bluuebunny/crossref_metadata_2025 huggingface dataset:
1596 Adult Colocolic Intussusception: A Case Series
Authors: Shahid Tamoor , Hertan Hilary
Published: October 2019

INTRODUCTION:

Intussusception of the bowel is defined as the telescoping of a proximal segment of the gastrointestinal tract within the lumen of the adjacent segment and is found frequently in children. It is less common in adults. Most of the intussusceptions in adults are caused by a definite underlying disorder such as neoplasm.

CASE DESCRIPTION/METHODS:

•A 26-year-old healthy male presented with acute left abdominal pain. Examination showed minimal tenderness in the left lower quadrant with no palpable mass. An abdominal CT scan showed intussusception along with regional pericolic lymph nodes. Colonoscopy was performed which showed a 5 cm ulcerated, partially obstructing mass in the descending colon. The patient underwent laparoscopic left hemicolectomy later and biopsy results showed moderately differentiated invasive adenocarcinoma, mucinous type, with no lymphovascular invasion. •A 44-years-old healthy male presented with severe abdominal pain and distention. Examination revealed severe abdominal tenderness and distention with diminished bowel sounds. Abdominal imaging revealed right-sided colocolic intussusception with possible underlying mass, dilated small bowel loops consistent with small bowel obstruction and innumerable hepatic metastases. The patient went for emergent right hemicolectomy. Pathology showed invasive adenocarcinoma of the cecum. The patient is planned for chemotherapy by oncology. •An 84-years-old female with no history of colonoscopy came for evaluation of right side abdominal pain. She had abdominal imaging which showed colocolic intussusception noted at the hepatic flexure with associated wall thickening, suggestive of underlying colonic mass. GI and Surgery evaluated the patient for endoscopic diagnostic workup and possible surgical intervention based on that but the family refused and opted for comfort care.

DISCUSSION:

Adult intussusception occurs relatively rarely; accounting for 5% of all cases of intussusceptions. A specific lead point is identified in more than 90% of cases while 10% of cases are idiopathic. Malignant lesions account for up to 30% of cases in the small intestine and 66% of the cases in the large intestine. An abdominal CT scan is the diagnostic modality of choice in these patients. It may also help in defining the location, the nature of the mass and it may help to stage the patient with suspected malignancy causing the intussusception. Intussusception associated with malignancy should be managed by multispecialty collaboration.
1598 Late-Onset Post-Transplant Lymphoproliferative Disorder Presenting as Diffuse Large B-Cell Lymphoma in the Ascending and Transverse Colon
Authors: Levine Louis J. , Groff Andrew , Gordin Yuri , Manzo Carl , Munyon Ryan , Krok Karen
Published: October 2019

INTRODUCTION:

A serious complication of solid organ transplantation is post-transplant lymphoproliferative disorder (PTLD). The vast majority of PTLD was previously found to present within the first year after transplant, when immunosuppression is highest. However, newer studies suggest a bimodal peak in incidence.
1
This case describes PTLD occurring in the colon as a late complication of multi-organ transplant.

CASE DESCRIPTION/METHODS:

A 54-year-old male with a complicated transplant history, on tacrolimus for immunosuppression, presented with worsening abdominal pain, nausea, diarrhea, and weight loss. His transplant history includes cardiac transplants in 1980 and 1993 for idiopathic cardiomyopathy, and renal transplant in 2003 due to tacrolimus toxicity. He denied fever, night sweats, or recent sick contacts, and was hemodynamically stable. On exam, he had diffuse abdominal pain with mild guarding but no rebound. Laboratory findings revealed a tacrolimus level of 11.1. Abdominal computed tomography scan was significant for fluid-filled loops of small bowel with focal thickening of the transverse colon, concerning for colonic malignancy (Figure 1). Gastroenterology was consulted for urgent colonoscopy, which showed mucosal ulceration and inflammation throughout the colon, with sparing of the sigmoid and rectum (Figure 2). Biopsy of the cecum, ascending colon, and transverse colon revealed diffuse infiltrate of pleomorphic large cells in the lamina propria and submucosa with focal ulcerations and necrosis, consistent with PTLD of monoclonal diffuse large-B cell morphology. The biopsy was negative for EBV and CMV. Immunohistochemistry was positive CD45RB, CD79a, CD30 and BCl2. He was referred to hematology-oncology and followed-up as an outpatient to begin chemotherapy.

DISCUSSION:

Though PTLD is classically described as an early complication of solid organ transplant, this case presents the development of colonic PTLD after over 15 years since last transplant. This finding supports the notion that there is a bimodal peak in incidence. This case also demonstrates the insidious, non-specific gastrointestinal findings of colonic PTLD. Because of this, and as survival after organ transplant continues to increase, providers must have a high index of suspicion for PTLD in the colon as a late complication of transplant.
1604 Multidisciplinary Approach for Prolonged Survival of Patients With MMIHS
Authors: Nallapeta Naren S. , Kohen Aniqa A. , Saleemi Maryam , Conway-Habes Erin
Published: October 2019

INTRODUCTION:

Megacystis microcolon intestinal hypoperistalsis syndrome (MMIHS)/Berdon syndrome is a rare disorder characterized by a distended non-obstructed bladder, microcolon, and decreased intestinal peristalsis with average life expectancy less than 6 months. We present case of a patient with MMIHS.

