bluuebunny/crossref_metadata_2025 huggingface dataset:
2501 A Rare Case of Sofosbuvir/Velpatasvir/Voxilaprevir Failure in a Patient With Hepatitis C Virus Infection and Previously Undiagnosed Hepatocellular Carcinoma
Authors: Agostini Tandy , Vangimalla Shiva , Lalos Alexander
Published: October 2019

INTRODUCTION:

The advent of direct acting antiviral (DAA) agents has revolutionized the treatment for chronic hepatitis C virus (HCV) infection with greater than 95% success rate. In 2017, a combination of sofosbuvir, velpatasvir, and voxilaprevir (sof-vel-vox) was approved after clinical trials demonstrated a 97-100% sustained virological response (SVR) rate in patients who had failed a previous NS5A inhibitor regimen. We present a rare case of treatment failure with sof-vel-vox in a non-cirrhotic patient with previously undiagnosed hepatocellular carcinoma (HCC).

CASE DESCRIPTION/METHODS:

The patient is a 68-year-old African-American male with a history of HCV-G1b infection who had previously failed treatment with a 12-week regimen of sofosbuvir/ledipasvir. He was subsequently retreated with 12 weeks of sof-vel-vox. He had an end of treatment response but had a viral relapse at 3 months post-treatment. He denied hepatitis exposure in the interim and repeat genotyping was G1b. He was compliant with his medications. He was referred to Hepatology for salvage treatment options. Prior labs and images did not show evidence of cirrhosis and he did not have a history of hepatic decompensations. Combined HIV Ab/Ag and Hepatitis B Core Ab were negative. A Fibrosure test revealed F3 fibrosis but unfortunately, he did not undergo HCC surveillance. At our initial evaluation a contrast MRI was ordered and revealed a 4.6 cm right lobe enhancing lesion with delayed washout consistent with HCC. Resection was not possible due to the location of the lesion, so he underwent locoregional therapy and is currently listed for liver transplantation with MELD exception.

DISCUSSION:

Treatment failure with sof-vel-vox is a rare event. Underlying HCC is known to be associated with lower SVR rates in patients treated with DAAs. Some have surmised a protection from eradication due to immunologic changes in cancer patients. We hypothesize that the presence of HCC was the most likely factor for this treatment failure. With sof-vel-vox as the last available option in the treatment paradigm, failure of this regimen in previous NS5A treated patients leads to a situation where there is not an available proven treatment regimen for salvage therapy. As such, we suggest that patients being considered for sof-vel-vox have “up to date” advanced imaging of the liver even in the absence of documented cirrhosis. If treatment failure does occur, one should consider the possibility of an underlying diagnosis of HCC.
2510 Bacteremia With Liver Abscess and Endophthalmitis: A Rare Case of Invasive Klebsiella Pneumoniae Syndrome
Authors: Tageldin Omar , Parsa Nour , Copare Jennifer , Mansoor Muhammad Sohail , Alexandre Cassidy , Richter Seth
Published: October 2019

INTRODUCTION:

Pyogenic liver abscesses are often polymicrobial with Escherichia coli being the most common isolated organism. Klebsiella pneumoniae is a rare cause of pyogenic liver abscesses and often affects patients with immunodeficient states. Here we discuss a rare case of primary Klebsiella pneumoniae liver abscess with subsequent metastatic infection leading to vision loss.

CASE DESCRIPTION/METHODS:

A 68-year-old African American woman presented with complaints of intermittent fever, chills, right upper quadrant abdominal pain and blurry vision of the left eye. Her past medical history was notable for recent laparoscopic hernia repair, cataract surgery, and hypertension. The abdominal exam showed moderate tenderness of the right upper quadrant; ophthalmic exam of the left eye revealed afferent pupillary defect and decreased visual acuity. Labs were notable for leukocytosis, total bilirubin of 2.7, AST of 161, ALT of 135 and an alkaline phosphatase of 110. CT abdominal imaging revealed an abscess within the dome of the right liver measuring 5.2 × 6.3 × 4.1 cm. She was admitted to the intensive care unit and started on broad-spectrum empiric antibiotic therapy. Blood culture revealed gram-negative rods. B-scan ultrasonography of the left eye showed vitritis with loculation confirming the diagnosis of endophthalmitis. Intravitreal antibiotics were promptly administrated. She underwent CT guided sampling and drainage of the hepatic abscess with fluid culture growing the same organism identified in the blood cultures: mucoid Klebsiella pneumoniae complex. The patient was diagnosed with invasive Klebsiella bacteremia, liver abscess, and endophthalmitis and developed permanent vision loss in the left eye despite prompt intravenous and intravitreal antibiotic therapy.

DISCUSSION:

Klebsiella pneumoniae invasive liver abscess syndrome is a rare condition in the United States making timely diagnosis and treatment a challenge per se. Known risk factors for invasive liver abscess syndrome include diabetes mellitus, hepatobiliary disease, alcoholism, chronic renal failure, and cancer. While our patient did not have any of these specific comorbidities and had no recent international travel, her age, and recent surgical interventions likely predisposed her to an immunocompromised state. Invasive liver abscess syndrome can be fatal with poor prognosis if treatment is delayed. Timely abscess drainage and administration of intravenous antibiotics is crucial and should be implemented early on in the clinical course.
2516 Use of Ustekinumab in Pediatric Crohn's Disease: A Report of Three Cases
Authors: Sarles Harry E. , Whitney Annette E. , Van Anglen Lucinda J. , Kuten Samantha A. , Hardin Thomas C.
Published: October 2019

INTRODUCTION:

Treatment options for pediatric IBD are limited. Use of non-FDA approved agents to manage difficult pediatric IBD patients (pts) may be considered. Ustekinumab (UST) is a humanized IgG1κ monoclonal antibody designed to block interleukin-12 and interleukin-23, suppressing cytokine activation and inflammatory response. While UST is approved for the treatment of moderate-to-severe Crohn's disease (CD) in adults, there are little safety and efficacy data in pediatric CD pts. We describe our experience with UST in pediatric CD.

