bluuebunny/crossref_metadata_2025 huggingface dataset:
2594 An Unusual Case of Small Bowel Intussusception
Authors: El Imad Talal , Gao Yinglin , Gumaste Vivek
Published: October 2019

INTRODUCTION:

Intussusception is the telescoping of a part of the intestine into a more distal segment. The first case of intussusception was reported in 1674 by Barbette and detailed in 1789 by John Hunter. It is often classified by location into entero-enteric (65%), Ileocecal (19%), Colo-colic (9%) and finally duodeno-duodenal (<5%). It typically presents between the age of 6 and 36 months making adult presentation rare. We report a rare case of Duodeno-duodenaI intussusception secondary to tubular adenoma.

CASE DESCRIPTION/METHODS:

A 57 year old African American female with a history of rheumatoid arthritis and hysterectomy presents to the emergency room with complaints of epigastric pain for two days. The pain was intermittent, aggravated by food, and associated with nausea and two episodes of vomiting. She denies any other symptoms or similar episodes in the past. Last bowel movement was reported a day prior to presentation. Vital signs upon admission were within normal limits. On physical examination abdomen was soft, non distended with epigastric tenderness. Blood work on admission was unremarkable except for White blood cell count of 11.6 k/ul and Lactate level of 1.6 mmol/L. Computer Tomography (CT) scan of Abdomen showed telescoping of the apparent 2nd and 3rd portions of the duodenum compatible with intussusception (Figure 1). Patient underwent upper endoscopy with biopsies that showed a 3 cm duodenal polypoid lesion with pathology revealing tubular adenoma (Figures 2 and 3). Patient's symptoms resolved 2 day after presentation with supportive care only. Patient underwent endoscopic submucosal dissection of the lesion.

DISCUSSION:

Adult small bowel intussusception is a very rare entity that accounts for 5% of all cases of intussusception and 1%-5% of intestinal obstructions. The diagnosis can be challenging as symptoms are nonspecific and includes abdominal pain, nausea and vomiting. CT scan was found to be the preferred imaging study with specificity of 100% and sensitivity of up to 87% in adults. It often shows a “target sign” on the sagittal view or a sausage-shaped mass on axial and coronal views. It is always associated with a lead point such as a lipoma, hamartomatous polyps. The etiology in our case was a tubular adenoma which makes it more intriguing. Although duodenal intussusception is rare, recognition is critical for institution of appropriate therapy and prevention of complications. It should be considered in the differential diagnosis of any abdominal pain with signs of bowel obstruction.
2604 Celiac Disease: No Longer a Diagnosis of Exclusivity
Authors: Kim Brian , Chaput Kimberly J. , Wey Bryan , Tayel Hussam
Published: October 2019

INTRODUCTION:

Celiac disease (CD) is a chronic autoimmune enteropathy that occurs in genetically susceptible individuals when exposed to gluten proteins. In the past, CD was thought to be exclusive to Caucasians of European descent. With the advent of serological screening tests, CD has become increasingly recognized in other ethnic populations around the world.

CASE DESCRIPTION/METHODS:

A 56-year-old female of Indian descent was evaluated for chronic epigastric abdominal pain. The pain did not radiate and worsened with certain movements and spicy foods. She also reported an occasional acidic taste suggestive of reflux. Medical history included arthritis, hyperlipidemia, and a cholecystectomy. A colonoscopy performed two years ago was unremarkable. She underwent an EGD which demonstrated a normal esophagus, mild antral gastritis, and flattening of duodenal villi. Biopsies were obtained and an anti-tissue transglutaminase (anti-tTG) IgA level was ordered for suspicion of CD. Histology of the duodenal mucosa revealed moderate villous atrophy and increased intraepithelial lymphocytes. Anti-tTG IgA levels were elevated at 39 U/mL (normal 0–3 U/mL). H. pylori testing was negative. CD was diagnosed based on the histological findings and positive serology. The patient was instructed to begin a gluten-free diet (GFD) and referred to a medical nutritionist for further assistance. After starting a GFD, she reported significant symptomatic improvement.

DISCUSSION:

Few population studies in the past have looked at the prevalence of CD in non-Caucasian ethnic groups where the disease may have been underdiagnosed. Several recent studies suggest that gluten intolerance is more common than previously estimated in certain populations. Cataldo et al reported that 26–49% of Indian children presenting to tertiary care hospitals with chronic diarrhea had been diagnosed with CD.1 And a review by Yachha et al of an earlier study from the UK found 20 of 106 CD patients to be of South Asian origin.2 This case highlights the changing global paradigm of CD prevalence and provides valuable insight for clinicians in Western countries serving diverse immigrant populations. In conclusion, we recommend that physicians assess for CD without racial bias if clinical suspicion warrants an evaluation.
2605 Distal Intestinal Obstruction Syndrome Resulting in Gastric Perforation in a Patient With Cystic Fibrosis
Authors: Li Muyi , Syed Bakhtiar , O'Brien Corey
Published: October 2019

INTRODUCTION:

Distal Intestinal Obstruction Syndrome (DIOS) is a unique entity that occurs in patients with cystic fibrosis. DIOS results from the accumulation of mucous and undigested food contents in the small intestine due to decreased luminal water secretion which ultimately leads a proximal obstruction that can cause perforation, shock, and death if not treated. DIOS has an incidence rate of 35 in 1000 adults with cystic fibrosis. Here, we present a unique of DIOS which resulted in gastric perforation.