CASE DESCRIPTION/METHODS:

A 23-year-old female with MMIHS presented to the emergency department for abdominal pain and inability to tolerate oral or feeds through gastrostomy tube for 3 weeks. She had extensive surgical history since birth with LADD’s procedure due to intestine malrotation, exploratory laparotomy and subtotal colectomy for volvulous, colectomy with end ileostomy, Bilroth I, gastrostomy tube, and multiple nephrostomy tube for recurrent urinary infection. Patient had similar recurrent symptoms thought to be due to small intestinal bacterial overgrown and recurrent urinary tract infection. It appeared with each hospitalization her ability to tolerate oral intake declined to a lower baseline. At home patient was on Cisapride 14ml four times daily. During hospitalization lab work and imaging was non-contributory other than urine culture positive for Klebsiella. A small bowel follow through showed delayed gastric empting. Due to inability to tolerate oral intake or feeds patient was started on total parenteral nutrition (TPN). Esophagogastroduodenoscopy showed esophagitis, moderate chronic active gastritis with widely patent gastrojejunostomy anastomosis and jejunal limb. Her symptoms were likely due to progression of hypomotility syndrome. Cisapride was increased by 14%, under direction of outpatient pediatric gastroenterologist, with good response. However, due to prolonged QTc on electrocardiogram, upon discharge she was changed to Lubipristone.

DISCUSSION:

Our case demonstrates a complex presentation of a rare but fatal intestinal myopathy with most patients not surviving past infancy with even fewer cases surviving long term. Complications such as perforation, sepsis, malnutrition, multi-organ failure and pseudo-obstruction is not well understood in these patients and needs to be ruled out at each hospitalization. A multidisciplinary approach is needed for long term survival of patients with MMIHS. Main goals of treatment include providing a bladder-emptying strategy and adequate nutrition. In our case study, we demonstrate off label use of Cisapride and Lubiprostone for dysmotility. Close long term follow-up is necessary with multidisciplinary approach for long term survival.
1606 A Very Unusual Case of Colonic Adenocarcinoma Originating From an Enterocutaneous Fistula
Authors: Moore Andrew , Lee Salina , Jakate Shriram
Published: October 2019

INTRODUCTION:

Enterocutaneous fistulas are a well known sequelae of intrabdominal surgeries. Common complications of these fistulas include sepsis, electrolyte abnormalities, and nutritional deficiencies. We present an unusual case of a mucinous colonic adenocarcinoma originating from an enterocutaneous fistula. To our knowledge, there are no other known cases of colonic adenocarcinoma originating from an enterocutaneous fistula.

CASE DESCRIPTION/METHODS:

Patient was a 65-year-old male with a past medical history significant for Korsakoff dementia and OLT ten years ago who presented to GI clinic. He had complaints of weight loss, decreased appetite, and increased lethargy. The patient had an enterocutaneous fistula as a result of a bowel resection following perforation from ERCP nine years prior. The fistula was never repaired as the patient was thought to be a poor surgical candidate and it did not seem to interfere with his quality of life.

Physical exam was notable for a tender abdomen with several scattered erythematous and excoriated lesions. There was an ostomy bag covering a 10cm fungating, necrotic appearing, malodorous mass with greenish liquid in the ostomy bag (Figure 1). This was surrounding the fistula site. Based on CT abdomen results from six months prior, it was suspected that this was an enterocutaneous fistula that may connect to the transverse colon. Biopsies were taken at bedside which revealed mucinous moderately differentiated adenocarcinoma, morphologically suspicious for colonic-type adenocarcinoma (Figure 2). Repeat CT abdomen showed a large heterogeneous abdominal wall lesion and mild wall thickening of adjacent mid-transverse colon consistent with the known mass.

DISCUSSION:

The prevalence of enterocutaneous fistulas in the population is not known; most are iatrogenic or postoperative in etiology (75-85%), with the ileum being the most common location. This patient’s enterocutaneous fistula was never repaired and was likely the result of a bowel resection following perforation from ERCP several years prior. As with chronic inflammatory states, such as that seen in IBD which can predispose to colorectal cancer, we hypothesize that a similar mechanism of chronic inflammation from a fistula connection to the outside environment may have contributed to this patient developing a colonic malignancy, especially in the setting of his immunosuppression. Furthermore, in patients who are unable to undergo repair of enterocutaneous fistulas, their risk of colorectal cancer may be increased.
1609 Spontaneous Perforation of a Sigmoid Gastrointestinal Stromal Tumor
Authors: Ngu Sam , Haddad Fady , Kingsley Ebare , Kong Fanyi , Wu Hueizhi , Deeb Liliane
Published: October 2019

INTRODUCTION:

Most gastrointestinal stromal tumors (GISTs) are asymptomatic and involve the stomach and small intestine. Spontaneous rupture of a large sigmoid GIST is an exceptionally rare complication. Only three other cases of sigmoid perforation due to a GIST were described in literature.

CASE DESCRIPTION/METHODS:

A 90-year-old male with acutely worsening lower abdominal pain underwent emergent bowel resection for presumptive colonic perforation secondary to sigmoid diverticulitis. Initial abdominal computed tomography (CT) showed wall thickening in the sigmoid colon as well as an air-containing interloop heterogeneous mass measuring 3.5 × 2.0 cm with free intraperitoneal air. Laparotomy thereafter revealed a mass at the perforation site which was resected. Histopathologic examination revealed an infiltrative high-grade spindle cell neoplasm with marked cellular atypia, involving the muscularis propria and submucosa with extension to the adjacent pericolonic fat. CD117 (C-kit), CD34 and DOG1 biomarkers were negative, as well as actin, desmin, keratin and S100 stains. Hence, the diagnosis of a dedifferentiated KIT-negative GIST was made based on the favorable histopathology of the tumor via a consensus from the pathology department.

