bluuebunny/crossref_metadata_2025 huggingface dataset:
2657 Novel Use of Radiofrequency Ablation in the Treatment of AVMs of Small Bowel Mucosa
Authors: Lysek Michael , Kumar Manoj , Fahmawi Yazan , Mizrahi Meir
Published: October 2019

INTRODUCTION:

Radiofrequency ablation (RFA) is a well-authorized treatment in a number of gastrointestinal conditions such as dysplastic Barrett’s, gastric antral vascular ectasia and biliary stricture. We are presenting a case series focused on the use of RFA in the treatment of small bowel AVMs through small bowel enteroscopy, using a novel through the scope radio frequency ablation catheter.

CASE DESCRIPTION/METHODS:

Cases: This case series encompasses five cases using a new through the scope radio frequency ablation caterer to treat AVMs found in the small bowel and cecum. The age for these patients ranged from 56 to 72 years old, with two being males and three being females. Our patients presented for various reasons, including abdominal pain, abnormal CT findings, and gastrointestinal bleeding. Colonoscopies and endoscopies on these patients were unremarkable. All patients underwent single balloon enteroscopy, and multiple arteriovenous malformations (AVMs) were found. AVMs were successfully ablated using a novel through the scope radio frequency ablation catheter (RFA-SB). AVMs in these patients were found in the cecum, jejunum, ileum and stomach. 12 J/cm2 energy was applied with each paddle application. All patients recovered well after the procedure and follow up CBC showed improvement in their hematocrit. No immediate or late procedure related complications were reported.

DISCUSSION:

AVMs are one of the common causes of gastrointestinal bleeding. Ablation of AVMs in the small bowel has typically utilized argon plasma coagulation (APC) as a treatment modality. This case series looks at the use of a new RFA-SB as a new treatment modality for small bowel AVMs. This series is novel, due to the length of the new RFA catheter, as it is able to pass through a 200 cm small bowel enteroscope with better maneuverability and providing a uniform therapy than traditionally used APC technique without healthy tissue damage and achieving satisfactory hemostasis.
2660 Duodenal Perforation Caused by Inferior Vena Cava Migration
Authors: Daid Sarav , Seo Dong Joo , Mangala Yashvin Onkarappa , Toubia Nabil
Published: October 2019

INTRODUCTION:

The Inferior Vena Cava filter is known as an effective method for preventing pulmonary thromboembolism in patients with deep vein thrombosis. Usually, the remaining IVC filters are asymptomatic and do not cause clinical problems. We report two cases of duodenal perforation caused by a remaining IVC filter which is very rare.

CASE DESCRIPTION/METHODS:

Case 1: 67 year old female patient with past medical history of heartburn,IVC filter placement presented at the GI outpatient clinic with complains of abdominal pain and heartburn for 6 months.After initial negative work up, Upper Endoscopy done showed small polyp at the metallic clip adjacent to the ampulla.Endoscopic ultrasound subsequently revealed a metal object traversing the duodenal wall. No biopsies or additional manipulation of the metal object were done until we did a CT scan which showed two distal anterior legs of the IVC filter extending into the transverse duodenum.This patient was referred to vascular surgeon for IVC filter removal but the patient's symptoms started resolving and after discussion with the patient it was decided not to proceed with the surgery and manage her conservatively. CASE 2: 37 y/o female seen in GI clinic for repeated episodes of nausea, vomiting, and abdominal discomfort which had been going on for 4 months and after negative initial work up, patient was scheduled for an Upper endoscopy which showed a metal like foreign body in the second portion of the duodenum and irritation of the opposite wall of the second portion of the duodenum with nodularity and represented a prong of the IVC filter which migrated into duodenum.Patient was referred to vascular surgeon for IVC filter removal and after the procedure post operatively she was kept on intravenous antibiotics and was discharged after she was able to tolerate regulate diet and was ambulating well.

DISCUSSION:

IVC filter perforation of the duodenum is fairly uncommon. It can manifest with abdominal pain, gastrointestinal bleeding, cava-duodenal fistula, or small bowel obstruction. Diagnostic evaluation include plain abdominal radiographs, CT scan and/or Upper Endoscopy.To prevent potential sequelae caused by IVC filter leg penetration, like that reported in this case, the removal of the IVC filter, when possible, is preferred.Also manipulations of the foreign body should be avoided until further confirmation is done by abdominal imaging.
2663 A Rare Presentation of Duodenal Carcinoid Tumor Complicated by Hemorrhagic Shock
Authors: Baseer Yaseen
Published: October 2019

INTRODUCTION:

A carcinoid tumor is a tumor that develops from enterochromaffin cells. These cells produce hormones and chemicals that have a profound impact on the circulatory system, gastrointestinal tract, and the lungs. Duodenal carcinoid tumors are rarely encountered in the clinical setting making up only 2–4% of all carcinoid tumors. They are also difficult to diagnose due to their nonspecific clinical presentation which include symptoms such as abdominal pain, jaundice, pancreatitis and weight loss. According to the general guidelines for the treatment of duodenal carcinoid tumors, endoscopic therapy is recommended for tumors measuring less than 1 cm in diameter, whereas surgical resection may be preferable for those measuring 1 cm or more. However, treatment guidelines for duodenal carcinoids are not yet standardized as a result of the lack of consistent data. The most feared complication of carcinoid tumors include carcinoid crisis but milder presentations may include anemia, shortness of breath and diarrhea.

