeries. Our patient had an acute abdomen and therefore underwent surgical evaluation. Presence of CD20 and CD5, indicated a CD5 positive B-Cell lymphoma. FISH did not show any genetic rearrangements for Cyclin D- t(11,14), a marker for Mantle cell lymphoma, nor Myc and Bcl, markers for Burkitt’s and Follicular cell lymphomas, leading to the diagnosis of DLBCL. Localized tumors undergo surgical resection followed by radiation. TNM stage IIIE or higher is treated with combination chemotherapy, CHOP and rituximab, as was our patient. SBL is a rare entity; this case provides some insight and we hope such knowledge can only improve the management of patients to come.
2642 Diffuse Large B-Cell Lymphoma Presenting as Partial Small Bowel Obstruction and a Fistula
Authors: Gajjar Bhavesh A. , Gabriel Joseph , Minhas Ahmed , Schmidt Lawrence
Published: October 2019

INTRODUCTION:

Non-Hodgkin lymphoma (NHL) is one of the most common cancers in the United States, accounting for 4% of all cancers. Diffuse Large B-Cell Lymphoma (DLBCL) the most common type of NHL. Gastrointestinal (GI) tract is a significant site of extranodal NHL and accounts for 30%–40% of all extranodal NHL. Out of this, 44 % are due to DLBCL. Ileocecal DLBCL accounts for 9.7% to 15% of total GI DLBCL. They lack specific symptoms and diagnosed when complications occur. We report a case of elderly male hospitalized for partial small bowel obstruction and a possible fistula due to DLBCL involving the ileocecal valve extending to the ileum.

CASE DESCRIPTION/METHODS:

A 75-year-old male presented with complaints of abdominal pain, nausea, and nonbilious vomiting for a day. He denied any fever, chills, sick contact, night sweat, or weight loss. On physical exam, he had moderate lower abdomen tenderness without palpable masses. CT scan of the abdomen and pelvis showed partial small bowel obstruction with a transition point at an ileocecal junction with amorphous soft tissue at the level of the terminal ileum and possible stricture or neoplastic involvement (Figure 1). Three days later, he had a colonoscopy which showed a large mass behind the ileocecal valve with a fistula (Figures 2 and 3). We were unable to intubate the ileocecal valve. Multiple biopsied taken from the mass that confirmed the diagnosis of DLBCL. PET scan showed cecal mass without any distal involvement. As recommended by surgery and oncology consultations, he had right hemicolectomy.

DISCUSSION:

Ileocecal region is a rare place for DLBCL occurrence. Majority of the cases are diagnosed incidentally or when complication like obstruction, perforation, or bleeding occurs like our patient who had bowel obstruction on presentation. We also found a fistula in cecum during colonoscopy. Clinically we suspect fistula as the patient was able to tolerate diet and complete bowel preparation easily in spite of having complete closure of ileocecal valve on colonoscopy. Due to the lack of oral contrast, it was not identified on the initial CT scan. Endoscopic features of DLBCL are nondiagnostic. The only way to confirm a diagnosis is, immunohistopathology staining specific for DLBCL. Majority of ileocecal DLBCL are at stage I or II diseases at the time of diagnosis. Surgical resection followed by chemotherapy had shown prolongation of survival. In conclusion, ileocecal DLBCL should be considered as a differential diagnosis for bowel obstruction or fistula.
2650 Severe Celiac Disease Presenting With Intussusception Without Lead-Point in an Adult Male
Authors: Paz Sandra Gomez , Jiyani Rucha , Jacob Bobby , Rizvon Kaleem , Mustacchia Paul
Published: October 2019

INTRODUCTION:

Adult celiac disease is an autoimmune disorder that usually presents with abdominal pain and diarrhea. We present the case of an adult man who presents with chronic diarrhea and intussusception, who was diagnosed with severe celiac disease.

CASE DESCRIPTION/METHODS:

38 year old male with history of depression, presents with three months of abdominal pain and intermittent watery diarrhea, associated with thirty-pound weight loss, fatigue, nausea, diffuse joint stiffness and mild swelling, and tingling and numbness that started two weeks prior. Physical exam was remarkable for thin body habitus, hyperactive bowel sounds and diffuse abdominal tenderness with guarding. Laboratory testing was significant for microcytic anemia and INR 2.7, work up for infectious causes of diarrhea was negative. Liver and renal function tests were normal. CT of the abdomen showed fluid filled colon as well as entero-enteric intussusception of approximately 10 cm in left mid abdomen. Further investigation included tissue transglutaminase (TTG) antibodies of more than 100 U/mL and IgA 227. Colonoscopy with random biopsies was performed, pathology revealed partial villous atrophy negative for increased intraepithelial lymphocytes, suggestive of celiac disease. Patient was diagnosed with severe celiac disease, associated with multiple vitamin deficiencies secondary to malabsorption and peripheral neuropathy. Patient was managed conservatively and eventually discharged with follow up of Gastroenterology and Rheumatology practices.