DISCUSSION:

Spontaneous bowel perforation, particularly in the sigmoid colon, is an exceedingly rare complication of GIST. Immunohistochemical studies can confirm the diagnosis; however, the absence of positivity for biomarkers does not exclude it in which case consensus from the pathology department is required to confirm the diagnosis. Physicians need to be cognizant of the propensity for GISTs to lead to bowel perforation, including the sigmoid colon.
1615 Rare Case of Abdominal Wall Metastasis Secondary to Colon Cancer
Authors: Badrinath Madhuri , Tambe Ajay , Masood Umair , Manocha Divey
Published: October 2019

INTRODUCTION:

Colorectal cancer(CRC) with direct abdominal wall and skin invasion is an extremely rare finding. We present a unique case of CRC with an oligometastatic lesion in the abdominal wall.

CASE DESCRIPTION/METHODS:

Patient is a 56-year-old male who presented to the gastroenterology clinic with 2 months of constipation and hematochezia, in the absence of melena,weight loss, anorexia and abdominal pain. A screening colonoscopy revealed severe stenosis in the descending colon(50 cm proximal to the anus) with inability to further advance the scope. This area was biopsied and tattooed; pathological diagnosis was confirmed to be moderately differentiated adenocarcinoma.Tumor markers were negative and CT of the abdomen/pelvis was done which showed lymphadenopathy around the descending colon with no evidence of metastasis. 2 weeks later he underwent a robotic-assisted left colon resection with intracorporeal anastomosis, with no immediate postoperative complications.The histopathology of the resected mass was consistent with the initial biopsy findings and lymph nodes were negative for malignancy. Patient underwent adjuvant chemotherapy with capecitabine and oxaliplatin for 4 cycles which was well tolerated.A year later he developed a slowly progressive asymptomatic mass in the right abdominal wall.CT of the abdomen revealed a focal soft tissue mass measuring 3 × 3cm, involving the right lower anterolateral abdominal wall and rectus abdominis muscle.CT guided biopsy revealed metastatic adenocarcinoma consistent with primary CRC. PET scan was devoid of any metastatic or recurrent disease in other locations. Hence proceeded with resection of the mass and mesh placement for the abdominal wall defect. Patient tolerated the procedure well. The follow up scans have shown no evidence of recurrence or metastatic disease, and patient is symptom free.

DISCUSSION:

CRC often metastasizes to regional lymph nodes,liver, lung or bone via lymphatic and hematogenous routes. Abdominal wall metastasis is very rare and can be caused by direct invasion, lymphatic or hematogenous routes, and direct cancer cell implantation during prior surgical intervention which is the probable source in our patient. Laparoscopic resection is a feasible treatment option for solitary abdominal wall metastasis along with the advantage of assessing the abdomen for other metastases; especially in patients with advanced CRC who are at higher risk of developing fatal complications like peritoneal dissemination that may affect management.
1616 Unusual Baby Bump: Hidden Pregnancy in the Setting of Chronic Opioid-Induced Pseudo-Obstruction
Authors: Brar Tony , Jacobs Chelsea , Riverso Michael , Perbtani Yaseen , Yang Dennis
Published: October 2019

INTRODUCTION:

Opioid addiction and abuse have become a serious public health problem in the United States. The most common gastrointestinal adverse effect is dysmotility and decreased peristalsis, manifesting as constipation. We present an extreme case of a young woman with chronic constipation in the setting of opioid abuse. Imaging obtained during her diagnostic workup revealed unexpected findings and further highlight the consequences of the opioid crisis in the United States.

CASE DESCRIPTION/METHODS:

A 26-year-old woman with known opioid-induced chronic constipation (OIC) presents to an outside emergency department with abdominal pain, distention, and leakage of yellow-brown fluid from the anus and vagina. She had been admitted multiple times over the course of the past year for management of chronic pseudo-obstruction.

Outside abdominal computed tomography (CT) revealed a diffusely dilated colon with large amounts of stool. Incidentally, an advanced intrauterine pregnancy was identified on imaging. The patient was unaware of the pregnancy. Ultrasound exam was consistent with a gestational age of 32 weeks and 6 days complicated by oligohydramnios and cord prolapse. The patient underwent emergent cesarean delivery without immediate complications. Flexible sigmoidoscopy was performed following delivery. Extensive amounts of solid stool were removed with digital disimpaction and copious lavage. During hospitalization, the patient was counseled regarding opioid abuse, management of chronic constipation, and scheduled for outpatient follow-up.

DISCUSSION:

The opioid epidemic in the United States has reached epic proportions, with drastic consequences on public health. OIC is the most frequent and prevalent adverse effect among opioid users. While conventional and new laxatives have been shown to be effective for OIC, focus should be shifted towards awareness and prevention of opioid abuse.

Another important note to be made is the importance of history taking on a patient with multiple hospitalizations with similar presentations. While she did have an extraordinary stool burden that did require manual disimpaction, the patient was also found to be in her third trimester of pregnancy on CT imaging. Fortunately, no harm occurred to the patient or child, however obtaining the proper history and diagnostic work-up could have helped limit any potential injury that might have resulted.
1623 Extra Nerves in the Gut: A Case of an Incidental Ganglioneuroma in the Colon
Authors: Jencks Kara J. , Bilal Mohammad , Luthra Gurinder
Published: October 2019

INTRODUCTION:

Ganglioneuromas are exceedingly rare in the gastrointestinal tract and are typically found in the head, neck, or adrenal glands. We present a unique case of a ganglioneuroma in the colon found incidentally on a screening colonoscopy.