CASE DESCRIPTION/METHODS:

Pt 1 is an 18 y/o female, diagnosed (dx) with CD in 2015. She was stable on infliximab (IFX) and methotrexate (MTX) but presented in Nov 2016 with worsening scalp psoriasis thought attributable to IFX. IFX was D/Ced and UST initiated in Dec 2016 (260 IV mg, then 90 mg q8wks) with concomitant MTX 15 mg weekly. By Feb 2017, CD was quiescent and psoriasis improving. She presented in Nov 2017 with abdominal cramping and loose stools after running out of MTX. CRP was 8.8 mg/L on UST alone; psoriasis had resolved. MTX was restarted at this time. Pt continued to do well until early Feb 2019 when she had a CD flare associated with a delay in UST dose. She responded to a prednisone taper and restarted therapy. UST serum level in Mar 2019 was 2.5 mg/L and the dose was increased to 90 mg q4wks. The patient continues to do well. Length of therapy (LOT) to date is 2.5 yrs. Pt 2 is an 18 y/o male, dx with CD in 2017. He has intermittently unstable CD, treated with various combinations of adalimumab (ADA), MTX, and prednisone in the past. In Aug 2018 ADA was D/Ced, and UST initiated (390 IV mg, then 90 mg IV q8wks). His CD responded well to UST with a reduction in CRP from 18 to 1.6 mg/L. In late Dec 2018 he reported frequent bloody stools but was otherwise stable. Colonoscopy and upper GI endoscopy in early Jan 2019 were unremarkable; hematochezia resolved with the addition of mesalamine. LOT to date is 10 mos. Pt 3 is a 15 y/o female, dx with CD in 2013. She was stable on ADA until Aug 2018 when she presented with increased symptoms. ADA was D/Ced and UST initiated in Sep 2018 (390 mg IV, then 90 mg IV q8wks). Significant improvement was noted (CRP 1.3 mg/L) in Dec 2018. LOT to date is 10 mos.

DISCUSSION:

Clinical improvement in CD was observed in these pts following conversion to UST, with no significant safety concerns observed. Further studies are warranted to determine the place in therapy for UST in unstable pediatric CD pts.
2525 A Case of IgA Vasculitis Diagnosed With Small Bowel Biopsy
Authors: Samies John , Kumar Vikas , Zhu Shaobo , Khara Harshit S. , Confer Bradley
Published: October 2019

INTRODUCTION:

Immunoglobulin A (IgA) vasculitis is an immune-mediated condition that primarily targets small vessels. Presentation may vary- colicky abdominal pain, palpable purpura, acute arthritis, or nephritis. Adult annual incidence is 0.8-1.8/100,000. In adults, abdominal pain is rarely the presenting symptom. We report a case that presented with abdominal pain and was diagnosed with IgA vasculitis via duodenal biopsy.

CASE DESCRIPTION/METHODS:

A 60 year old male presented with acute onset severe periumbilical pain and watery diarrhea for several days. Pain was associated with vomiting and worsened after meals. Physical examination revealed marked periumbilical and right lower quadrant tenderness. Other review of systems and physical exam findings were unremarkable. Laboratory tests were remarkable for mild leukocytosis with neutrophilic predominance and elevated C-reactive protein. CT scan of the abdomen/pelvis showed significant patchy small bowel thickening with surrounding inflammatory changes. Small bowel enteroscopy showed edematous, purpuric and friable mucosa in the duodenum and proximal jejunum with stigmata of recent bleeding. Biopsies were obtained. Immunostaining for IgA was positive in the lamina propria, suspicious for small bowel IgA vasculitis. Shortly after that, he developed palpable purpura on upper and lower extremities. Punch skin biopsy confirmed IgA vasculitis. He was started on taper of systemic steroids, which lead to the resolution of skin and abdominal vasculitis within a few days. Currently, patient is in remission on rituximab maintenance therapy.

DISCUSSION:

In cases of abdominal involvement, IgA vasculitis has a predilection for small intestine. The classic endoscopic findings are diffuse mucosal reddening with hemorrhagic erosions and hematoma-like protrusions. Treatment is dependent on severity of vasculitis activity. For moderate to severe disease, systemic corticosteroids and analgesics are the mainstay of treatment. The diagnosis of IgA vasculitis is challenging, especially if abdominal pain precedes other manifestations. This case highlights the diagnostic value of early endoscopy in patients suspected of developing IgA vasculitis.
2542 Emerging Use of Hemospray in Lower Gastrointestinal Bleeding: Primary Mucosal Melanoma of the Jejunum
Authors: Alsheikh Mira , El Imad Cheikh Talal , Andrawes Sherif , Weissman Simcha , Deeb Liliane , Kamar Khalil
Published: October 2019

INTRODUCTION:

Small bowel (SB) primary melanomas (PM) are extremely rare; around 30 cases are reported to date. Diagnosis is challenging due to difficult endoscopic access and dealing with its complications such as bleeding is even more difficult. We describe in this report a case of jejunal primary melanoma presenting with lower gastrointestinal (GI) bleeding controlled with Hemospray.