DISCUSSION:

Intussusception is well described in patients with previously diagnosed celiac disease, in which small intestinal lymphoma or adenocarcinoma may represent the “lead point” causing the intussusception. Much rarely seen is intussusception as the presenting symptom of previously undiagnosed celiac disease, particularly in the absence of a lead point. Theories of its development include presence of flaccid, dilated small bowel, fold abnormalities, lymphadenopathies and fluid excess. Intussusception in celiac disease is often multiple, transient and repetitive, so surgical intervention should be avoided. In our case, the presence of intussusception without a lead point was suggestive of celiac disease, confirmed by serologic and histologic testing. Intussusception without a lead point should prompt investigation for celiac disease as it may represent initial presentation, in order to avoid unnecessary surgical intervention.
2655 A Unique Case of Polyarteritis Nodosa Involving the Gastrointestinal Tract
Authors: Bergenstock Marika , Tufail Kashif , Tariq Umar , Confer Bradley
Published: October 2019

INTRODUCTION:

Polyarteritis nodosa (PAN) is a rare, systemic necrotizing vasculitis that affects medium-sized arteries and leads to inflammation resulting in vessel narrowing, thrombosis, and aneurysms. It can involve multiple organs and therefore presents with a range of non-specific symptoms. Gastrointestinal (GI) involvement of PAN is uncommon and may manifest as abdominal pain and rectal bleeding. Herein we describe an unusual case of PAN involving the small bowel in a patient presenting with abdominal pain.

CASE DESCRIPTION/METHODS:

A 49 year old man presented with acute onset left upper quadrant abdominal pain associated with nausea, vomiting, constipation, and multiple episodes of rectal bleeding. Vitals were unremarkable. Physical exam notable for abdominal tenderness and external hemorrhoids. Lab work revealed WBC 25, hemoglobin 11.6, platelets 476, and BMP unremarkable. Autoimmune markers revealed CRP 200, ESR 76, and ANA, ASMA, p-ANCA, c-ANCA, and acute hepatitis panel was negative. CT revealed splenic infarcts with no evidence of acute bowel ischemia. Arteriogram revealed multiple abnormalities including focal narrowing and irregularities of renal artery, distal splenic artery, as well as ileal and jejunal arteries (Figure 1a). Small bowel enteroscopy revealed jejunal erosions with biopsies showing focal erosive jejunitis and small caliber arteries without evidence of vasculitis. Colonoscopy positive only for large external hemorrhoids. Video capsule identified partial loss of villi, mucosal flattening, and multiple areas of ulceration throughout the small bowel (Figure 2) concerning for ischemia. Due to the high degree of concern for PAN with small bowel involvement, high dose prednisone and cyclophosphamide were initiated with improvement of symptoms. Follow-up angiogram revealed improvement in previous focal narrowing and segmental stenosis (Figure 1b).

DISCUSSION:

Diagnosing PAN is challenging and involves biopsy of an affected organ to identify medium-sized artery vasculitis. As in this case, establishing PAN with GI involvement is difficult due to the low likelihood of identifying medium-sized artery vasculitis on endoscopic biopsy of the GI tract. Invasive small bowel resection is oftentimes unrealistic. Untreated PAN can lead to devastating outcomes including ischemia of multiple organs as ongoing inflammation of vessels results in progressive narrowing. Thus, consideration should be given to initiating aggressive therapy based on imaging findings and clinical presentation if GI-PAN is suspected.
2661 A Rare Case of Poorly Differentiated Lung Carcinoma With Duodenal Metastasis
Authors: Ahmed Ahmed , Delle Donna Paul , Nasir Umair M. , Swantic Vanessa , Ahmed Shahida , Lenza Christopher
Published: October 2019

INTRODUCTION:

Lung cancer metastasis to the gastrointestinal (GI) tract is uncommon, with the duodenum being particularly rare. We present a unique case of a 61-year-old male with a history of lung cancer, who was found to have a metastatic mass on esophagogastroduodenoscopy (EGD) that was histologically similar to his lung cancer, ultimately being a diagnosis of poorly differentiated carcinoma (PDC) with focal neuroendocrine differentiation (FND).