CASE DESCRIPTION/METHODS:

A 55-year-old male with no prior medical history underwent a routine screening colonoscopy. He had no hematochezia, melena, changes in bowel habits, weight loss, or other alarm symptoms. He had not had a previous colonoscopy and did not have any family history of gastrointestinal malignancies. Physical examination was unremarkable. The patient was found to have two sub-centimeter polyps in the transverse and descending colon, which were removed via cold snare. In addition, a 2-cm pedunculated polyp was found in the sigmoid colon [Figure 1]. The polyp was removed using hot snare polypectomy, and two endo-clips were placed post-polypectomy. The two sub-centimeter polyps were reported to be tubular adenomas. Hisotological examination of the pedunculated polyp showed spindle and ganglion cells. Immunohistochemical staining was performed, and it was positive for S-100, consistent with a ganglioneuroma. The patient has been scheduled for surveillance colonoscopy in 1 year.

DISCUSSION:

Ganglioneuromas are rare, slow-growing tumors that are derived from sympathetic ganglion cells in the nervous system. When present in the colon, patients are usually asymptomatic. However, patients can present with constipation, ileus, hematochezia, abdominal pain, or other nonspecific symptoms. Our patient was asymptomatic, which is the case in most colonic ganglioneuromas. As colonic ganglioneuromas are rare, there is no clear consensus on how to approach surveillance in these cases. Our report and several other recent reports highlight the need for consensus guidelines regarding approaching surveillance strategies in these patients.
1626 Primary Adenoid Cystic Carcinoma Presenting as Distant Metastasis to Ascending Colon
Authors: Collins Kelsey , Dong Ray , Rozenshteyn Frederick , Naik Jahnavi
Published: October 2019

INTRODUCTION:

Salivary gland tumors are rare, often benign, mostly originating from the parotid gland. Tumors can also arise from submandibular and sublingual glands, and while these tumors tend to be more rare, they are more often malignant. Salivary gland tumors usually metastasize to the lung, bone, and liver.

CASE DESCRIPTION/METHODS:

A 77-year-old Albanian male with history of a right-sided mandibular abscess s/p drainage in 2015 presented with confusion and abdominal pain. Labs were unremarkable. He underwent CT head, which was concerning for an occipital lesion, for which he proceeded with an MRI brain that revealed multiple intracranial lesions concerning for metastatic disease. He then had a CT Abdomen/Pelvis that revealed several hepatic lesions, innumerable pulmonary nodules, and an area of focal thickening and enhancement of the proximal ascending colon. Bone scan revealed likely metastasis to the L5 vertebral body. His CEA was 4.7 and CA 19-9 was 43.6. AFP was 1.7. He then had a colonoscopy, which was significant for 2 polyps in the descending colon, 2 umbilicated polyps in the transverse colon, a 4 mm sessile polyp in the transverse colon, and a submucosal and ulcerated non-obstructing mass in the proximal ascending colon distal to the ileocecal valve. Pathology showed small, round, blue cells with trabecular growth pattern and necrosis, consistent with invasive, poorly differentiated carcinoma with basaloid features. In addition, the immunohistochemistry was positive for CK7 and Sox10, focally positive for S100, and weakly positive for CD 117, all suggestive of an adenoid cystic carcinoma. Treatment first consisted of palliative radiation to his CNS lesions, a dexamethasone taper, and an Oncology consult for consideration of palliative chemotherapy. He was offered palliative paclitaxel and carboplatin, however he ultimately decided to return to Albania and forego treatment.

DISCUSSION:

This patient likely had undiagnosed, malignant, primary salivary gland cancer for many years; despite having his mandibular ‘abscess’ drained several years prior. In addition, the lesion metastasized to several uncommon locations, notably the brain and colon, which are the 2 sites that ultimately produced symptoms that prompted him to receive further medical care. Salivary gland tumors must be considered in patients presenting with head and neck swelling, and proper diagnostic workup must be obtained. In addition, uncommon sites of metastasis, such as colon, must be considered during staging of disease.
1627 Segmental Colitis Associated With Diverticulosis: An Emerging Entity Among the Non-Specific Colitis
Authors: Estremera-Marcial Rodolfo , Marzan-Loyola Adriana , Martin-Ortiz Jose , Martinez-Souss Jaime , Cerra-Franco Javier
Published: October 2019

INTRODUCTION:

An 86 y/o male with diverticulosis and hypertension, arrived at the ER due to intermittent episodes of bright rectal bleeding associated with lower quadrant abdominal pain since 3 weeks ago. Laboratories without anemia, leukocytosis, eosinophilia or any other abnormality. CT abd/pelvic revealed a segmental area of concentric mural thickening and narrowing of the lumen of the sigmoid colon, concerning for a mass. No prior colonoscopies or GI alarming features. GI service consulted for diagnostic endoscopic procedure.

CASE DESCRIPTION/METHODS:

Sigmoidoscopy was remarkable for severe diverticular disease of the rectal mucosa with associated significant erythema, exudative material and loss of vascular pattern consistent with an inflammatory process. At 20 cm from the anal verge, a luminal narrowing covering > 90% of the lumen extended up to 27 cm. Pathology report from the area of obstruction showed acute over chronic inflammation without granulomas, microorganisms or dysplasia. He was started on rectal mesalamine and a 14-day course of oral antibiotics (metronidazole and ciprofloxacin). Surgery service consulted which agreed with medical management. Within two weeks after completion of antibiotics, colonoscopy was performed revealing marked improvement of the luminal narrowing evidenced in the previous colonoscopy at 20cm, including less degree of inflammation and fewer loss of vascular pattern among the segmental area within multiple diverticuli. Biopsies taken from the same narrowing were remarkable for chronic inflammation without dysplasia. All findings were consistent with segmental colitis associated with diverticulosis (SCAD).