CASE DESCRIPTION/METHODS:

A 70-year-old man with coronary artery disease on aspirin presented with symptomatic anemia. He endorsed recurrent melena associated with weight loss. Vital signs were stable. Physical exam remarkable for melena on rectal exam. Computed tomography scan of the abdomen revealed a jejunal mass. The patient underwent a push enteroscopy, which showed a large ulcerated necrotic mass in the mid-jejunum that was actively bleeding. The entire mass was oozing from multiple foci with a large surface area. It was invading the jejunal wall with larger vessels exposed. Hemospray was used to achieve hemostasis. Pathology revealed malignant melanoma; a thorough skin and eye exam was negative for PM. The patient denied any history of excision of pigmented skin lesions. The final diagnosis was primary melanoma of the jejunum.

DISCUSSION:

Malignant melanomas are mostly cutaneous. Only 3-4% originate in mucosal membranes as primaries. The diagnosis is challenging due to nonspecific manifestations and difficult pathologic access. Radiological studies are the first diagnostic approach. Balloon enteroscopy allows histopathological diagnosis and management of complications such as bleeding. In our case, the jejunal tumor was ulcerated with an extensive surface area and multiple foci of actively bleeding vessels. Due to the abundant lymphovascular supply of the intestinal mucosa, SB melanoma is a highly vascularized tumor. Hemospray was the preferred initial modality in this particular scenario and was successfully used for hemostasis. It is an inorganic powder that provides hemostasis by acting as mechanical tamponade and increasing the local concentration of clotting factors. It is easy to use with an excellent safety profile, does not require precise targeting, and is efficacious in large surfaces. Mucosal tissues do not absorb it; thus, it has no risk of systemic toxicity. It is FDA approved for hemostasis of non-variceal GI bleeding. It is contraindicated in varices and fistulas. It was also used in cancer-related bleeding with promising results. It can be applied repeatedly as a bridge to other definitive modalities.
2547 Atraumatic Paraduodenal Hematoma in a Patient Presenting With Gastric Outlet Obstruction
Authors: Sannapaneni Shilpa , Assaf Andrew , Feldman Mark
Published: October 2019

INTRODUCTION:

Paraduodenal hematomas are hematomas occurring alongside, near, and/or around the duodenum, the latter of which is characterized by hemorrhage into the duodenal wall. They have been reported in the setting of abdominal trauma, coagulopathy/anticoagulants, malignancy, chemotherapy, pancreatic disease, alcoholism, and endoscopic procedures.

CASE DESCRIPTION/METHODS:

A 56-year-old Caucasian male presented with epigastric pain that started 10 days prior to presentation. He described the pain as sharp, up to 10/10 in intensity, non-radiating, waxing and waning, and associated with nausea and multiple episodes of coffee ground emesis. He denied any abdominal trauma and was on no anticoagulation. He drank 2-3 glasses of alcohol every night. On presentation, he was afebrile with normal vital signs. He had a soft abdomen, normal bowel sounds and mild tenderness to palpation in the epigastric region. Laboratory studies were significant for a Hgb of 11.7 g/dL and a WBC count of 13.4 × 109/L. A CT scan of the abdomen with IV contrast revealed an 8 × 8 cm paraduodenal mass. Abdominal magnetic resonance imaging with and without contrast revealed a paraduodenal hematoma approximately 7 × 10 × 8.2 cm in size. The patient was kept NPO and a nasogastric tube was placed. Upper endoscopy revealed intrinsic traversable moderate stenosis at the 2nd part of the duodenum. Repeat abdominal CT scan with and without IV contrast was negative for any aneurysm with no interval change in the paraduodenal hematoma. Total parenteral nutrition was started on the second day of hospitalization and was discontinued on the sixth day. The patient's diet was slowly advanced until he was able to tolerate a full liquid diet. On the day of discharge, the patient did not have abdominal distention, abdominal pain or nausea. The patient was followed two weeks later; he was advanced to a regular diet and had complete resolution of his symptoms.

DISCUSSION:

Duodenal hematoma was first described by MacLauchan in 1838. Up to 80% of cases are secondary to high impact abdominal trauma. The esophagus, duodenum, jejunum have all been reported to have cases of intramural hematomas. Duodenal hematomas have a higher incidence secondary to the fixed retroperitoneal position; a location that is anterior to the spine makes it highly susceptible to blunt abdominal trauma. Patients can present with abdominal pain, signs of small bowel obstruction, hematemesis, anemia and rarely pancreatitis. Treatment is usually conservative.
2554 A Hefty Hematoma: A Rare Case of Pancreaticobiliary Obstruction After Gastrectomy With Roux-en-Y
Authors: Lech Diana , Wander Praneet , Ashamalla Michael , Pizzuti Jessica , Cheung Mary
Published: October 2019

INTRODUCTION:

Pancreaticobiliary obstruction is an uncommon complication of total gastrectomy with Roux-en-Y reconstruction. We present a case of a patient with a closed loop obstruction due to a hematoma at the location of jejunojejunal anastomosis. The patient underwent EGD with clot evacuation resulting in decompression of the pancreaticobiliary limb.