CASE DESCRIPTION/METHODS:

61-year-old male presented with 1 month of worsening dizziness, fatigue, and early satiety. On physical exam, he was tachycardic with a blood pressure of 92/60. Labs were notable for a Hgb of 7.2 (baseline of 12). Of note, 6 months prior, he was having hemoptysis and was found to have a left apical lesion on computerized tomography (CT) scan of the chest. Results from a fine needle aspiration (FNA) of the mass showed PDC that was weakly positive for CK-7, and synaptophysin on immunohistochemical staining (IHCS); thus, he was started on chemoradiation therapy. His EGD showed an oozing ulcer in the third portion of the duodenum with heaped up borders. Bipolar cautery was performed, and biopsies were obtained which showed PDC, histologically and immunohistochemically similar to his previous lung biopsy. The patient’s Hgb continued to drop during the hospital course requiring multiple transfusions, and ultimately, a gastroduodenal artery embolization. He was eventually discharged after monitoring his hemodynamics, with close outpatient follow up, as he wanted to pursue continued medical management.

DISCUSSION:

The results of the lung FNA showed sheets of atypical cells with focal necrosis, and prominent nucleoli being dispersed without a specific pattern, consistent with a diagnosis of PDC with FND. IHCS was weakly positive (very few scattered cells) for CK-7, and synaptophysin but negative for CK-20, P63, TTF-1, chromogranin, and CDX2. The duodenal mass biopsy showed PDC with IHCS negative for CK-7, synaptophysin, CK-20, P63, P40, Napsin-A, P40, CDX-2, TTF-1, chromogranin, calretinin, CD20, and CD3; making it histologically similar to his previous lung biopsy. The IHCS of both biopsies could not identify a specific type of carcinoma and histological analysis only showed areas of FND; highlighting the unique aspect of this case. Treatment of duodenal metastasis is challenging and depends on many variables. He was deemed a poor surgical candidate due to his comorbidities/metastatic disease and eventually had a palliative embolization.
2668 Pleural Effusion From an Unexpected Source!
Authors: Alsheikh Mira , Kamar Khalil , Fady Haddad , Deeb Liliane
Published: October 2019

INTRODUCTION:

Gastric adenocarcinoma (GAC) is a global health burden. It is the third-leading cause of cancer-related mortality. Diagnosis is often delayed given the non-specific symptoms attributed to this disease. Gastric cancer is well known to cause distant metastases to other organs. However, it is unusual for patients to develop malignant pleural effusion as a presenting manifestation. Our case illustrates a unique diagnosis of an occult GAC after initial presentation with shortness of breath that deemed to be due to a malignant pleural invasion by signet ring cell cancer of the stomach.

CASE DESCRIPTION/METHODS:

A 70-year-old woman presented with worsening dyspnea and orthopnea of 1-month duration. Her past medical history included asthma and hypertension. Initial evaluation revealed a saturation of 98% on room air with decreased breath sounds halfway up upon auscultation of the right lung. Chest x-ray demonstrated a moderate right pleural effusion. Thoracentesis was performed with removal of 1 L of amber-colored fluid. The cytological analysis revealed adenocarcinoma with signet ring cell features. Upper endoscopy showed an 8 cm irregular necrotic ulcer at the lesser curvature of the stomach. Pathology confirmed the presence of a moderately differentiated infiltrative signet ring cell adenocarcinoma. Giemsa stain revealed helicobacter pylori (HP). Immuno-histochemical stains were positive for CK 7, hMLH1, 2 and 6. A positron emission tomography showed evidence of metastasis in right pleural space and lumbar spine. The patient received triple therapy for HP and confirmed eradication as well as modified FOLFOX 6 therapy every two weeks.