CASE DESCRIPTION/METHODS:

A 79 year old male with a history of hypertension, hyperlipidemia, spinal stenosis, aortic stenosis and carcinoid tumor at the gastric bulb who previously refused interventional surgery presented to the hospital with a primary complaint of shortness of breath. Initial hemoglobin on presentation was 5.1 and patient noted to be in hemorrhagic shock with vital signs that included heart rate of 116 and blood pressure of 91/52. Patient was subsequently admitted to the intensive care unit and transfused a total of 6 units of packed red blood cells over the course of his 8-day hospital course. An octreotide scan performed during the hospital stay showed a carcinoid tumor at the gastric bulb that was not actively bleeding. This may be explained by the patient’s late presentation to the hospital after the carcinoid tumor bleeding had resolved. The patient at the conclusion of the hospital stay continued to decline any surgical intervention.

DISCUSSION:

This case highlights an unusual presentation of a patient with a history of carcinoid tumor that presented in hemorrhagic shock secondary to a duodenal carcinoid tumor. Previous research has shown complications of carcinoid tumors that range from diarrhea and shortness of breath to carcinoid crisis. However, hemorrhagic shock has not been demonstrated to be an association with carcinoid tumor. Further large scale retrospective studies may be needed to better evaluate to the full scope of carcinoid tumor complications.
2672 Gastric Amyloidosis: A Rare Cause of Gastropathy and GI Bleeding
Authors: Gregory Nicholas , Kachru Sumyra
Published: October 2019

INTRODUCTION:

Amyloidosis is a disorder of protein deposition that often presents with systemic symptoms. Symptoms of GI amyloidosis include abdominal pain, upper and lower GI bleeding, weight loss, diarrhea, malabsorption, esophageal reflux, and spontaneous bowel perforation. GI amyloidosis involves, from most to least common, the duodenum, stomach, colorectum, and the esophagus. In this case report, we will present a rare case of symptomatic AL amyloidosis localized to the stomach in which diagnosis and management was delayed by 3 months.

CASE DESCRIPTION/METHODS:

The patient was a 64-year-old African American woman who presented with a one-day history of fatigue and shortness of breath and a one-week history of dark stools. She had a past medical history significant for untreated plasma cell myeloma and chronic anemia. The patient had an EGD for intermittent dark stools 3 months prior to this admission which demonstrated severe gastropathy on endoscopic exam, but unfortunately no biopsies were taken at that point. The etiology of gastropathy remained unclear and nonspecific. During this hospitalization, with the patient’s ongoing history of melena, she underwent a repeat EGD which again showed severe localized gastropathy in the proximal stomach. A gastric biopsy was obtained from the area. On pathology review, the biopsy showed deposition of amorphous, eosinophilic material, suspicious for amyloid. Congo Red stain highlighted apple green birefringent material, consistent with amyloid. Patient remained hemodynamically stable during the hospital admission and was discharged before the pathology results were back. A week later, she was called to notify her of the results and to follow up with hematology oncology, but unfortunately patient had passed away at home, and the reason of death remained unclear.

DISCUSSION:

In a patient with GI bleed or other GI symptoms such as abdominal pain, nausea/vomiting, or change in bowel habits a probable etiology of amyloidosis should be on the differential, especially with history of plasma cell dyscrasia. Evaluation should include endoscopy with biopsy and specific amyloid staining if any obvious lesion is noted. Localized gastric amyloidosis presenting with GI bleeding is rare. This rarity may lead clinicians to dismiss it as a possibility which can delay diagnosis and proper management. This case report demonstrates such a situation in which a patient with plasma cell myeloma and symptoms of GI bleeding was delayed diagnosis and management by 3 months.
2680 IgG4 Related Disease Presented as Diffuse Gastric Wall Thickening Resembling Gastric Cancer
Authors: Al Jobori Hussein , Castano Juan , Al Gburi Karrar , Garrison Keith , Chacon Ingrid , Herrera Henry R.
Published: October 2019

INTRODUCTION:

IgG4 related disease (IgG4-RD) is an immune-mediated condition first described in 2001 as part of autoimmune pancreatitis with subsequent recognition as a systemic condition in 2003. IgG4-RD is characterized by lymphoplasmacytic infiltrates enriched with IgG4-plasma cells that involve different organ systems. The pathogenesis is still being studied. We present a case of gastric IgG4-RD initially suspected to be gastric cancer.

CASE DESCRIPTION/METHODS:

A 64-year-old woman with a history of Sjogren’s disease, presented with a one-month history of nausea, vomiting, abdominal pain, and poor appetite. Home medication included prednisone 10mg TID. Physical exam was non-contributory. Pertinent lab results showed elevated serum IgG, normal IgG4, elevated ANA and SS-A/Ro antibodies. CT abdomen/pelvis showed diffuse wall thickening in the stomach. EGD showed severe diffuse gastropathy with areas of ischemic tissue and fistula tracts. EUS showed marked submucosal gastric thickening. Endoscopic biopsies showed gastric epithelium with ulceration, inflammation, granulation tissue, and atypical cells, negative for H. Pylori. Endoscopic and EUS FNA biopsies were not diagnostic. The patient then underwent full thickness biopsy which showed IgG patchy dense plasma cells with an increase in IgG4 positive plasma cells. The patient had a complicated course with a gastric leak from the surgical biopsy site that eventually healed with observation and steroid therapy.