CASE DESCRIPTION/METHODS:

A 57-year-old male, with hypertension, who had recently immigrated from China presented for evaluation of persistent heartburn. He underwent an upper endoscopy, which showed erythematous gastric mucosa and pathology was positive for superficial invasive adenocarcinoma. He was referred to surgery and underwent laparoscopic esophagogastroduodenoscopy, robotic assisted total gastrectomy and Roux-en-Y reconstruction with jejunostomy tube placement. On postoperative day one, there was bright red blood on aspiration from his nasogastric tube and J-tube. Laboratory tests were notable for downtrending hemoglobin and he required 2 units of packed cells. Due to concern for active bleeding, the patient underwent an upper endoscopy in the operating room, which demonstrated no active bleeding and presence of a blood clot at the JJ anastomosis. Epinephrine was injected at the site of the clot. Post procedure, he had increasing total bilirubin which peaked at 5.9. A computed tomography was done on postoperative day 3, demonstrating marked dilation of the pancreaticobiliary limb, which was suspicious for a clot within the small bowel at the level of the JJ anastomosis, concerning for a closed loop obstruction. He then underwent a repeat endoscopy using a duodenoscope. A 9 cm clot was visualized at the JJ anastomosis causing pancreaticobiliary obstruction. The clot was removed with cold soft snare, grasping forceps and roth net with resultant free flow of bile at the site of JJ anastomosis. Total bilirubin subsequently downtrended and returned to normal. The patient's recovery was uneventful, and he was discharge 16 days after clot evacuation.

DISCUSSION:

The most common early complications of total gastrectomy with Roux-en-Y reconstruction include SBO and anastomotic leak. Our case highlights a rare complication of pancreaticobiliary limb obstruction due to hematoma at the JJ anastomosis. Early EGD allowed for clot evacuation and limb decompression without need for re-operation.
2556 Duodenal Candidiasis Presenting as Mass-Like Lesion: A Rare Presentation
Authors: Alakkam Anas , Masood Umair , John Savio
Published: October 2019

INTRODUCTION:

Candida is a normal inhabitant in the GI tract. It is typical for candidiasis to appear in the esophagus and oropharynx in immunocompromised patients. However, candidiasis of the stomach or duodenum is rare. We report a case of a gastric outlet and biliary obstruction due to a duodenal mass-like lesion in the setting of duodenal candidiasis.

CASE DESCRIPTION/METHODS:

Patient is a 66 year old female with past medical history of diabetes mellitus type 2, hypertension and osteoarthritis who presented to the hospital with progressive non-bloody vomiting, poor oral intake and constipation for two months. She endorsed abdominal pain and yellowing of the eyes and skin. Her vitals on admission were normal. Physical exam was pertinent for diffuse abdominal tenderness and scleral icterus. Her laboratory findings were significant for AST of 137 U/L, ALT of 130 U/L, alkaline phosphatase of 205 U/L, total bilirubin of 8.9 mg/dL and direct bilirubin of 5.3 mg/dL. Abdominal CT scan showed duodenal thickening with possible mass-like lesion causing gastric outlet obstruction. MRI of the abdomen and MRCP only showed duodenal wall thickening. She had a subsequent EGD that showed mild gastric erythema and a mass like lesion in the duodenum hindering the visualization of the papilla. Biopsy results were significant for active chronic duodenitis with presence of Candida albicans. Gastric biopsy was positive for H. pylori infection. The patient was treated with a 21 day course of Fluconazole followed by bismuth based quadruple therapy. Follow-up EGD showed resolution of the duodenal lesion. At two months follow up after treatment, the patient had no symptoms and liver enzymes were normal.

DISCUSSION:

Candida is part of the normal flora of the GI tract and commonly causes infection in the mouth and esophagus. Stomach and duodenal infections are less common due to their relatively acidic environment creating a harsh environment for the fungal species to grow and cause disease. However, immunocompromised patients and patients on acid suppressive therapy are vulnerable to opportunistic candidal infection. The long standing history of diabetes may have predisposed patient to the infection. In conclusion, our case highlights a rare presentation of a duodenal candidal infection; mass-like lesion causing gastric outlet and biliary obstruction. This case should serve as a reminder to clinicians to keep candidiasis in the differentials for duodenal infections especially in diabetic patients.
2564 Rare Malignant Peritoneum Mesothelioma Masquerading With Respiratory Manifestation
Authors: Patel Ravish , Vekaria Pratikkumar , Vaishnani Devin , Mao Johnnie , Raiyani Chandrika , Vaishnani Marvin , Raiyani Tejas
Published: October 2019

INTRODUCTION:

Mesothelioma is a rare and aggressive cancer that affects the linings of the pleura, peritoneum and pericardium. Pleural involvement is however most common. Malignant Peritoneal mesothelioma (MPM) is a cancer developing in the lining of the peritoneum, which is extremely rare. Most MPM cases are caused by asbestos exposure. Common symptoms of MPM include abdominal distension, abdominal pain, swelling or tenderness and constipation or diarrhea, with most common being abdominal swelling. MPM is difficult to diagnose due to its vague, nonspecific symptoms.

CASE DESCRIPTION/METHODS:

67-yo-Male presented to the ER with complaint of Shortness of Breath for 6 weeks and dry cough. He was treated as an outpatient with bronchodilator, steroid and 2 rounds of antibiotics with no relief. He also had poor appetite, unexpected 10 lb weight loss and generalized weakness. CT Chest was pertinent for abdominal findings with bilateral anterolateral mesenteric nodularity along with ascites. CT abdomen & pelvis subsequently asserted it with likely malignant diagnosis. Surgical biopsy confirmed mesothelioma of the peritoneum. Patient denied any exposure to asbestos, but had worked in construction his entire adult life. Oncology offered palliative chemotherapy, which he refused. Follow-up CT Abdomen 1 month later showed progressive MPM. With rapidly worsening disease, no chemotherapy and overall poor prognosis, patient accepted comfort care. Unfortunately, he succumbed to his fatal diagnosis within 2 months on hospice care.