DISCUSSION:

Gastric adenocarcinoma is the fifth most common cancer in the world. Helicobacter pylori is a well recognized underlying risk factor for GAC. Around 1-3% of patients infected with HP progress to develop GAC. Chronic infection in this setting results in hypochlorhydria that leads to atrophic gastritis and intestinal metaplasia followed by dysplasia and subsequent neoplasia. Malignant pleural effusion is a rare presenting manifestation of GAC accounting for only two percent of cases. In advanced stage GAC, common metastatic sites include distant lymph nodes, liver, peritoneum with rare metastasis to lungs, bone, brain, and leptomeningeal space. Our case was distinctive as the pleural effusion was the initial presentation of an occult GAC diagnosed after that. Prognosis of metastatic GAC remains poor because of limited effective therapies.
2669 Mucosa-Associated Lymphoid Tissue Lymphoma: Crossing the Borders!
Authors: Dhruv Samyak , Fady Haddad , Oana Rosca , Andrawes Sherif
Published: October 2019

INTRODUCTION:

Mucosa-associated lymphoid tissue (MALT) lymphoma or MALTomas are responsible for half of the primary gastric lymphomas and up to 8% of B-cell lymphomas. It mostly affects patients in their 5th or 6th decade of life. MALT lymphoma is well known to remain localized in the stomach and to follow a benign course. Despite that gastric MALToma is well defined in the literature, it is rather uncommon to present as a peri-pancreatic mass. Herein, we present the case of a patient with an incidental peri-pancreatic mass diagnosed as an aggressive form of MALT lymphoma.

CASE DESCRIPTION/METHODS:

A 76-year-old male with hypertension presented to the gastroenterology clinic for the evaluation of peri-pancreatic mass incidentally found during computed tomography (CT) scan performed for renal colic. Physical examination was remarkable for an epigastric fullness with no tenderness. Laboratory tests were remarkable for iron deficiency anemia. CT showed a 7 cm ill-defined soft tissue mass within the pancreaticoduodenal groove abutting the pancreatic head and encasing the gastroduodenal artery suspicious for a pancreatic neoplasm (Figure 1). Endoscopic ultrasound (EUS) showed a hypoechoic heterogeneous mass arising from the gastric wall in close proximity to the pancreas (Figure 2). EUS-guided biopsies were consistent with extra-nodal marginal zone lymphoma of MALT (Figure 3). Gastric biopsies confirmed the presence of MALToma and revealed positive Helicobacter Pylori (HP) infection. Staging workup confirmed extensive bone marrow as well as para-aortic, mediastinal and paratracheal lymph node involvement. The patient received curative HP treatment and was started on bendamustine and rituximab.

DISCUSSION:

The stomach is the most commonly affected organ by MALT lymphoma. Helicobacter Pylori is a major precursor for the development of gastric MALT lymphoma as up to 90% of affected patients show H.Pylori on stomach biopsies. Chronic HP infection leads to lymphoid tissue proliferation within the stomach and progression towards lymphoma. In this setting, the course is usually indolent with the disease usually confined to the stomach but aggressive tumor behavior has been reported. HP antibiotic eradication remains the first line therapy for early-stage HP positive gastric MALT lymphoma. In other instances, a patient-tailored approach is recommended based on the stage, involved site, HP status and clinical characteristics. Therapeutic options include radiation therapy, chemotherapy and surgery accordingly.
2677 A Rare Case of Primary Signet Ring Cell Bladder Adenocarcinoma With Metastases to the Stomach
Authors: Yohannan Bryce , Hayat Maham , Hanafi Muhammad Z. , Moten Aqsa , Hayat Muhammad Hashim , Fazili Javid
Published: October 2019

INTRODUCTION:

Primary signet ring cell adenocarcinoma (SRCA) of the urinary bladder is a rare malignancy, accounting for about 0.24% of all bladder malignancies. Additionally, metastases to the stomach regardless of primary malignancy is also rare, with rates estimated to be between 0.2-0.7%. Here we are reporting a case of primary SRCA of the bladder with eventual metastases to the stomach.

CASE DESCRIPTION/METHODS:

A 65-year-old male with rheumatoid arthritis on chronic immunosuppression and history of T4N0M0 primary SRCA of the bladder status-post radical cystectomy was admitted with persistent nausea, vomiting and reduced oral intake leading to acute kidney injury. Symptoms were refractory to conservative measures so CT Abdomen was obtained which revealed distal esophageal wall thickening. Due to concern for infectious esophagitis given his chronic immune suppression, esophagogastroduodenoscopy (EGD) was performed. EGD revealed multiple nodules (5-10 mm) with central umbilication scattered within the gastric fundus and body. The lesions were biopsied and stains were consistent with signet ring cell adenocarcinoma positive for CX7, CX20, CDX-2; Beta-catenin was not performed. Bladder specimen from prior cystectomy was also positive for CX7, CX20, CDX-2, and predominately membranous staining for Beta-catenin. PET scan obtained after EGD was significant only for retroperitoneal lymphadenopathy thought to represent metastases. Previous workup at the time of initial bladder adenocarcinoma diagnosis including colonoscopy and imaging were all negative for additional foci of malignancy confirming primary bladder adenocarcinoma. Hence, it was concluded that the gastric lesions represented metastasis to the stomach from primary SRCA of urinary bladder. Due to underlying comorbidities and poor baseline functionality, patient elected to proceed with hospice care.