CASE DESCRIPTION/METHODS:

A 43-year-old male with cystic fibrosis and double lung transplant was admitted with cramping abdominal pain and decreased oral intake. On admission, he was noted to have abnormal liver function tests with total bilirubin of 9.6 and alkaline phosphatase of 888. A CT scan showed dilation of his common bile duct to 1 cm with ultrasound demonstrating distal common bile duct stones. He underwent endoscopic retrograde cholangiopancreatography with stone extraction and improvement in abdominal symptoms. He received significant narcotics for pain, and his hospital course was then complicated by constipation, worsening abdominal pain, and emesis. Gastroenterology was consulted and recommended a nasogastric tube (NG) and hyperosmolar enema to treat DIOS. An NG tube was unable to be passed and the patient’s abdominal pain suddenly worsened. An upright x-ray was obtained and demonstrated lucency over the right crus with non-contrast CT confirming pneumoperitoneum suggestive of a small bowel perforation. He was emergently taken to the operating room where he was found to have a 2 cm gastric perforation. A gastric wedge resection and omental patch was performed. The patient’s post-operative course involved total parenteral nutrition, scheduled enemas, and strict NPO status. An upper GI series showed no extravasation of contrast. The patient was extubated, started on oral intake, and eventually discharged on an aggressive bowel regimen.

DISCUSSION:

This case highlights a rare complication of DIOS. Typically, patient with DIOS are at risk for intestinal perforation; however, this patient developed a gastric perforation possibly from prior area of structural weakness. This case also highlights the importance of an aggressive bowel regimen in patients with cystic fibrosis to prevent DIOS. Once DIOS is identified, hyperosmolar enemas such as hypaque enemas and oral laxatives containing polyethylene glycol should be used for aggressive treatment to stymie such complications.
2608 Teduglutide Therapy for a Patient With Chronic Intestinal Failure Following Multi-Visceral Transplantation
Authors: Kaur Randeep , Muszkat Yakir , Nagai Shunji , Jafri Syed-Mohammed
Published: October 2019

INTRODUCTION:

The use of glucagon-like peptide-2 (GLP-2) agonists, such as Teduglutide, and recombinant human growth hormones (HGH), remain important for making advances in Short Bowel Syndrome and intestinal failure to reduce parenteral nutrition requirements. The efficacy of these agents have yet to be studied in the intestinal transplant population who experience decreased absorption with no evidence of acute rejection. We present a case of Teduglutide therapy for chronic intestinal failure following a multi-visceral transplant including stomach, pancreas and small bowel.

CASE DESCRIPTION/METHODS:

A 47-year-old Caucasian female presented with a history of corrected, congenital duodenal atresia, complicated by recurrent obstructions, requiring a Whipple procedure with bowel to bowel bypass and anastomosis. She developed short bowel syndrome and began to lose weight. She was placed on long-term total parenteral nutrition (TPN), with consequent hospital admissions for fungemia. She underwent a multi-visceral transplant including stomach, pancreas, and small intestine and placed on immunosuppressive therapy. Years later, she developed ongoing, severe watery diarrhea with recurrent need for TPN. She was placed on Pancrelipase and lipids, without any improvement. Intestinal biopsies repeatedly showed no signs of acute rejection or cytomegalovirus (CMV). Loperamide and Diphenoxylate were also trialed. Given a lack of progress, she was placed on Teduglutide. The patient experienced significant symptomatic improvement after 10 days of therapy. She was able to decrease her intravenous fluids (IVF) needs by 50%. After one month she again experienced worsening symptoms. She was placed on Linaclotide in addition to Teduglutide with the need to maximize TPN requirements. Repeat intestinal biopsies did not show evidence of infection or acute rejection. Teduglutide was discontinued after 10 months as it did not improve symptoms.

DISCUSSION:

Intestinal absorption can remain an issue in short bowel syndrome until transplant can be achieved. It remains problematic when multi-visceral transplant is performed and patients continue to experience malabsorption. Unfortunately, although our patient had a good initial response, this response did not persist and therefore therapy was discontinued. Research is ongoing to discover pharmacologic treatment options that significantly decrease the necessity of TPN and IVF. HGH and GLP-2 agonists are options at this time, however remain in question if they are effective long term.
2620 Salmonella typhi Gastroenteritis as a Rare Cause of Small Bowel Obstruction
Authors: Sandhu Sunny , Alhankawi Dhuha , Prajapati Devang
Published: October 2019

INTRODUCTION:

Salmonella gastroenteritis is a common foodborne illness that presents with diarrhea, nausea, vomiting, and abdominal cramps or constipation after 6 to 72-hour incubation period, and resolves in 4–10 days. Small bowel obstruction (SBO) as a result of acute bacterial infection however is extremely rare. Here we report a case of SBO caused by Salmonella typhimurium, a rare clinical manifestation of the infection that has not been reported. In this case, we discuss how successful diagnosis and subsequent antibiotic therapy led to resolution of the small bowel obstruction.