DISCUSSION:

SCAD is an inflammatory process that affects colonic luminal mucosa in areas that are affected by diverticulosis. The prevalence is 1.5 – 11.4% among those with diverticular disease. The pathogenesis of SCAD is unclear. The clinical presentation is not specific and thus similar to other pathologies, including inflammatory bowel disease, for which makes this condition difficult to diagnose. There are currently no guidelines for its management. It is frequently based on the administration of salicylates, antibiotics and surgical intervention for refractory cases. Currently it is unclear if SCAD is in fact a spectrum of IBD or if it is itself a separate entity. The rarity of SCAD supports the claim that further research is needed to better understand the disease and thus improve its management and clinical outcomes.
1631 A Rare Case of Myxedema Ascites and Ischemic Colitis
Authors: Riaz Sana , Gowtham Sriharsha , Shafi Chilsia , Masood Umair , Kudaravalli Pujitha , Sharma Anuj , Mirchia Kanish , Ozden Nuri
Published: October 2019

INTRODUCTION:

Myxedema is a severe form of hypothyroidism with various signs and symptoms. We present a rare case of myxedema ascites complicated with ischemic colitis (IC).

CASE DESCRIPTION/METHODS:

A 71-year-old female with a history of coronary artery disease and congestive heart failure (Ejective fraction 40%) presented with abdominal distention. Pertinent vitals included blood pressure of 100/54 mmHg and heart rate 38 beats/min. Pertinent labs included hematocrit of 28.2 %, albumin 3.1 g/dL, transaminases mildly elevated, alkaline phosphatase (ALP) 382 IU/L, thyroid stimulating hormone (TSH) 141 IU/mL, free triiodothyronine (T3) 1.26 pg/ml, total T3 45.30 ng/dL. Rest of the electrolytes, blood counts, including coagulation parameters, were normal. Electrocardiogram showed sinus bradycardia. She was started on levothyroxine for severe hypothyroidism. Abdominal ultrasound showed a large volume of ascites and normal liver contour. Paracentesis showed total nucleated cells of 2242, total protein 3.6 g/dL, lactate dehydrogenase 229, albumin 1.8 g/dL, serum ascites albumin gradient (SAAG) < 1.1, and glucose 86 mg/dL. Ascitic fluid cultures were negative. Hence, the patient was diagnosed with neutrocytic ascites and treated with empiric antibiotics. Ascitic fluid was negative for malignancy and tuberculosis. She was managed with diuretics (furosemide and spironolactone) and therapeutic paracentesis. She later developed bloody diarrhea, and flexible sigmoidoscopy showed mild to moderate IC of the rectosigmoid colon. She was treated conservatively. Her transaminases normalized, but ALP remained elevated. She was discharged after a two-week hospital stay and six weeks follow up showed significant improvement in ascites and TSH of 10 IU/mL.

DISCUSSION:

Myxedema ascites is seen in only 4% of the patients with uncontrolled hypothyroidism. There are no case reports on IC in the setting of myxedema ascites thus far. It is a rare complication of myxedema megacolon; however, our patient had no signs of megacolon on repeated imaging. Therefore, our case is unique as it highlights a rare (ascites) and uncommon (IC) complication of severe hypothyroidism. Ascites with SAAG < 1.1 should prompt physicians to consider hypothyroidism in the differential diagnosis for ascites especially when total ascitic fluid protein is > 2.5 g/dL and other causes such as portal hypertension, malignancy, and infections are ruled out. It is easy to treat, can lead to complete resolution of ascites and decrease morbidity.
1637 Bacterial Enteritis as a Red Herring in Workup for Fever of Unknown Origin
Authors: Wahid Nabeel , Buffie Charlie , Wan David
Published: October 2019

INTRODUCTION:

The evaluation for fever of unknown origin (FUO) can often be misled by anchoring on incidental findings. Here, we describe the case of a patient with a FUO and new-onset diarrhea incidentally found to have a bacterial colitis.

CASE DESCRIPTION/METHODS:

A 72-year-old female was seen by the Gastroenterology consult service for new-onset of diarrhea in the context of 2-3 weeks of fevers, leukocytosis, and malaise. CT revealed colonic wall thickening suggestive of colitis and GI PCR revealed enteroaggregative Escherichia coli (EAEC). Inflammatory markers revealed ESR >130, and CRP 37.7. The patient had persistent fevers and leukocytosis despite antibiotics. PET scan showed no evidence of infection or malignancy. A bilateral temporal artery biopsy was obtained, which showed temporal arteritis (GCA). Fevers resolved with steroids.

DISCUSSION:

Uncomplicated gastrointestinal infections without abscesses typically do not cause ESR elevations >100. Our patient’s markedly elevated inflammatory markers suggested that EAEC colitis was an unlikely explanation for her diarrhea and fever. Though similar data is lacking in adults, a cohort of children with E. coli enteritis had ESR ranging from 2-48 and CRP from 0.02-10.25 (Kim, Y et al., Infect Chomother, 17 Dec 2017, 275-281). Common etiologies of ESR elevations >100 include infectious (mostly pneumonia, cellulitis, bacteremia, abscesses, or osteomyelitis), autoimmune, and malignancy (Daniels, LM et al., Mayo Clinic Proc., Nov 2017, 1636-1643). Thus, EAEC colitis was a red herring in our workup for our patient with a FUO. A widely used algorithm for FUO (Figure 1) would have suggested that no further workup was necessary for our patient after her CT revealed colitis in the setting of diarrhea and EAEC. We conclude that systemic inflammatory markers may be helpful in patients with suspicion for bacterial enteritis as an etiology of prolonged fevers. In our case, the profoundly elevated systemic inflammatory markers lead us to continue down the algorithm for FUO, leading to our biopsy proven diagnosis of GCA. GCA is most commonly seen in patients >50 years old and should be considered in patients with FUO within this demographic even when symptoms are not present.
1641 Ganglioneuroma Found on Routine Screening Colonoscopy
Authors: Engelberg Rachel , Wan David
Published: October 2019

INTRODUCTION:

Ganglioneuromas are benign tumors of the sympathetic nervous system that carry a great prognosis with almost no change in clinical mortality. They are often asymptomatic, though can present with symptoms such as abdominal pain or constipation if large enough. These tumors are exceedingly rare and are curative with resection. Currently, there are no clear guidelines in the literature on appropriate surveillance for such patients. Here we present a case of a ganglioneuroma found in an asymptomatic patient on routine screening colonoscopy.