DISCUSSION:

Most cases of IgG4-RD involve 2 or more organs and commonly include pancreas, lymph nodes, bile ducts, salivary glands, lacrimal glands, kidneys, retroperitoneum, & lungs which account for 85% of IgG4-RD. Involvement of the GI tract is rare. Our case represents an example of isolated IgG4-RD of the stomach. Literature review showed 13 case reports of gastric IgG4-RD although most were presenting as a solitary mass treated with surgical therapy. Our case report is unique in that our patient presented with diffuse gastric involvement with the appearance of linitis plastica. It is also interesting because IgG4-RD was previously reported to have an association with Sjogren’s Syndrome (SS) or its subtypes; Mikulicz disease, and Küttner tumor. Our patient did not have a further investigation of her SS. Since IgG4-RD of the stomach could mimic gastric cancer clinically, it is essential to recognize it early with immunohistochemical, pathological testing, clinical correlation, and treatment to avoid the morbidity associated with gastrectomy.
2681 Emphysematous Gastritis: A Rare Consequence of Small Bowel Obstruction
Authors: Landesman Nathan , Patel Kruti , Kahl Ryan , Price Michelle D.
Published: October 2019

INTRODUCTION:

Emphysematous gastritis is a rare form of gastritis that is characterized by presence of gas in the gastric wall and portal venous system. Prompt diagnosis along with early treatment is key in preventing fatal outcome. Etiology can be ingestion, infectious, mechanical, or ischemic with high mortality. We present a case of emphysematous gastritis in a patient with small bowel obstruction presenting with hematemesis.

CASE DESCRIPTION/METHODS:

A 70 year African American female with past medical history significant for HTN and Atrial Fibrillation (anticoagulated with Eliquis) presented with complaint of epigastric pain and hematemesis. CT abdomen/Pelvis without contrast showed acute high grade small bowel obstruction at the distal ileum, non-obstructing umbilical hernia and stomach distention with emphysematous gastritis with air in the portal venous system. Patient was hemodynamically stable. Laboratory findings with hemoglobin 13.0 g/dL (11.0-16.2 g/dL), mean corpuscular volume 76.7 fl (80.0—100.0 fl), platelet count 138 K/cmm(140-440L/cmm), white blood cell count 8.2 K/ccm (4.5-11.0 L/cmm) with 32% segmented neutrophils.Patient underwent exploratory laparotomy with release of small bowel obstruction and primary repair of umbilical hernia. Intraoperative Esophagogastrodudenoscopy (EGD) showed diffuse erythema and ulceration in the esophagus, areas of black/purple mucosal discoloration in the gastric cardia, fundus and body with clear demarcation of abnormal and normal tissue at body/antrum. Pylorus was patent with unremarkable first and second part of the duodenum. Findings were consistent with emphysematous gastritis. Patient tolerated the procedure well and was extubated without any hemodynamic decompensation. Broad spectrum antibiotics which were initiated were stopped as blood cultures x 2 had no growth. Patient was discharged from hospital on post op day four with Pantoprazole 40 mg twice daily and follow up endoscopy.

DISCUSSION:

Emphysematous gastritis is a condition with very high mortality rate of 50-80%. No standardized/definitive approach has been described in the literature though many cases do undergo prompt surgical exploration. Our case portrays a multidisciplinary approach to management of emphysematous gastritis with exploratory laparotomy for small bowel obstruction and intraoperative endoscopy without any need for resection or manipulation of effected area.
2686 Collagenous Gastritis: A Rare Entity
Authors: Yazdanpanah Fariba , Hindy Pierre , Rahmani Rabin , Tin Kevin
Published: October 2019

INTRODUCTION:

Collagenous gastritis is a rare entity characterized by subepithelial deposition of collagen bands thicker than 10 μm and the infiltration of inflammatory mononuclear cells in the lamnia propia. While collagenous colitis has become more common in clinical practice, collagenous gastritis is rare. These two entities generally present differently. Collagenous colitis presents more commonly with diarrhea, while collagenous gastritis presents more commonly with abdominal pain. Since the disease was reported in 1989, only 60 cases have been documented in English literature. We present a case of collagenous gastritis in a pediatric patient.

CASE DESCRIPTION/METHODS:

A 17-year-old male patient presents to our office with a three month history of epigastric pain with no changes in bowel habits. He denies any previous past medical or surgical history. He immigrated to the United States from China. Physical examination was unremarkable aside from mild epigastric tenderness. A CMP, CBC and celiac serologies were unremarkable. Upper endoscopy was performed which revealed moderate erythematous mucosa in the gastric antrum (Figures 1 and 2). Biopsies of the antrum yielded mild chronic gastritis with sub-epithelial collagenous gastritis in the antrum (Figure 3). Helicobacter Pylori was negative. Patient symptoms gradually responded to a proton pump inhibitor.

DISCUSSION:

Collagenous gastritis is a rare condition with limited data in the literature. Most patients are young, abdominal pain and anemia occur secondary to stomach-specific infiltration. The etiology is mostly unknown and hypothesized. The endoscopic findings that are commonly reported include nodular changes in the mucosa, due to chronic inflammatory infiltration, mucosal atrophy and deposition of bands of collagen. Compared with the diffuse and continuous deposition seen in collagenous colitis, the changes in collagenous gastritis are heterogenous. Collagenous gastritis as a rare entity should be in the differential in younger patients who present with epigastric pain.
2696 Dysphagia: A Rare Presentation of Multiple Myeloma
Authors: Ghazaleh Sami , Nehme Christian , Khader Yasmin , Ghanim Marcel , Alhmoud Tarik
Published: October 2019

INTRODUCTION:

Dysphagia is a common symptom with a broad differential diagnosis. Although the etiology of dysphagia is usually benign, it is critical to rule out serious causes. It is also important to think outside the box when the cause is not obvious. We describe a case of multiple myeloma that presented with dysphagia.