DISCUSSION:

Ours is a rare case of MPM where patient presented with atypical respiratory symptoms. Generally, abdominal symptoms are common to present. Early on, he was treated as cough variant asthma. But without improvement, further evaluation was carried out leading to incidental unexpected abdominal findings on CT Chest. Further workup with concluding biopsy confirmed MPM. Due to rarity and short life expectancy, MPM does not have set staging system. Early and timely diagnosis aids rearranging goals of care in such instances. In terminal illnesses, quality of life with timely discussion of comfort care is crucial. With red flag symptoms, like rapid weight loss in our case despite atypical presentation, should warrant careful evaluation as it could change goals and treatment plans substantially. However, it can offset the balance for high value care at times. We hope that future medical advances will bridge this disparity positively for rare cases also.
2565 Clostridioides difficile Enteritis Refractory to Multiple Fecal Microbiota Transplantions
Authors: Sharma Bashar , Antoine Marsha , Shah Mili , Hasan Muhammad , Rawlins Sekou
Published: October 2019

INTRODUCTION:

Clostridioides difficile (CDI) is a spore-forming, toxin-producing, gram positive bacteria that can colonize the colon when the normal flora is disrupted causing colitis. However, it can rarely colonize the small intestines causing enteritis, especially in patients with recent antibiotic use, on immunosuppression or have surgically altered intestinal anatomies.

CASE DESCRIPTION/METHODS:

A 77-year-old female with a history of fulminant CDI colitis requiring subtotal colectomy with end ileostomy presented with abdominal pain and increase in ileostomy output two months after surgery. Her ileostomy drainage tested positive for CDI by PCR and she was started on oral vancomycin for CDI enteritis with resolution of her symptoms. Over the next year, she had multiple recurrences of her CDI that failed vancomycin, fidaxomicin and IV immunoglobulin (IVIG). She eventually had fecal microbiota transplantation (FMT) with stool infused into the proximal jejunum. Her symptoms improved initially, however recurred and her ileostomy drainage tested positive for CDI again. She had a total of four FMT due to recurrence. After her fourth FMT, her symptoms recurred, however; she tested negative for CDI this time. Infectious diarrhea as well as celiac disease were negative and her symptoms did not improve with antidiarrheal agents. She developed significant anxiety and requested to be placed on vancomycin understanding the risks of long-term use of antibiotics. She was started on a prophylactic daily dose of oral vancomycin 125 mg which helped to improve her symptoms.

DISCUSSION:

CDI enteritis is rare; yet, its incidence is rising. Diagnosis is made both clinically and biochemically by testing for CDI toxin by PCR. In the literature, there are no prospective studies on the treatment of CDI enteritis except for a few case reports. Oral metronidazole has been used, with oral vancomycin used for refractory cases. In our case, the patient failed vancomycin, fidaxomicin, IVIG and three FMT with recurrence of the symptoms after the fourth one. Prophylactic oral vancomycin was started on the patient's request and she noticed improvement in her symptoms. Prophylactic vancomycin has been effective in preventing recurrence of CDI in patients with a history of CDI being treated with oral antibiotics. Our case is unusual given the ongoing symptoms in a PCR negative CDI state. Further research is needed in patients with refractory CDI enteritis with analysis of their bowel flora to better understand this disease and how to treat it
2574 15 Years Out, a Small Bowel Transplant That Defeated the Odds
Authors: Khan Ummi , Soliman Isaac , Nathan Swami
Published: October 2019

INTRODUCTION:

Small bowel transplant has been shown to have good short-term patient survival rates, however long-term rates are often dismal. We present one of the longest documented survivals of a small bowel transplant.

CASE DESCRIPTION/METHODS:

A 69-year-old female underwent multiple surgical interventions due to recurrent small bowel obstruction during her 3rd and 4th decades of life. Unfortunately, this resulted in a short gut syndrome. At the age of 54, she underwent an isolated small bowel transplant. She had a prolonged post-transplant hospitalization requiring 11-month stay. Despite being compliant with mycophenolate and tacrolimus, she had multiple admissions for sepsis and volume depletion from her ileostomy losses. Due to nephrotoxicity form immunosuppressive drugs, she developed ESRD requiring HD in the last 3 years. Despite the challenges, she has continued to live independently.

DISCUSSION:

Isolated small intestine transplantation is a rare procedure in adult patients. This continues to be the last measure for intestinal failure in patients who cannot tolerate or receive total parental nutrition. Some of the common causes of intestinal failure in adults include bowel ischemia, volvulus, trauma, and Crohn's disease. Over the last two decades, the success rate of small bowel transplantation has improved due to advancements in immunosuppression, refined surgical techniques, and better post-transplantation care. However, despite this glimmer of hope, both the procedure and post-transplanted state are associated with high morbidity and mortality rates. Post-transplant complications include opportunistic infections due to immunosuppressive agents, graft rejection and surgical complications including anastomotic leaks. Graft rejection appears to be the most common and at times difficult to manage complication, though this too has improved. Today, patient survival at one year is close to 85%, 5 years at 61% but at 15-years survival is unfortunately at 35%. Our patient has no signs of graft rejection after 15 years post-transplant and her liver synthetic function remains normal.
2578 Meckel's Diverticulum: A Diverticulum Like No Other
Authors: Alsheikh Mira , Haddad Fady , Mulrooney Stephen
Published: October 2019

INTRODUCTION:

Meckel's diverticulum (MD) is a relatively uncommon cause of gastrointestinal (GI) bleeding in adults. “Often looked for and seldom found,” MD is challenging to diagnose despite the various imaging modalities available. Herein, we present the case of a young man who presented with lower GI hemorrhage and negative endoscopy, bleeding scan, and angiography. Meckel's diverticulum was later diagnosed via scintigraphy scan. We review the noninvasive diagnostic imaging for Meckel's diverticulum, mainly technetium-99m (Tc 99m) pertechnetate scan, and bleeding scan.