CASE DESCRIPTION/METHODS:

A 78-year-old woman with a past medical history significant for atrial fibrillation and hypertension was referred for routine screening colonoscopy for colorectal cancer. The patient was asymptomatic and had no diarrhea, constipation, hematochezia, or melena. She had no family history of gastrointestinal diseases nor record of any previous colonoscopy. Upon colonoscopy, four polyps were visualized on colonoscopy within the hepatic flexure, splenic flexure, descending colon and sigmoid colon, as well as diverticulosis in the sigmoid and ascending colon. Polyps were fully resected and retrieved with cold snare. The pathology returned with normal colonic mucosa within the splenic flexure, tubular adenomas in the hepatic flexure and descending colon, and a ganglioneuroma in the sigmoid colon. The patient was recommended for repeat surveillance colonoscopy in three years based on the adenoma.

DISCUSSION:

Ganglioneuromas are an exceedingly rare benign neoplasm of the colon, often with no clinical symptoms as seen in our patient. Therefore, these tumors are primarily diagnosed on routine screening colonoscopy. Given the rarity of this clinical entity, there are no current guidelines available for how to appropriately follow these patients. Such tumors have an excellent clinical prognosis and tend not to recur, therefore it is generally accepted that these patients require no surveillance screening. Given that our patient had concomitant tubular adenomas, she was recommended for follow up colonoscopy in three years. Resection of ganglioneuromas is curative and thus the mainstay of treatment. Our patient is unique as identifying these tumors is rare and infrequently reported in the literature.
1642 Pelvic Congestion Syndrome: An Unusual Manifestation of Sigmoid Pneumatosis Cystoides Intestinalis
Authors: Hussain We'am , Akram Salma
Published: October 2019

INTRODUCTION:

Pneumatosis cystoides intestinalis (PCI) is a rare condition characterized by gas-filled cysts in the intestinal subserosa and submucosa. We present a rare case of primary PCI affecting sigmoid colon complicated by pelvic congestion syndrome (PCS).

CASE DESCRIPTION/METHODS:

A 34-year-old morbidly obese female presented with diffuse lower abdominal pain and intermittent foamy diarrhea without blood or mucus for the past 5 months. CT abdomen showed small bubbles of gas in the peritoneum in the left upper quadrant and large amount of cystic pneumatosis in a loop of sigmoid colon. Lab work was unremarkable. She was given one week course of antibiotics. A repeat CT scan 5 months later showed interval resolution of free intraperitoneal air but pneumatosis bubbles had enlarged in size. A colonoscopy was performed which showed large cystic-appearing air-filled bullae in sigmoid colon causing some luminal narrowing and the scope could not be safely advanced beyond mid-transverse colon. Patient underwent laparoscopic sigmoid colectomy and intraoperatively noted to have dilated and tortuous bilateral gonadal veins. Surgical pathology showed multiple clear fluid-filled cysts throughout the length of the specimen with viable and unremarkable proximal and distal resection margins. Patient recovered well from surgery and was discharged with no further complaints.

DISCUSSION:

PCI is an unusual condition caused by a myriad of underlying pathophysiological processes that range from benign to life-threatening conditions. Primary PCI is rare (15%), while underlying conditions for secondary PCI can be divided into several groups; traumatic, mechanical, inflammatory, autoimmune, infectious, pulmonary and drug (steroids and chemotherapeutic agents) induced. Conservative management is preferable except in cases of clinical deterioration. This case is unique because even after the resolution of free intraperitoneal air the patient continued to have lower abdominal and pelvic pain with worsening of pneumatosis on repeat CT scan several months later. It is possible that sigmoid anatomic changes due to pneumatosis resulted in chronic intermittent venous obstruction of pelvic veins leading to gonadal veins dilation and tortuosity and hence secondary PCS which resulted in ongoing lower abdominal pain. This case highlights the fact that persistent PCI, with ongoing abdominal symptoms even in the absence of any obvious etiology warrants laparoscopic exploration to rule out any underlying disease process.
1643 Colonic Malakoplakia: An Exquisitely Rare Cause of Lower GI Bleeding
Authors: Jessamy Kegan , Rawlins Sekou , Sheth Yesha , Zhang Shengle
Published: October 2019

INTRODUCTION:

Malakoplakia is a rare chronic granulomatous disease that may affect many organs. The gastrointestinal tract is the second most common site of involvement (after the urinary tract). The most common sites of colonic involvement are the rectum, sigmoid, and right colon, in descending order of frequency. The pathogenesis of malakoplakia is unknown. The treatment of malakoplakia ranges from antibiotic therapy to surgical resection. Here we describe a case of a 33-year-old man who presented with hematochezia and was noted to have malakoplakia on rectal mass biopsy during colonoscopy.