CASE DESCRIPTION/METHODS:

An 81-year-old male patient presented with progressive dysphagia to solid food associated with poor appetite and weight loss of 50 lb. over the last 6 months. Past medical history was significant for coronary artery disease, essential hypertension, hypothyroidism, chronic hepatitis B infection, and sarcoidosis. Past surgical history and family history were insignificant. Home medications included aspirin, atenolol, quinapril, levothyroxine, and entecavir. He denied the use of tobacco, alcohol, and illicit drugs. Review of systems was unremarkable On physical exam, the patient looked chronically ill and cachectic. Vital signs were within normal limits. Abdominal exam showed a soft, non-tender, and non-distended abdomen without organomegaly. Initial laboratory workup revealed microcytic anemia with a hemoglobin of 11.6 g/dL. He underwent upper endoscopy which revealed patchy erythema in the gastric antrum. Gastric biopsy was performed with findings of acellular, eosinophilic deposits and a Congo red stain showed apple-green birefringence on polarized light consistent with gastric amyloidosis. Further workup was done to look for the cause of amyloidosis. Serum and urine protein electrophoresis failed to show a monoclonal (M) band. Immunofixation revealed elevated free kappa light chains of 104.90 mg/dL and elevated free Kappa/Lambda ratio of 156.57. Bone marrow biopsy revealed that plasma cells constituted 28.5% of bone marrow cells. The patient was diagnosed with multiple myeloma (light chain myeloma) and was started on bortezomib, lenalidomide, and dexamethasone. During a follow-up visit 1 month later, he reported improvement in dysphagia and weight gain.

DISCUSSION:

Gastrointestinal involvement is common in patients who have amyloidosis. However, it is rare for amyloidosis to initially present with gastrointestinal symptoms. Depending on the site involved, patients can present with dysphagia, gastrointestinal bleeding, constipation, malabsorption, or protein-losing gastroenteropathy. Identification and treatment of the underlying disease, e.g. multiple myeloma, is important because it can lead to regression of gastrointestinal amyloidosis.
2700 A Rare Case of Hypersalivation as the Presenting Symptom of Zollinger-Ellison Syndrome
Authors: Kucharski Kimberly , Clayton Steven
Published: October 2019

INTRODUCTION:

Zollinger-Ellison Syndrome (ZES) is characterized by hypersecretion of gastrin from duodenal or pancreatic gastrinomas. Ectopic secretion of gastrin results in high gastric acid output due to the trophic action of gastrin on parietal cells and histamine-secreting ECL cells. ZES typically presents with symptoms of severe acid-related peptic ulcer disease such as abdominal pain, diarrhea, heartburn, and weight loss as well as complications from acid hypersecretion such as GI bleeding, stricture, and perforation. We report a novel case of a 60-year-old female who presented with hypersalivation as her chief complaint.

CASE DESCRIPTION/METHODS:

A 60-year-old female with type 2 diabetes mellitus, gastroparesis, and GERD presented to her gastroenterologist with nausea, hypersalivation and a “sour taste” in her mouth over the past few months. She states that this sour taste is constantly in her mouth and throat but is worse in the evenings. Her symptoms are associated with belching but she denies any heartburn. Medications at that time included pantoprazole 40 mg daily and ranitidine 150 mg BID. She initially underwent EGD with findings of chronic gastritis. Gastric biopsies were consistent with mild chronic gastritis with foveolar hyperplasia and intestinal metaplasia and staining for H.pylori was negative. Serum fasting gastrin level was significantly elevated at 1,379 pg/mL (normal < 100 pg/mL). CT abdomen/pelvis revealed a 13 × 12 mm subtly enhancing soft tissue density between the pancreatic head and the lumen of the duodenum, with concern for neuroendocrine tumor. The patient is scheduled to undergo further evaluation of these CT scan findings with endoscopic ultrasound and fine needle aspiration.

DISCUSSION:

This case is an example of an atypical presentation of ZES leading to delayed diagnosis and treatment. Symptoms of hypersalivation have been described in GERD, however the literature does not describe any cases of hypersalivation as a presenting symptom in patients with ZES. It is thought that reflux of stomach acid into the pharynx may lead to an increase in saliva production in order to neutralize the excess acid. The rare nature of ZES can lower clinical suspicion for the disorder and ultimately result in a delay in diagnosis. This case provides a unique example of ZES that highlights the importance of increased awareness of this disorder in patients who present with chronic GI symptoms despite adequate therapy.
2710 Asymptomatic Bochdalek Hernia in an Adult Male: A Rare Entity
Authors: Then Eric O. , Castillo Adonis , Ofosu Andrew , Gayam Vijay , Culliford Andrea , Gaduputi Vinaya
Published: October 2019

INTRODUCTION:

Bochdalek hernias (BH) are a type of congenital diaphragmatic hernia that mostly present in children. The diagnosis of a Bochdalek hernia in an adult patient is extremely rare accounting for an estimated 0.17% to 6% of all diaphragmatic hernias. Here we present a case of an asymptomatic Bochdalek hernia in adult patient.

CASE DESCRIPTION/METHODS:

Patient is a 51 year old female with a medical history of mental retardation, diabetes mellitus type 2, who was referred to our gastroenterology clinic for chronic constipation and abdominal mass. Per the patients nursing aid, on prior exam an abdominal mass was palpated on routine physical exam. On presentation to our clinic her physical exam was unremarkable. Recent complete blood count and comprehensive metabolic panel were within normal limits. Given these findings a computed tomography scan of the abdomen was done. This was done and showed no masses within the gastrointestinal tract, but was remarkable for a moderate sized left bochdalek type hernia with associated herniation of the third and fourth portions of the duodenum and the splenic flexure of the colon, without CT evidence of incarceration. On return visit, the patients nursing aid and family were notified of the findings, but refused surgical intervention for possible correction. She remained asymptomatic on follow up visits and the family continued to refuse treatment.