DISCUSSION:

Primary urinary bladder SRCA is a rare type of malignancy that typically presents at an advanced stage. Standard therapy of local urinary bladder SRCA is radical cystectomy. Despite advances in identifying immunohistochemical markers which aid in determination of primary bladder vs. colorectal origin, rates of metastases after surgical intervention are uncertain which limits the discussion regarding the role of adjuvant therapy. Our case highlights the need for further investigation to evaluate the risk-benefit ratio of adjuvant chemotherapy after radical cystectomy in primary bladder SRCA in minimizing development of future distant metastases.
2693 Gastric Emphysema: A Complication of Intractable Vomiting
Authors: Kelts Andrew , Steimle Cassandra , Jeng Jennifer , Kochik Michael , Golikov Edwin , Ali Farhan , Raborn Eric
Published: October 2019

INTRODUCTION:

Gastric pneumatosis is a term used to describe gas within the wall of the stomach. It is due to either one of two causes: emphysematous gastritis or gastric emphysema. The latter carries a better prognosis and is generally characterized by hemodynamic stability and spontaneous resolution with conservative management8.

CASE DESCRIPTION/METHODS:

A 58 year old female presented to the hospital with dyspnea and vomiting. Past medical history included coronary artery disease and diabetes mellitus type II. She was found to have a non-ST elevation myocardial infarction which was treated medically. Because of persistent vomiting, a gastroenterology consultation was requested. Physical examination at the time of consultation revealed an obese female with stable vital signs and a moderately distended abdomen. Laboratory tests revealed white blood cell count: 13.7 10 × 3/uL, hemoglobin 12.4 g/dL, lactic acid 1.0 mmol/L, lipase 30 U/L, and amylase 52 U/L. Computed tomography (CT) scan of the abdomen/pelvis was performed and revealed diffuse wall thickening of the stomach and a large amount of intramural air, particularly involving the fundus. Based on her symptoms and radiological findings, the diagnosis of gastric emphysema was made and she was treated with conservative measures. Her symptoms improved and a repeat CT scan of the abdomen ten days later failed to reveal any gastric pneumatosis.

DISCUSSION:

Gastric emphysema is benign and managed with observation and conservative treatment. Patients are hemodynamically stable without any associated infection3,8 The cause of either gastric emphysema or emphysematous gastritis can be due to an increase in intraluminal pressure or a mucosal injury that leads to intramural gas formation. Mucosa may be compromised in patients who are on immunosuppressive/cytotoxic therapy or in those patients who suffer from autoimmune and inflammatory diseases7. Diagnosis of gastric pneumatosis is made using CT imaging6 which can detect small amounts of gas in the stomach wall.3,5 Treatment for gastric pneumatosis includes supportive care. This includes adequate bowel rest and fluid support as needed. Surgical intervention or antibiotic therapy may be needed in certain cases of emphysematous gastritis5. In our patient, we suspect her development of gastric emphysema was due to her intractable nausea and vomiting. As in the majority of cases, her symptoms improved with conservative treatment and follow-up radiological imaging revealed resolution of her findings.
2703 Gastric Metastasis From a Primary Ovarian Cancer
Authors: Nathani Komal G. , Zamir Asif
Published: October 2019

INTRODUCTION:

Metastasis to stomach is very rare in general and often related to a breast or a lung primary. Ovarian cancer metastasizing to the stomach is extremely rare. We are reporting a very unusual case of a lady who had gastric metastasis from the primary ovarian cancer more than 3 years after the initial diagnosis. Serosal tumors are more likely to metastasize in comparison to the mucinous type.