CASE DESCRIPTION/METHODS:

A 33-year-old man presented to our clinic due recurrent episodes of painless hematochezia in the setting of warfarin for recent lower extremity deep venous thrombosis. He is a resident of a nursing home due to a complex neurosurgical history which includes resection of a right temporal glioblastoma multiforme tumor followed by chemo and radiation therapy. He also had subsequent craniotomy and ventriculo-peritoneal shunt placement and used oral dexamethasone for recurrent episodes of cerebral edema related to residual brain tumor. Despite stopping warfarin he continued to have rectal bleeding. Colonoscopy showed a frond-like/villous, fungating and polypoid non-obstructing circumferential mass in the rectum. Biopsies showed malakoplakia. After multidisciplinary discussions, a decision was made to continue dexamethasone to minimize cerebral edema and bowel resection was declined by patient’s parents. We opted to use a prolonged course of Ciprofloxacin, however, the patient developed severe urosepsis and unfortunately died.

DISCUSSION:

First reported by Michaelis and Gutmann in 1902, malakoplakia is derived from the Greek “malakos” (soft) and “plakos” (plaque) and reflects its usual endoscopic appearance as a friable, yellow mucosal lesion. Coliform bacteria in macrophage cytoplasm (von Hansemann histiocytes), and laminated intracytoplasmic inclusion bodies (Michaelis-Gutmann bodies) are characteristic. A decrease in macrophage cyclic GMP activity with resultant impaired bactericidal activity is hypothesized to be the cause of malakoplakia. Macrophage abnormalities and clinical symptoms resolve after discontinuation of glucocorticoids. Antibiotics such as ciprofloxacin have been successful treatments in few case reports. Unfortunately our patient did not have the opportunity to utilize any of these antibiotics prior to his passing.
1648 A Rare Case of Primary Colonic Lymphoma With Paraneoplastic Hypercalcemia
Authors: Augustine Thomas , Perisetti Abhilash , Khan Salman Ali , Garg Shashank , Inamdar Sumant , Tharian Benjamin
Published: October 2019

INTRODUCTION:

Primary colonic lymphoma (PCL) is a rare malignancy accounting for 1% of all gastrointestinal (GI) lymphomas and 0.1-0.5% of all colorectal malignancies. 15% of Non-Hodgkin Lymphoma develop hypercalcemia at some point during their clinical course but rarely symptomatic at the time of diagnosis. We report a rare case of symptomatic hypercalcemia from an ascending colon mass which was diagnosed as Diffuse large B cell lymphoma (DLBCL).

CASE DESCRIPTION/METHODS:

A 63-year-old male with history of type II Diabetes mellitus and hypertension presented with worsening confusion over a week. He also endorsed weight loss of 35 lbs in a month, intermittent right sided abdominal pain, constipation and dark colored stools on multiple occasions. He had a normal colonoscopy 5 years ago. Physical examination showed stable vital signs and hard palpable mass with ill-defined borders in the right flank. Labs were significant for Hemoglobin 8.2 g/dL, Creatinine 3.7 mg/dL, Calcium 13.1 mg/dL and ionized calcium of 7 mg/dL. Liver function tests and serum ammonia were normal. Computed tomography (CT) scan of abdomen showed 16 × 15 × 15 cm exophytic mass with central necrosis arising from the distal ascending colon (Figure 1). Colonoscopy (Figure 2) mediated biopsy was consistent with DLBCL. Bone marrow biopsy and PET- CT scan were negative for extracolonic lymphoma. A diagnosis of PCL was made based on Dawson’s criteria. He underwent a right hemicolectomy. Grossly the mass measured 20 × 18 × 14 cm with a necrotic center eroding the colonic mucosa (Figure 3). He was started on combination chemotherapy (R-CHOP regimen: Rituximab, Cyclophosphamide, Doxorubicin, Vincristine, Prednisolone) and Lenalidomide was added as his DLBCL was ABC (Activated B cell) type. Work up for hypercalcemia showed suppressed PTH levels, normal PTHrP, normal 25 OH Vitamin D and elevated calcitriol, consistent with increased production of calcitriol as the cause.

DISCUSSION:

Cecum is the most common site for PCL (60 – 75%), followed by rectosigmoid region (8.5 – 35%). This patient had mass in distal ascending colon which is an unusual location. Immunosuppression and Inflammatory bowel disease are the known risk factors for PCL, but often none could be identified. Hypercalcemia in NHL is mostly due to extrarenal production of 1,25-dihydroxyvitamin D facilitated by the 1α-hydroxylase enzymes in the macrophages that surrounds the malignant lymphocytes. In most series, surgery followed by multiagent chemotherapy (R-CHOP) has led to improved outcome.
1652 Missing Intrauterine Device Rediscovered in a Sigmoid Colon Polyp Nearly a Decade After Insertion
Authors: Kobeszko Matthew , Kuruvilla Aneesh , Gordon Melanie , Aubeid Firas , Almouradi Tarek
Published: October 2019

INTRODUCTION:

Intrauterine devices (IUD) are a popular form of contraception with an overall low risk of complications. We report a patient with an IUD placed 8 years ago with the rare incidence of asymptomatic migration into a sigmoid polyp discovered with colonic rectal ultrasound requiring surgical removal.

CASE DESCRIPTION/METHODS:

A 50-year-old gravida 5 para 5 female presented with right lower quadrant pain for 1 week. Pain described as intermittent and radiating to her right flank. Last menstrual period was 3 weeks prior to presentation. She denied any fever, nausea, vomiting, vaginal bleeding, hematochezia or melena. History included IUD placement 8 years ago, nevertheless became pregnant. At that time, patient was informed her IUD had fallen out and proceeded with tubal ligation postpartum. Labs were within normal limits with a negative urine analysis and pregnancy test. Computed tomography of the abdomen/pelvis demonstrated translocation of IUD to the sigmoid colon wall. Gastroenterology performed a colonoscopy with rectal ultrasound that confirmed a metallic object in a sigmoid colonic polypoid lesion. Subsequently, general surgery performed a robotic assisted laparoscopic sigmoid colon resection. Her abdominal pain subsidized and patient was discharged home in stable condition.