DISCUSSION:

Bochdalek hernias (BH) result are a rare congenital anomaly that results from a persistent pleuroperitoneal that occurs due to failure of the postero-lateral foramina to fuse. This allows contents of the abdomen to herniate into the thorax. Symptoms of BH depend on location. Right sided BHs may present with herniation of the liver and intestine. Left sided BHs may present with herniation of the stomach, small intestine and colon. Diagnosis of BH in adults can be challenging as symptoms are non-specific (mild abdominal pain) and up to 25% of patients are asymptomatic. Diagnosis of BHs in adults can be accomplished through imaging modalities such as computed tomography, magnetic resonance imaging, and fluoroscopy. The treatment of choice for BH is surgical repair. This should be considered in asymptomatic patients as well, given the potential for strangulation of the herniated contents.
2719 A Rare Cause of Chronic Diarrhea: Gastrocolic Fistula
Authors: Som Aniruddh , Mahmood Syed , Nath Anand , Patel Mitesh R.
Published: October 2019

INTRODUCTION:

Gastro-colic fistula is a pathological fistulous tract usually between the stomach and the transverse colon. It is a rare presentation of both benign and malignant diseases of the GI tract. Most cases in the modern world are related to adenocarcinomas of the colon. Benign fistulas are a rarer occurrence due to advancements in the medical management of peptic ulcer disease. Here we present a case report of a benign gastro-colic fistula occurring in the setting of a prior Whipple’s surgery.

CASE DESCRIPTION/METHODS:

A 61-year-old male presented with chronic diarrhea associated with a 50-pound weight loss, fatigue, and weakness. His past surgical history was notable of a Whipple’s procedure done 10 years ago. A trial of lactose-free diet and a course of antibiotics did not improve his symptoms. Upon further investigations, it was revealed that patient had anemia, hypokalemia and a low albumin level. Workup was negative for celiac disease, carcinoid syndrome, gastrinomas, and therefore the patient had an endoscopy which revealed a benign gastro-colic fistula in the setting of an anastomotic pyloric ulcer eroding into the transverse colon. He was then referred for surgery following optimization of his nutritional status.

DISCUSSION:

A majority of cases are due to malignancy, specifically gastric cancer or transverse colon cancer, although fistulas due to benign causes have also been described. In addition, cases of gastrocolic fistula have been observed in the setting of prior gastric surgeries but the interval duration of development has been reported to be around 8 to 9 months. Patients generally present with undifferentiated symptoms like diarrhea, weight loss, abdominal pain, nausea and vomiting making the diagnosis difficult. Radiologic imaging studies such as barium enema (most sensitive test) and barium meals are the mainstay of diagnosis. Endoscopy is usually not recommended as a diagnostic tool. Endoscopy with biopsy is primarily done as part of the workup to rule out malignancy. Definitive treatment includes surgical resection. Conservative medical management such as proton pump inhibitors should be considered when surgery is contraindicated or in cases that occur in the setting of peptic ulcer disease.
2720 Iron Pill-Induced Gastropathy in Elderly Patients: A Case Series Report
Authors: Comba Isin Y. , Henriquez Richard , Kumar Sundeep , Wallis-Crespo Maria , Srinivasamurthy Ruthvik , Bhatia Lakhinder , Shultz Joshua
Published: October 2019

INTRODUCTION:

Iron deficiency anemia is a global health problem with an estimated two billion cases worldwide. Oral iron supplementation is considered the first line treatment. However, recent studies favor the use of short-term IV iron especially in patients with drug tolerance and efficacy concerns. In this report, we present three cases of iron pill gastropathy in patient's whose clinical courses were complicated by gastric erosion, ulcer or gastrointestinal (GI) bleeding. All of our patients had a history of iron deficiency anemia and were being treated with oral ferrous sulfate.

CASE DESCRIPTION/METHODS:

The first case involved a 72-year-old male with multiple comorbidities was admitted to the hospital for an NSTEMI. Initial labs revealed severe microcytic anemia (Table 1). He denied any hematemesis, melena, or hematochezia. During his hospital stay, he underwent an EGD which showed several erosions in the antrum with no active hemorrhage or visible vessels. Biopsy taken from the erosions demonstrated reactive gastritis with chronic inflammation and focal pigmented deposits stained positive with iron dye. After establishing the diagnosis iron gastropathy, the patient was transitioned to IV iron. In a second case, an 81-year-old male presented with a three-day history of abdominal pain associated with nausea and vomiting. The patient was started on proton pump inhibitors, IV hydration, and antiemetics for suspected acute gastritis with complete resolution of the symptoms. Severe anemia on initial labs prompted an EGD, which showed a superficial ulcer in the gastric body with a caustic appearance. Microscopically, focal iron deposits were remarkable in the area of erosions and were consistent with iron gastritis. Lastly, an over-90-year-old female presented with acute shortness of breath. Initial labs revealed worsening iron deficiency anemia. An EGD showed erosions within the gastric body with mild superficial gastritis. Microscopically, biopsied erosions showed yellow deposits within the mucosa, which stained positive for iron.