CASE DESCRIPTION/METHODS:

A 26-year-old man presented with multiple episodes of melena. He had acute onset anemia. Workup, including upper endoscopy, colonoscopy, and push enteroscopy were not able to identify the site of bleeding even after repeat procedures. A computed tomography scan with intravenous contrast and mesenteric angiography were also unrevealing. A Technetium 99m bleeding scan was read as negative. Persistent bleeding necessitated recurrent transfusions. Capsule endoscopy was deployed. A Meckel's scan (Tc 99m Pertechnetate scan) revealed an abnormal focus of uptake in the right lower abdomen suggesting the diagnosis of Meckel's diverticulum. The patient underwent laparoscopic resection of the diverticulum and was discharged home (Figures 1 and 2). A retrospective review of the bleeding scan revealed isolated uptake in the location of the Meckel's Diverticulum. Review of the capsule endoscopy revealed a diverticulum in the small bowel in the right lower quadrant without active bleeding (Figure 3).

DISCUSSION:

Bleeding Meckel's diverticulum is easier to diagnose than MD presenting with other symptoms, but still an outstanding challenge. High suspicion for MD should be sought in the evaluation of a young patient presenting with GI bleeding; the gold standard for diagnosis is the technetium-99m pertechnetate scan or so-called Meckel's scan. Bleeding scan is another noninvasive imaging modality that helps to detect a bleeding MD. Although both scans use Tc 99m, the mechanism is different. Meckel's scan uses Tc 99m, which is secreted by parietal cells in the mucus, thus detecting gastric cells within MD. On the other hand, the bleeding scan works via identifying Tc 99m that is bound to hemoglobin, therefore identifying a bleeding MD. Both scans are noninvasive and safe. The use of either one should be tailored according to the clinical presentation.
2588 You May Spread but Can't Hide! A Rare Case of Metastatic Renal Cell Carcinoma to the Small Bowel After Nephrectomy
Authors: Aggarwal Pankaj , Singh Tamneet , Diallo Souleymane Y. , Rampy Jacqueline , Thompson Adrianne K. , Perry William , Govani Shail
Published: October 2019

INTRODUCTION:

Renal cell carcinoma (RCC) is a type of kidney cancer that rarely metastasizes to the small bowel. There are only a few reported cases. We present a rare case of metastatic RCC to the small bowel 13 years after nephrectomy.

CASE DESCRIPTION/METHODS:

A 70-year-old man with a history of RCC treated with nephrectomy 13 years prior presented to the hospital with melena and a hemoglobin of 10 g/dL. Upper endoscopy was unrevealing. Colonoscopy showed diverticulosis and scant blood in the cecum. After discharge, a capsule endoscopy showed bright red blood starting in the mid to distal small bowel. The patient later underwent a repeat capsule endoscopy which did not identify any further bleeding or a source of blood loss. The patient subsequently underwent an anterograde enteroscopy to the mid-small bowel without identifying a source GI bleeding. With oral iron supplementation, his hemoglobin normalized and the patient had no further episodes of melena. One year later, the patient presented to the hospital with abdominal pain and was found to have a distal small bowel obstruction and to be anemic with a hemoglobin level of 11 g/dL. A non-contrast CT abdomen and pelvis did not identify a cause of obstruction. After conservative management, patient was referred for MR enterography which showed a 5 cm enhancing mass in the terminal ileum (Figure 1). The mass was biopsied via ileocolonoscopy (Figure 2), which showed metastatic renal cell carcinoma, clear cell type. He subsequently underwent surgical metastasectomy (Figure 3). Surgical pathology confirmed metastatic RCC with no evidence of lymph node involvement.

DISCUSSION:

Metastatic RCC to the small bowel is rare and has mostly been described anecdotally thus far. Despite undergoing a presumably curative nephrectomy, this patient had a recurrence 13 years after surgery. Thus, this case adds to the growing body of literature to support late gastrointestinal metastasis from RCC as a potential cause of occult GI bleeding. Additionally, this patient's case is unique in that both capsule endoscopy and CT failed to identify the site of bleeding. Given the size of the mass, this case highlights the miss rate of capsule endoscopy. The poor distal small bowel prep likely reduced the ability to detect this distal small bowel lesion. Ultimately, the mass was identified via MR enterography. This case sheds light on an important issue regarding the utility and efficacy of capsule endoscopy compared to magnetic resonance imaging in the identification of small bowel neoplasms
2596 Diagnosis of Terminal Ileum Carcinoid Tumor Despite Prior Screening Colonoscopies—Making the Case for Routine Terminal Ileoscopy During Colon Cancer Surveillance: A Case Report
Authors: Shafi Amaan , Lankarani Daisy S. , Dhindsa Banreet , Ohning Gordon
Published: October 2019

INTRODUCTION:

The term carcinoid is generally applied to well-differentiated neuroendocrine tumors originating in the tubular digestive tract, lungs or rare primary sites. Small bowel neuroendocrine tumors may be asymptomatic at presentation and found incidentally. Among symptomatic patients, 40% experience abdominal pain as an initial symptom. The pain is usually vague, nonspecific and misconstrued to represent irritable bowel syndrome for years before a diagnosis is made. A diagnosis may be delayed, or even missed, due to terminal ileum visualization not being a routine part of screening colonoscopy, a result of the perceived difficulty of the maneuver. We present the case of a female patient who was diagnosed with carcinoid tumor only after she became symptomatic despite having routine colonoscopy screening prior.