DISCUSSION:

Uterine perforation and migration into abdominopelvic structures is a known, but rare complication to IUD usage, at a rate of less than 1 per 1000 applications. Perforation generally occurs during IUD insertion and risk factors include anatomically flexed uterus, clinician inexperience, and placement postpartum when the uterus is relatively thin walled. Many cases of perforation are asymptomatic and not discovered until years later. However, relatively few cases in the literature describe perforation with migration into the sigmoid colon. Reported cases describe IUDs placed postpartum becoming embedded in the uterus, with subsequent pregnancy, and uterine contractions forcing the IUD through the uterine wall and into the pelvic cavity. Treatment typically involves endoscopic foreign body retrieval. However, cases at high risk for bleeding or endoscopic limitations require surgical laparoscopy for safe removal. We highlight the utility of colonic ultrasound as safe and minimally invasive procedure to establish the diagnosis. While typically asymptomatic, migrated IUDs are a serious complication that can be diagnosed through computed tomography or colonic ultrasound requiring prompt foreign body removal.
1655 Removal of a 6CM Appendiceal Orifice Polyp With Snare Cautery Polypectomy
Authors: Castano Juan , Rapoport Grigoriy , Rivera Arturo Suplee , Nathani Muhammed , Zamir Asif
Published: October 2019

INTRODUCTION:

Appendiceal orifice (AO) polyps are uncommon. They are usually removed surgically due to technical difficulties and high risk of perforation with endoscopic intervention. In the following case we present a patient with a 6 cm AO polyp removed successfully with snare cautery technique during colonoscopy.

CASE DESCRIPTION/METHODS:

A 66-year-old man presented to our clinic for colorectal cancer screening. During colonoscopy, careful inspection of the AO revealed a subtle bulge. A submucosal injection of the AO using Eleview revealed a 6cm cauliflower-like lesion. The AO polyp was then removed with snare cautery polypectomy technique without any complications. The edges were approximated with endoscopic mechanical clips. Biopsy results showed tubular adenoma without dysplasia.

DISCUSSION:

The majority of AO polyps are removed surgically due to potential complications, especially perforation. Currently, there are no guidelines that discuss management of these polyps due to lack of available data. A retrospective study involving 131 patients from multiple tertiary centers showed that polyps more than 20 mm in size undergoing endoscopic resection had significantly higher rates of perforation. Another retrospective study of 691 patients found that AO polyps greater than 5 mm in size were more likely to require surgery. Additionally, it has been reported that AO polyps encompassing more than 75% circumference have low resection rates. To our knowledge, this case is one of the largest endoscopic removal of an AO polyp encompassing the majority of the AO circumference without complications. Although traditionally AO polyps are removed surgically, our case suggests an alternative, less invasive and effective method of removing these difficult polyps. In order to validate our claim, documentation of more cases would be required.
1656 Gastrointestinal Whipple’s Disease Complicated With Meningoencephalitis, Ataxia, and Bilateral Uveitis
Authors: Castano Juan , Rapoport Grigoriy , Rivas Cynthia , Rivera Arturo Suplee , Zamir Asif
Published: October 2019

INTRODUCTION:

Whipple’s disease (WD) is a rare systemic infection caused by the gram-positive bacterium Tropheryma whipplei. It classically presents as a malabsorption syndrome, but can involve other organs. Incidence is estimated to be 1–3 persons for every one million people. We present a patient with WD complicated by meningoencephalitis, ataxia, and bilateral uveitis.

CASE DESCRIPTION/METHODS:

A 68-year-old man presented to clinic for nonbloody diarrhea, unintentional weight loss, and joint pains. EGD with duodenal biopsy revealed intracellular periodic-acid Schiff positive bacteria compatible with WD. He was began on a one year course of oral Bactrim twice daily. Eight years later, he presented with altered mental status and ataxia to the hospital. Head imaging was unremarkable. Polymerase chain reaction (PCR) for Tropheryma whipplei was positive in both cerebral spinal fluid (CSF) and vitreous fluid. Repeat EGD with duodenal biopsy was negative for WD. He received a three-week course of IV Meropenem and was switched to IV Ceftriaxone on discharge with plans to receive 2 weeks as outpatient. Afterwards, he once again received a one year course of oral Bactrim. On follow up, his diarrhea had resolved and mentation had improved.

DISCUSSION:

WD presents a diagnostic challenge due to nonspecific symptoms similar to those in our patient. Histology of duodenal mucosa is the most reliable diagnostic method, however, molecular–biological methods are often required. In one cohort, 99.4% of patients had positive duodenal biopsies. PCR of duodenal biopsies can also be performed. Central nervous system (CNS) involvement is found in 90% of post-mortem autopsies; yet, overt symptoms develop in only 10–40% of patients. Extended antibiotic courses are often required to prevent relapse; however, relapse can still occur years after proper treatment. Manifestation of relapse usually include mental status changes. Time can range from 1.5 to 12 years and the mean reported time is 4.2 years. Our patient falls within the latter portion in terms of relapse time. In a review of 696 patients with WD, one study noted that only 19 had eye involvement including uveitis, vitritis, retinitis, and retrobulbar neuritis. In another article, among 33 WD patients, 1 had eye involvement. Combination of ocular and CNS involvement in WD like in our patient is uncommon. Clinicians must remain vigilant when patients with history of WD exhibit acute mental status changes after adequate therapy as neurologic involvement can be irreversible.