DISCUSSION:

Iron pill gastropathy is an underrecognized condition particularly in the elderly. The liquid form of oral iron has been shown to be less toxic to the gastric mucosa compared to the tab formulation. Transition to liquid or IV iron should be considered in patients with iron gastropathy as use of iron pills can lead to gastric erosions, ulcers, and GI bleeding, which can worsen the underlying anemia and result in cardiovascular symptoms related to severe anemia.
2723 Abdominal Aortic Aneurysm: An Uncommon Cause of Gastric Outlet Obstruction
Authors: Taylor Rachel A.
Published: October 2019

INTRODUCTION:

Gastric outlet obstruction is a highly uncommon presentation for abdominal aortic aneurysm.

CASE DESCRIPTION/METHODS:

A 65 year old male with past medical history of AAA, HCV treated with Harvoni, GERD with gastritis, and HTN presented with intractable nausea and non-bloody, bilious vomiting for 6 hours associated with sudden onset generalized abdominal pain. Patient reports that he had been having regular bowel movements and passing flatus in the days leading up to presentation. GERD had been previously well-controlled with a PPI. Physical exam revealed a 5 cm pulsating mass in the epigastrium. CTA demonstrated gross distension of both the stomach and the proximal duodenum. The abdominal aortic aneurysm measured 5.2 cm by 4.2 cm and extended over 10 cm in length; an increasingly large false lumen was also noted. There was no other obstructing lesion appreciated on CT, either intra- or extra-luminal. The enlarging aortic aneurysm impinged upon and caused the obstruction of the distal duodenum.

DISCUSSION:

An expanding abdominal aortic aneurysm can compress the duodenum against the mesenteric artery or abdominal wall, causing gastric outlet obstruction; this obstruction leads to patients presenting with nausea and vomiting. Aortoduodenal syndrome was first described in 1905 by Osler. There are a few dozen case reports of aortoduodenal syndrome in the literature. Any patients presenting with protracted vomiting and pulsatile abdominal mass should raise suspicion for aortoduodenal syndrome. Abdominal tenderness and distension are not common findings in this syndrome. CT is required to rule out an alternative cause of duodenal obstruction; diagnosis may be confirmed with upper GI series with contrast or upper endoscopy. Patient should be initially optimized with gastric decompression, fluid resuscitation, and electrolyte correction before preceding to definitive treatment. Previously, gastric bypass was the general treatment prior to the introduction of surgical aortic repair. Aortic aneurysm repair is the mainstay of therapy with endovascular repair becoming increasingly common.
2736 A Rare Case of Gastric Sarcoidosis
Authors: Prakash Sameer , Merza Nooraldin , Beggs Daniel
Published: October 2019

INTRODUCTION:

Gastrointestinal involvement in sarcoidosis is quite rare, in which it either presents as systemic disease or as an isolated case. It can mimic other disease processes, including malignancy, gastritis, and peptic ulcer disease. We present a 28-year-old female who had weight loss, epigastric pain, and early satiety found to have symptomatic gastric sarcoidosis that rapidly improved with steroid treatment.

CASE DESCRIPTION/METHODS:

A 28-year-old with no past medical history presented to the emergency department with complains of epigastric pain, weight loss, and early satiety. She had onset of pain in epigastrium described “like ringing out a washrag”, better with eating and marked early satiety. She was found to have an iron level of 11 with period less heavy than years ago. Vitals showed Wt 142 lb, BP 118/66, Pulse 85, and O2 sat 98% on room air. Physical exam was significant for only epigastric tenderness and bilateral edema. Labs showed hemoglobin 8.9, MCV 57, iron level 11, Na 138, Cl 108, and CO2 20. EGD showed body and antrum with markedly thickened, pale appearing, firm/friable folds. Colonoscopy showed no abnormalities. Gastric fold biopsies showed noncaseating epithelioid granulomatous infiltrate suggestive of sarcoidosis. AFB and GMS fungal stains showed no microorganisms and H. Pylori was negative. The patient was initially started on prednisone 40 mg daily tapering dose and had near immediate resolution of symptoms with increase in weight.

DISCUSSION:

Sarcoidosis is a systemic disease characterized by pathognomonic formation of noncaseating granulomas with rare gastrointestinal involvement. Infection, malignant, and inflammatory causes must be ruled out as part of the broad differential before making diagnosis of sarcoidosis. Patients typically have symptoms of early satiety, nausea, and weight loss. Gross findings on endoscopy typically include mucosal nodularity, thickened and enlarged irregular folds, and deformity of the antrum. For recurrence of symptoms, surveillance endoscopy is warranted to examine extent of disease. As in our patient, there is excellent response to glucocorticoid treatment and patients should be monitored clinically with tapering doses.
2744 A Scary Case of Gastroenteritis
Authors: Dave Kairavee , Choksi Vivek , Cantave Rulz T. , Sorathia Sufian J. , Kaplan Steven R.
Published: October 2019

INTRODUCTION:

Gas in the gastric venous system or the portal venous system is a critical finding and can be from a life threatening abdominal catastrophe as well as from benign conditions.