CASE DESCRIPTION/METHODS:

A 74-year-old female without significant past medical history initially presented to clinic with complaints of non-specific abdominal pain and intermittent non-bloody diarrhea. Vital signs and physical exam were unremarkable. The patient subsequently underwent a colonoscopy, during which she was found to have inflamed ileal mucosa. Biopsy was taken and microscopic findings revealed a tumor composed of small uniform cells demonstrating a festoon growth pattern with ovoid nuclei. Immunoperoxidase staining revealed the tumor cells to be positive for pankeratin, chromogranin and synaptophysin, confirming a diagnosis of carcinoid tumor. Patient has since been referred for surgical evaluation.

DISCUSSION:

Due to the high amount of patients being screened, there is an urgency now more than ever to minimize colonoscope advancement and mucosal inspection time. As depicted in our case, patients may go through more than one surveillance colonoscopy with a missed diagnosis, particularly in the terminal ileum. This is especially a concern in asymptomatic patients with carcinoid tumors. Though evidence has shown improvement in colonic diagnoses, completion of colonoscopy by passage through the ileocecal valve is not yet routinely performed in screening colonoscopies. Difficulty in intubation of the valve as well as an anticipated increase in procedure time have become barriers in establishing this as a standard. With practice, ileoscopy may be highly achievable in routine colonoscopies. This will allow for a decrease in missed diagnoses, early detection and thus more treatable cases overall.
2598 Jejunal Lymphocytic Enteritis: An Unusual Location for a Rare Condition
Authors: Dellatore Peter , Skole Kevin
Published: October 2019

INTRODUCTION:

Lymphocytic enteritis (LE), a subclassification of microscopic enteritis (ME), is defined as abnormal infiltration of intraepithelial lymphocytes (IELs) in the gastrointestinal mucosa. Causes include gluten exposure, H. pylori (Hp) infection, small intestinal bacterial overgrowth, autoimmune conditions, irritable bowel syndrome, or medications such as proton pump inhibitor (PPI), NSAIDs, and selective serotonin reuptake inhibitors. A majority of cases are found in the colon or duodenum; we report a rare case of jejunal LE.

CASE DESCRIPTION/METHODS:

A 51-year-old man with untreated Hp and diabetic gastroparesis, on chronic pantoprazole, presented with chronic intermittent watery diarrhea, diffuse abdominal pain, nausea, vomiting, and generalized malaise. A CT showed jejunal mucosal thickening. The jejunal mucosa appeared normal by deep enteroscopy; a subsequent colonoscopy was also normal. Jejunal pathology demonstrated IELs with normal villous architecture consistent with LE; colon biopsies were negative for IEL. Laboratory tests were remarkable for iron deficiency anemia, but otherwise negative for other nutritional deficiencies, transglutaminase antibodies, or IgA deficiency. The patient received 10 days of solumedrol and concomitant Hp therapy; the PPI was then stopped. His diarrhea improved and repeat enteroscopy demonstrated resolution of jejunal LE.

DISCUSSION:

LE is a rarely diagnosed subclass of ME, but growing epidemiologic trend confirms that it will become a common condition in clinical practice. Multiple potential causes have been identified and treatment includes steroids, and/or addressing the underlying cause. Our patient had at least two potential causes: Hp and PPI use. Due to the unusual location of his LE and his severe illness, we treated multiple possible causes at the same time, with notable clinical and histologic improvement. This case demonstrates the success of standard treatment modalities for a unique anatomical location of a rare condition. With increasing disease prevalence, LE represents a novel entity that warrants further investigation. Subsequent care will be dictated by his clinical course, and repeat biopsies if necessary.
2601 Small Intestine Angioedema Due to Angiotensin Converting Enzyme Inhibitors: A Great Mimicker
Authors: Uy Pearl Princess , Yap John Erikson
Published: October 2019

INTRODUCTION:

Angiotensin converting enzyme inhibitors (ACEI) are one of the most commonly prescribed anti-hypertensives. Angioedema, one of its known adverse effects, occur between 0.1% to 0.7% mostly affecting the lips, tongue, face and upper airways. Isolated small bowel angioedema due to ACEI is rare. We present a case of a middle-aged female with abdominal pain and imaging findings of ileitis which resolved after discontinuation of lisinopril.

CASE DESCRIPTION/METHODS:

A 48-year-old female with hypertension and organ limited granulomatosis with polyangiitis presents with a 1-year history of right lower quadrant abdominal pain and not associated with fever, weight loss, and diarrhea. Patient denies NSAIDs use but has been on lisinopril for 6 years. Upper endoscopy and colonoscopy were unremarkable. CT abdomen with contrast revealed focal segmental inflammation of the proximal ileum. Additional evaluations were negative including infectious etiologies, inflammatory bowel disease, ANCA, anti-transglutaminase antibodies, and c1-esterase inhibitor. Repeat CT abdomen 1 month after discontinuation of lisinopril showed interval complete resolution of the segmental ileal inflammation, and patient reports improvement of her abdominal pain.