CASE DESCRIPTION/METHODS:

A 49 year old Hispanic lady who had originally presented 3.5 years prior to her recent admission with abdominal pain and bloating. Work-up confirmed bilateral ovarian masses. Staging was negative for liver, lung and brain involvement. She had surgery. The pathology confirmed papillary serous adenocarcinoma with appendiceal and omental involvement. Estrogen and progesterone receptors were positive. She was considered to have Stage III-C disease, and started with chemotherapy. Unfortunately, within a few months, she came in with shortness of breath with imaging showing bilateral pleural effusions. She had thoracentesis which confirmed metastasis from her primary ovarian cancer. Her staging status was changed to IV. She was started on palliative chemotherapy. She would respond partially at first, but then she did show progression of the cancer. She then presented to the hospital recently with GI bleeding, anemia, sepsis, acute renal failure, leukocytosis and respiratory compromise. An upper endoscopy showed a large cratered malignant appearing ulcer in the body of the stomach. Biopsies confirmed adenocarcinoma from the ovarian source. Based on her advanced disease, and multi-system organ failure, the family decided on hospice care.

DISCUSSION:

Ovarian cancer metastasizing to the stomach is exceedingly rare. The symptoms are usually vague as the involvement is often serosal or sub-mucosal from local infiltration from the peritoneal carcinomatosis. However, hematogenous spread can occur as well. Presentation is often late, months to years after the initial diagnosis of the cancer. EGD should be considered in ovarian cancer patients presenting with upper GI symptoms. EUS/FNA biopsy may help in the diagnosis of the submucosal lesions. Prognosis is usually poor with average life expectancy after the diagnosis of gastric metastasis being 15 months.
2709 Metastatic Gastric Cancer to the Colon: A Rare Entity
Authors: Then Eric O. , Deda Xheni , Ofosu Andrew , Gayam Vijay , Liao Guanghong , Gaduputi Vinaya
Published: October 2019

INTRODUCTION:

Gastric cancer is one of the most common and deadly cancers worldwide, especially amongst older males. Current data suggests gastric cancer is the fifth most common neoplasm and the third most deadly cancer, with an estimated 783,000 deaths in 2018. Here we report a deadly case gastric cancer with colonic metastasis.

CASE DESCRIPTION/METHODS:

Patient is a 66 year old male with a medical history of hypertension and gastric cancer (status post partial gastrectomy) who presented to the emergency department complaining of progressive lower abdominal pain for the past 2 months. Notable laboratory workup included a hemoglobin of 10.1 gm/dL. Notable imaging included a computed tomography scan of the abdomen showing a mid transverse colon apple core mass measuring 30 mm × 44 mm resulting in proximal colonic obstruction. Given the size of the mass a joint endeavor between the gastroenterology service and surgery service was pursued in the operating room. A colonoscopy was initially done and showed a stenotic segment in the transverse colon with friable edematous mucosa. A stent deployment was attempted, but was unsuccessful due luminal compression by the tumor. Subsequently the surgical team performed an en bloc resection of the mass. The resected specimen was sent for biopsy and returned showing metastatic adenocarcinoma consistent with gastric origin. This diagnosis was supported by cell positivity to CK7 and negativity to CK20 and CDX2. Given his poor prognosis and complicated hospital course, the patient and his family decided to withdraw invasive care and opted for transfer to a hospice facility for end of life care.

DISCUSSION:

Risk factors associated with the development of gastric cancer include obesity, gastroesophageal reflux disease, helicobacter pylori infection, and low socioeconomic status. Diagnosis of gastric cancer can be accomplished by endoscopy, which allows the clinician to obtain a biopsy specimen. Endoscopic ultrasound is also an important modality that is helpful in assessing tumor invasion. The most common sites of metastatic gastric cancer in descending order are the liver, peritoneum, lung and bone. Rarely will gastric cancer metastasize to the colon. When suspected prompt evaluation with colonoscopy should occur for possible intervention and subsequent diagnosis of metastasis via biopsy. Surgery is the treatment of choice in gastric cancer limited to the stomach. In metastatic disease however, treatment with chemotherapy and targeted radiotherapy should be pursued.
2717 Gastric Mucormycosis and Pneumatosis in a Patient With APECED
Authors: Platt Jesse M. , Chu Jacqueline N. , Yarze Joseph C.
Published: October 2019

INTRODUCTION:

To describe a case of progressive, fatal gastric mucormycosis.