CASE DESCRIPTION/METHODS:

A 52 year old gentleman presented with nausea, vomiting and diarrhea for 2 days. He had multiple episodes of non bloody diarrhea for past two days and had an episode of vigorous non bilious/ non bloody vomiting. No fevers, chills or weight loss was reported. His medical history included diabetes mellitus type 2, hypertension, obstructive sleep apnea, depression and anxiety. On admission, his vitals were stable. The physical examination was completely benign. His laboratory data revealed mild leukocytosis of 13.3. Lactate was normal. There was no anemia or microcytosis. A CT scan of his abdomen was done which revealed gas in the gastric veins and the peri-gastric veins, which was very concerning. Urgent Surgical consultation was placed. The patient was admitted to step down unit and conservative management with hydration, anti emetics and supportive care was initiated. In the next 4 hours, the patient started feeling better and became asymptomatic. The CT of the abdomen was repeated. The entire patient care team was on high alert for a possible abdominal catastrophe/ischemia and need for emergent surgery. The repeat CT scan was done 6 hours later which revealed linear lucencies within the peripheral aspect of the left lobe of the liver, consistent with gas within the portal venous system. Urgent Infectious Disease consultation was called and piperacillin-tazobactam was initiated. At this time, the patient was asymptomatic, his vitals were stable, the lactate remained normal and the leukocytosis had resolved in the repeat laboratory analysis. Close monitoring was continued. The next day, the patient remained in the stable and asymptomatic. A third repeat CT scan of the abdomen revealed complete resolution of all the gas in the gastric and the portal venous system. The diet and activity were advanced gradually and the patient was discharged the same day.

DISCUSSION:

It is important to recognize that there are many benign causes of gastric venous gas and portal venous gas such as gastroenteritis. We believe that the mechanical trauma of retching and vigorous vomiting may have lead to this finding.
2748 The Apple Green GI Tract: A Rare Case of Gastrointestinal Amyloidosis
Authors: Ashamalla Michael , Wander Praneet , Pizzuti Jessica , Lech Diana , Rishi Arvind , Vitkovski Taisia , Greenberg Ronald
Published: October 2019

INTRODUCTION:

Amyloidosis is a heterogenous disease, characterized by the extracellular deposition of an abnormal fibrillar protein, which disrupts tissue structure and function. Gastrointestinal involvement in amyloidosis is a rare entity that can result from mucosal and neuromuscular infiltration, or extrinsic autonomic neuropathy. Diagnosis is difficult as significant variation can exist within an individual type of amyloid and visceral involvement is rarely on a clinicians differential diagnosis. We present a case of gastrointestinal amyloidosis in a 62 year old Male who presented with nausea and vomiting.

CASE DESCRIPTION/METHODS:

62 year old Male with a past medical history significant for tobacco use presented to the Emergency Department (ED) with a chief complaint of nausea and non bloody-non bilious emesis of three weeks duration. He reported early satiety, abdominal bloating, and unintentional 40 pound weight loss over one year. Several days prior to his presentation, he developed bilateral lower extremity edema. He denied any nausea, hematemesis, dysphagia, abdominal pain, melena or hematochezia and never had a previous upper or lower endoscopy. On presentation to the ED, his vitals were stable. He was ill appearing with temporal wasting and his abdomen was soft, nontender, without hepatosplenomegaly. Laboratory data was notable for a Hemoglobin 9.8 (MCV 78), Albumin 1.7, and a positive fecal occult test. Gastroenterology was consulted and the patient underwent an upper endoscopy given red-flag symptoms. His endoscopy revealed an edematous GE junction, severe diffuse gastric erythema with erosions, congested and friable gastric body folds, deformed duodenal bulb and edematous second portion of duodenum suspicious for extrinsic compression. Endoscopic biopsies were obtained using cold forceps. Small bowel biopsies detected amyloid deposits supporting a diagnosis of AL (lambda)- type amyloid deposition. He was referred to Hematology/Oncology and was subsequently started on standard triple therapy including lenaolidmide, bortezemib, and prednisone.

DISCUSSION:

Biopsy proven amyloidosis of the gastrointestinal tract is rare. Because presentation is insidious, with multiple vague symptoms, the possibility of systemic amyloidosis is often overlooked, resulting in substantial delays in diagnosis. A high index of suspicion is therefore required. Staining for amyloidosis should be considered in patients undergoing gastrointestinal biopsy who have unexplained chronic gastrointestinal symptoms.
2750 Acute Neck Pain Masquerading as Acute Gastric Volvulus
Authors: Saghir Syed Mohsin , Shafi Amaan , Elias Michael , Pellnitz Matthew , Riaz Jahan Z. , Ohning Gordon
Published: October 2019

INTRODUCTION:

Gastric volvulus is a rare cause of gastric outlet obstruction that if not recognized early can lead to ischemia, necrosis and death. Organoaxial is the most common type and is seen with secondary anatomic defects i.e. paraesophageal hernias, diaphragmatic hernias and diaphragm eventrations. It occurs in 60% of cases with 30% risk of strangulation. Risk factors include age >50 years, secondary anatomic defects, phrenic nerve paralysis and structural abnormalities of the stomach/spleen. Symptoms include abdominal pain, chest pain, retching and/or vomiting. Misdiagnosis occurs because of its nonspecific presentation. We describe a case of a patient who was admitted for suspect acute coronary syndrome and found to have an acute gastric volvulus.

CASE DESCRIPTION/METHODS:

75 yo m with pmh of HTN, who p/w sudden onset neck pain radiating to L arm, with N/V during activity. He denied chest pain, SOB or diaphoresis. Vitals were T 98 F, HR 85, BP 156/69, and RR 18. On exam pt had decreased breath sounds LLL, NT abdomen, and left paraspinal neck tenderness. Pertinent labs: WBC: 11. Chemistry with hypokalemia. Normal troponins. CXR showed L hemidiaphragm elevation and hiatal hernia. Neck imaging was normal. EKG was normal without st changes. Overnight the pt became altered with intractable neck pain, nausea and vomiting. Repeat cxr showed widened mediastinum. A stat CTA chest/abd/pelvis showed organoaxial gastric volvulus with fluid filled esophagus. EGD abnormalities lead to an ex-lap with gastrostomy, gastropexy and volvulus reduction. Pt did well and went to a rehab facility.