DISCUSSION:

Angioedema of the small intestine is a rare adverse effect of ACEI which is one of the top causes of drug-induced angioedema. It is thought to be due to elevated bradykinin level resulting in vasodilation and increase vascular permeability resulting in edema. Patients may present with diarrhea, nausea, vomiting, abdominal pain and rarely, as acute abdomen requiring laparotomy. Symptoms usually occur 72 hours after starting ACEI but can develop weeks or years after and resolve 48 hours after stopping the medication. Laboratory tests are often unremarkable and radiologic studies reveal segmental thickening of the small intestinal wall, ascites and mesenteric edema which may mimic inflammatory bowel disease, mesenteric ischemia, or vasculitis. Treatment involves discontinuation of the offending drug. Given that patient has been on lisinopril for 6 years and the unremarkable laboratory tests results, it is very important to have a high index of suspicion for drug induced small intestine angioedema aside from ruling out other possible etiologies. Clinicians must review each patient’s medication list and their side effects since small intestine angioedema is rare and under recognized. Early diagnosis help prevent unnecessary investigations and surgical interventions.
2614 Astrovirus Enteritis in an Immunocompetent Adult in the Setting of Chronic Proliferative Synovitis
Authors: Pillai Priyamvada , Hajifathalian Kaveh , Wan David
Published: October 2019

INTRODUCTION:

Astrovirus enteritis is a clinical entity seen mainly in children and immunocompromised adults resulting in severe diarrheal episodes. It is quite rarely implicated in acute gastroenteritis in immunocompetent adults with only few cases reporting its incidence. Here, we report a case of Astrovirus enteritis in an immunocompetent adult with chronic proliferative synovitis and positive ANA titers.

CASE DESCRIPTION/METHODS:

We present a 38-year-old woman with history of chronic proliferative synovitis who presented with acute nausea, crampy mid abdominal pain, and profuse non-bloody diarrhea after 12 hours of eating from a restaurant. The diarrheal episodes were associated with fevers up to 103oF with chills and rigors. The patient reported to have two recent sick contacts with similar diarrheal episodes and a course of amoxicillin 1 month ago for a dental indication. However, she denied any vomiting, recent meat, dairy or egg consumption or travel history. She had no past medical history of gastrointestinal complaints, immunosuppression or any new medications. Clinical examination only revealed mild abdominal diffuse tenderness. Initial clinical workup was remarkable for a mild leukocytosis, newly increasing AST and ALT, but normal total bilirubin, ALP and lipase levels. Microbiological investigation revealed positive Astrovirus in GI PCR, negative C. difficile assay and negative HIV status. An autoimmune workup revealed positive ANA titers of 1:80 in the setting chronic proliferative synovitis. The patient underwent supportive treatment for her diarrhea with Loperamide and IV fluids following which she improved clinically.

DISCUSSION:

Astrovirus is a positive single stranded RNA virus implicated in acute gastroenteritis in children and immunocompromised individuals. However, it has a low prevalence among healthy adults which is hypothesized to be due to acquired immunity gained from a prior childhood infection. In this patient, her chronic proliferative synovitis with raised ANA titers seems to have increased her predisposition to acquiring Astrovirus enteritis. Patients with chronic inflammatory conditions like SLE or synovitis seem to be more prone to viral infections due to their pro-inflammatory condition, making them more susceptible to infections that are otherwise cleared by the adult immune system. Hence, it is important to consider this clinical entity when assessing severe gastroenteritis in patients with pro-inflammatory status.
2617 Duodenal Leiomyosarcoma: A Rare Cause of Gastric Outlet Obstruction
Authors: Okoli Fidelis , Kantrowitz Michael , Zahir Ismail , Tsirlin Yuriy
Published: October 2019

INTRODUCTION:

Intestinal leiomyosarcoma (LMS) is a rare cancer comprising 0.2% of all malignant tumors and involves the ileum in nearly half of cases. The remainder occur in the proximal duodenum and jejunum primarily, or metastatically from non-intestinal sites such as the uterus. We report this case of primary duodenal LMS complicated by gastric outlet obstruction.

CASE DESCRIPTION/METHODS:

A 57 year old woman presented with a two month history of worsening epigastric and right upper quadrant pain without nausea, vomiting, weight loss, or altered bowel habits. On physical exam she had marked epigastric tenderness. Abdominal contrast CT demonstrated multiple hypodense liver lesions measuring up to 2cm and a mildly dilated and thickened descending segment of the duodenum. Laboratory evaluation including tumor markers was normal. Without a clear primary malignancy source, the patient underwent percutaneous liver biopsy. Histopathology revealed high grade smooth muscle sarcoma, which stained positively for desmin, SMA, CD 57, and CD 34. Chemotherapy with gemcitabine and docetaxel was initiated per oncology. Within weeks, the patient developed worsening abdominal pain, nausea, and vomiting. CT imaging showed a mass projecting over the descending duodenum causing gastric outlet obstruction. After nasogastric decompression, the patient underwent an EGD. A friable, circumferential mass was seen emanating from distal duodenal bulb extending proximally to the second portion. A duodenal self expanding metal stent was inserted from just proximal to the ampulla to the distal antrum, effectively bridging the mass. Biopsy of the mass was consistent with high grade sarcoma, identical to the liver biopsy. Upper GI contrast series confirmed stent patency; patient tolerated an appropriately advanced diet, and was discharged home to continue outpatient chemotherapy.

DISCUSSION:

Based on our literature review, there have been no documented cases of gastric outlet obstruction secondary to duodenal LMS. Such tumors often present with abdominal pain and bleeding due to their highly vascular nature. In general, small intestinal malignancies are rare and often difficult to diagnose due to non-specific symptomatic progression resulting in delayed evaluation. Disease is often advanced to lymphatic spread or metastasis at diagnosis as was the case in our patient. A broad differential diagnosis should be considered in patients with unclear primary malignancies presenting with obstructive symptoms.