CASE DESCRIPTION/METHODS:

A 33 yo female with a history of APECED (autoimmune polyendocrinopathy, candidiasis, ectodermal dystrophy) and autoimmune hepatitis was admitted to the hospital with epigastric pain, nausea and vomiting. Medications prior to admission included levothyroxine and azathioprine. An initial CT scan of the abdomen revealed only subtle nonspecific “stranding” around the pancreas. Blood cultures were positive for E coli. Initially, the source of septicemia was unclear and the patient was treated with IV vancomycin and meropenum. A repeat CT scan 10 days later revealed gastric pneumatosis (Figure 1). EGD revealed a 3 cm ulcer in the gastric cardia (Figure 2). Biopsies of the ulcer revealed inflamed gastric mucosa with broad, sparsely-septated 10 to 20- µmfungal hyphae (with 90 degree branching) invading the mucosa, most consistent with mucormycosis. PCR of gastric biopsies were consistent with Rhizopus oryzae (a fungus in the family of Mucoraceae). A multidisciplinary decision was made to treat the patient nonoperatively with IV liposomal amphotericin, micafungin and nasojejunal feeding. She initially made slow, steady recovery but later had decompensation which led to the diagnosis of a gastro-pleural fistula. Extensive surgical debridement with resection of grossly abnormal stomach, spleen, diaphragm spleen and distal pancreas was performed. Pathology revealed extensive angioinvasive mucormycosis. She was then treated with a prolonged course of antifungals and antimicrobials (liposomal amphotericin B, posaconazole, terbinafine, meropenem, daptomycin). After a prolonged hospitalization, the patient gradually deteriorated and ultimately chose comfort measures and succumbed.

DISCUSSION:

Despite aggressive management with multidisciplinary expertise, widespread angioinvasive mucormycosis can be associated with a fatal outcome. Although there is no known association, the spector is raised as to whether the patient's underlying APECED was in some manner a predisposing or exacerbating factor in this patient's illness.
2721 Back Pain Can Be Hard to Digest
Authors: Mendelson Avery , Iskenderian Ziyad
Published: October 2019

INTRODUCTION:

With over 1,000,000 new cases of gastric cancer in 2018, and 783,000 estimated deaths, gastric cancer remains an important cancer worldwide.1 Gastric malignancy will commonly present in patients with weight loss and persistent abdominal pain. Patients can also present with findings of metastatic disease. This clinical vignette is an example of a rare metastatic location of gastric cancer.

CASE DESCRIPTION/METHODS:

55-year-old Middle Eastern male presents with intractable low back pain. An MRI of the thoracic and lumbar spine revealed multiple osseous lesions of the thoracic vertebral bodies and fractures of the L2 and L3 vertebral bodies, concerning for metastasis (Figure 1). A CT of the chest, abdomen and pelvis revealed enlarged mediastinal and hilar lymph nodes. Enlarged lymph nodes at the gastrohepatic interval and celiac level measuring up to 2 cm were noted, and multiple enlarged mesenteric and retroperitoneal lymph nodes. The patient underwent bone biopsy during kyphoplasty of the L2 and L3 vertebrae, which revealed metastatic carcinoma. Serum markers of malignancy were unrevealing, a CA19-9 of 15, CEA of 7.1, and PSA of 0.74. Urology was consulted and cystoscopy performed. No mass or filling defect was noted, and urine cytology returned negative for malignant cells. Gastroenterology was consulted and upon further history, the patient did acknowledge a history of H. Pylori, in 2016, with eradication confirmed by a negative stool antigen test. Gastroenterology recommended EGD and colonoscopy, but patient was unable to tolerate the bowel prep. The patient underwent an EGD, which revealed a 3.0 × 3.5 cm, cratered gastric ulcer without stigmata of bleeding at the incisura (Figure 2). Biopsy of this ulcer was positive for adenocarcinoma.

DISCUSSION:

This case demonstrates a presentation of bony metastasis of gastric cancer. This metastatic location is rare and unusual. It highlights the importance of maintaining high clinical suspicion in patients with metastatic disease. Additionally, it reinforces the relevance of a multidisciplinary approach when evaluating malignancy.
2733 Gastroduodenal Intussusception: An Interesting Presentation of a Gastrointestinal Stromal Tumor in a Bahamian Male
Authors: Deleveaux Spencer , Rolle Gemma
Published: October 2019

INTRODUCTION:

Gastrointestinal stromal tumors (GISTs) are a mesenchymal neoplasm considered to be the most common nonepithelial neoplasm of the gastrointestinal tract. GISTs occur with a frequency of about 0.68 per 100,000 in the United States, but the incidence of GIST in the Bahamas is unknown. These tumors arise from the interstitial cells of Cajal, which assist in motility via the myenteric plexus. Mutation to the c-kit oncogene is highly implicated in this process. Symptomatic GISTs are primarily a disease of the middle aged and elderly and have been found to be more frequent in males and minorities, especially in the black population. This case serves to highlight a presentation of GIST that is uncommon in current literature.