DISCUSSION:

Gastric volvulus often manifests with abdominal pain in addition to nausea and vomiting rather than neck or chest pain. There have been reports of cases mimicking acute coronary syndrome. Intractable neck pain without abdominal pain is an extremely rare phenomenon in patients with acute gastric volvulus. In order to establish a diagnosis in our patient, a high index of suspicion was imperative for identifying an atypical presentation of acute gastric volvulus. This was illustrated by ordering a CT chest as soon as he became more ill-appearing. In retrospect, the intractable neck pain could have been considered as referred pain from the elevated left hemidiaphragm in the setting of a known hiatal hernia. Literature search was heterogeneous and scarce. Thus, we recommend high index of suspicion for acute gastric volvulus in the setting of intractable neck pain in order to intervene earlier and avoid worse outcomes.
2781 Plexiform Angiomyxoid Myofibroblastic Tumor of the Gastric Cardia: An Uncommon Tumor With an Even Less Common Location
Authors: Gardner Ramsey , Dukes Seth , Dustin Albert , Johnson Jeptha , Weeks Sharon , Laczek Jeffrey T.
Published: October 2019

INTRODUCTION:

Plexiform angiomyxoid myofibroblastic tumor (PAMT) is a rare gastric tumor of stromal origin with unique immunohistochemical characteristics that differentiate it from other more common gastric stromal tumors. Since its first description in 2007, nearly all have been localized to the gastric antrum. We present a case of a symptomatic PAMT in the gastric cardia successfully treated with resection.

CASE DESCRIPTION/METHODS:

A 51 year old female complained of left sided abdominal pain, nausea, and early satiety. Esophagogastroduodenoscopy showed a 3 cm endophytic sub-epithelial mass in the posterior wall of the gastric cardia. Follow-up endoscopic ultrasound revealed an 18 mm × 33 mm hypoechoic mass contiguous with the muscularis propria (MP). Biopsies revealed a myxoid lesion composed of bland spindle cells, consistent with a PAMT. The patient was considered for resection given the proximity to the GEJ. Unfortunately, endoscopic management was unsuccessful and the patient subsequently underwent laparoscopic gastric wedge resection sparing the GEJ. Histologic exam revealed bland spindled cells within an eosinophilic fibromyxoid stroma with eosinophilic cytoplasm. While SMA and desmin stains were positive, C-Kit (CD117), DOG-1, and S-100 stains returned negative, confirming a PAMT. The patient’s postoperative course was uneventful at the six week follow-up with resolution of abdominal pain, nausea, and early satiety.

DISCUSSION:

PAMT is a rare benign tumor most commonly located in the antrum. Although patients are often asymptomatic, ulceration with bleeding, and obstruction are reported. It presents as a submucosal mass ranging from 2 cm – 15 cm. Diagnosis is histological with a nodular to plexiform growth pattern with well-circumscribed islands of spindle cells located within the MP and possible extension into the submucosa with ulceration. The tumor is composed of bland spindled cells separated by loose stroma with myxoid to fibromyxoid material. Cells are indistinct with eosinophilic cytoplasm, bland nuclei with inconspicuous nucleoli. Limited is known about progression of a PAMT but they appear to be slow growing with a good prognosis. Treatment largely consists of surgical resection, although endoscopic mucosal resection has been reported. This case presents a rare location of this rare tumor highlighting the importance of considering it with proximal gastric lesions.
2792 A Retrospective Study of Probiotic Use in Patients With Chronic Pancreatitis
Authors: Aponte-Pieras Jose , Wassef Wahid
Published: October 2019

INTRODUCTION:

Chronic pancreatitis is a debilitating condition that develops following recurrent episodes of pancreatitis. It increases morbidity, decreases quality of life and leads to high utilization of medical resources. There is no definitive medical treatment. Studies have shown that gut microbiota may play a role in pancreatitis as bacterial and endotoxin translocation can contribute to severity. Bacteria such as lactobacillus, and bifidobacterium have been noted to be lower in chronic pancreatitis while enterobacteriaceae species were identified at higher levels in those. Probiotics can increase concentrations of bifidobacteria, lactobacilli and streptococci, preventing overgrowth of non-commensals. We are focused on researching new strategies to prevent disease progression and decrease length of hospital stay.

METHODS:

Retrospective chart review of a database of 86 chronic pancreatitis patients and probiotic use. All patients were cohorted based on severity of disease as rated on EUS using a scale of 1-5 with grades 1-3 grouped as “non-severe” and 4-5 as “severe.” We chose a null of 0.05 with a 95% confidence interval for statistical significance. Relative risk assessments were conducted on the rate of severe chronic pancreatitis in users of probiotics versus negative control.

RESULTS:

Our initial results revealed that 34% of patients had used probiotics since diagnosis of chronic pancreatitis on EUS. The rate of severe pancreatitis for the cohort of probiotic users was 0.241, and that for negative control was 0.298. A relative risk assessment for our population found a relative risk of 0.81 (95% CI, [0.379-1.727]; P = 0.2922) for the rate of severe chronic pancreatitis given exposure to probiotics. The result suggested a potential effect from probiotics on decreasing the risk of having severe chronic pancreatitis but was not statistically significant.

CONCLUSION:

There was no significant association between probiotic use and severity of chronic pancreatitis. We cannot exclude that probiotics may have a protective or therapeutic immunomodulatory effect on the microbiome of patients with chronic pancreatitis. This study is limited to a chart review in order to determine the extent of probiotic use in patients and cannot verify compliance with probiotics. We cannot report a correlation between probiotic use and severity of chronic pancreatitis.