CASE DESCRIPTION/METHODS:

A 59 year old male with history of alcohol abuse and no known chronic liver disease presented with history of four episodes of coffee-ground vomitus and two episodes of melena stools over a one day period. The patient presented with an Hb of 8.2 mg/dl and at the time of endoscopy it had fallen further to 6.6 mg/dl. On endoscopy, it was noted that a portion of the mid stomach telescoped through the pyloric channel into the duodenum, causing obstruction the gastric outlet. On reduction of this intussusception, a mass with a central ulcer with stigmata of recent hemorrhage was observed at the greater curvature. Due to the nature of the significant, symptomatic bleeding that preceded presentation the decision was made not to use endoscopic ultrasound with fine needle aspiration, but rather proceed to surgical resection. A wide local excision was later performed with the lesion measuring 4.1 × 3.7 × 3.2 cm. Pathology confirmed suspicion of GIST, with chemical markers positive for CD117 and negative for S-100 and CD34, while the mitotic count was low (<5.5 mm2).

DISCUSSION:

This case report describes an interesting case of a GIST. Although GISTs most commonly present as gastrointestinal bleeding, the unexpected finding of an intussuseption is a rare finding of a relatively uncommon lesion. A 2018 literature review found that there were 28 reports of intussusception secondary to GIST, with only 18 having immunohistochemical confirmation of the tumor. The diagnosis of GIST should be entertained in adults who give history of melena with additional gastrointestinal symptoms. As diagnostic methods improve, further study of GISTs in the Bahamian population may be warranted to ascertain the incidence of the tumor compared to the current data of other populations.
2735 Phlegmonous Gastritis
Authors: Gonzalez Lisandro , DeCino Andrea , Patel Harsh D. , Wright Randy P. , Parker Allan L.
Published: October 2019

INTRODUCTION:

Phlegmonous gastritis (PG) is a rare cause of abdominal infection with a mortality rate up to 42%. PG presents a diagnostic and therapeutic challenge given the low incidence and non-standardized treatment options. We present a case of PG successfully treated with early antibiotic therapy.

CASE DESCRIPTION/METHODS:

A 47-year-old man with uncontrolled type 2 diabetes mellitus presented with four days of subjective fevers, abdominal pain, and vomiting. The patient was tachycardic (122 beats/min) and had epigastric tenderness without guarding or rebound. Initial studies revealed leukocytosis (30,000/mm³) and Gram-positive bacteremia, later identified as ß-hemolytic group A Streptococcus. The stomach was diffusely thickened to 16 mm on contrast-enhanced computed abdominal tomography (Figure 1). Endoscopy revealed diffuse gastric thickening with erythema and a nonbleeding 6 mm ulcer on the lesser curvature of the gastric body. Deep biopsy of the ulcer by cold forceps produced a purulent drainage (Figure 2). Subsequent endoscopic ultrasonography (EUS) found a 12 mm thickened gastric wall involving the deep mucosa, thus further biopsy was obtained. The biopsies from both endoscopy and EUS showed acute neutrophilic inflammation with micro-abscesses; Helicobacter pylori was not identified. The patient received three days of piperacillin/tazobactam followed by seven days of ampicillin/sulbactam, with resolution of symptoms.

DISCUSSION:

PG is a rapidly progressive and frequently fatal bacterial infection of the gastric wall. The etiology of PG remains unclear, but can be caused by local or hematogenous spread of infection. Streptococcusspp. accounts for 70% of cases, and up to one-third of infections are polymicrobial. Risk factors include gastric mucosal injury, diabetes mellitus, and alcoholism. Diagnosis is commonly delayed as clinical manifestations are nonspecific. High clinical suspicion and early radiographic testing are important to identify gastric wall thickening, which is supportive of the diagnosis. PG primarily affects the gastric submucosa but may extend to deeper layers. Histopathology is of limited benefit, as standard forceps biopsy collects insufficient submucosal tissue. Optimal treatment is not known. When diagnosis is delayed, surgical intervention is often required. Medical therapy alone has been associated with increased mortality rates; however, in cases of early diagnosis and empiric antibiotic treatment, medical therapy alone may be sufficient.