CASE DESCRIPTION/METHODS:

A 72-year-old male with a history of remote testicular cancer, recent lung cancer pending resection, presented to the emergency department (ED) with fatigue, abdominal distention, vomiting and non-bloody diarrhea for 1 week. He reported having a new jalapeno artichoke dip a few days prior. No recent travel or prior abdominal surgery. In ED, vitals: BP 81/52, HR 117, RR 32, T 98.6. Exam showed abdominal distention with lower quadrant and rebound tenderness. Labs showed WBC 4 × 109/L (43% bands), lactic acid 7.3 mmol/L, and negative C. difficile. CT Abdomen showed significant small bowel dilation with abnormal thickening noted in the distal ileum; consistent with small bowel obstruction. He was admitted to ICU for sepsis likely secondary to SBO. IV fluids led to hemodynamic improvement, and conservative treatment with nasogastric tube and bowel rest were initiated. Serial X-rays showed persistent dilated bowel loops. Stool cultures returned day 4 for S. typhimurium, and ciprofloxacin was started with clinical improvement in 2 days. By day 7, X-ray showed resolution of dilated small bowel. Patient was transitioned to an oral diet and discharged in stable condition by day 9.

DISCUSSION:

Progression to SBO from Salmonella as in our patient, to the best of our knowledge has never been reported. Salmonella as a causal agent for enteritis or other complications can be extremely difficult to diagnose if not suspected. Terminal ileitis on CT can lead to mimicking of other diseases such as Crohn’s, however an infectious etiology should remain on the differential, even in the setting of SBO. Although definitive diagnosis is based on culture, CT findings of circumferential and homogenous thickening of the terminal ileum in the appropriate clinical context can also help facilitate timely initiation of antibiotics and avoid possible aggressive interventions including surgery
2622 A Case of Metastatic Renal Cell Carcinoma to the Jejunum Presenting as Iron Deficiency Anemia
Authors: Roccato Mary Kathryn , Choi Alyssa , Duh Erica , Samarasena Jason , Parekh Nimisha K.
Published: October 2019

INTRODUCTION:

Small bowel malignancies comprise only 0.35% of all malignancies and small bowel metastases only comprise 2% of malignancies, only 7.1% of which are from a primary renal cell carcinoma (RCC).This case demonstrates a rare metastatic RCC of the small bowel diagnosed through video capsule endoscopy (VCE) prompting an antegrade double-balloon enteroscopy (DBE).

CASE DESCRIPTION/METHODS:

A 53-year old male with hypertension, diabetes mellitus, and anemia presented with a rapidly worsening, necrotic right lower quadrant abdominal wall lesion. Dermatopathology from a wound edge biopsy demonstrated an ulcer with neutrophils and karyorrhectic debris, consistent with pyoderma gangrenosum (PG). He was found to have iron deficiency anemia (IDA) requiring multiple blood transfusions and iron infusions. Colonoscopy and esophagogastroduodenoscopy were unremarkable. VCE demonstrated markedly abnormal mucosa in the proximal jejunum, occupying at least 75% of the lumen with several satellite lesions. Antegrade DBE revealed a large ulcerated jejunal mass with leakage of serosanguinous fluid. Pathology showed poorly-differentiated carcinoma of unknown etiology. Pan-CT revealed a 5.6 × 5.4 cm solid mass in the right kidney with invasion of the right renal vein with thrombus extending into the inferior vena cava, liver masses, and pulmonary nodules consistent with metastatic renal cell carcinoma.

DISCUSSION:

This is a rare case of RCC metastatic to the small bowel. Only three other case studies report this in the literature. Approximately 25–30% of patients have metastatic disease at time of RCC diagnosis. The most common sites of metastasis for RCC include lymph nodes, lung, bone, liver and brain. Metastasis to the small bowel often originate from cancers of the breast, lung, esophagus, head and neck, and melanoma. While there have been case reports of jejunal metastases many years status-post nephrectomy, there have only been three reported cases of synchronous jejunal metastases from RCC. Metastatic RCC to the small bowel can present as gastrointestinal bleeding and intussusception. VCE and DBE were useful diagnostic tools in our particular case. CT or MR enterography may have also served as an appropriate diagnostic alternative, and in retrospect may have helped to make the diagnosis sooner. Overall, it is important to consider small bowel malignancy on the differential diagnosis in a patient who presents with IDA.
2624 A Classic Case of Peutz-Jeghers Syndrome Presenting as Recurrent Intussusception
Authors: Shenoy Vinayak , Park Connie , Nguyen Andrew , Okolo Patrick
Published: October 2019

INTRODUCTION:

Peutz-Jeghers syndrome (PJS) is a rare autosomal dominant genetic disorder associated with mucocutaneous hyperpigmentation and hamartomatous gastrointestinal polyps. Here, we present a case of PJS presenting as abdominal pain due to recurrent intussusception in a patient without family history of gastrointestinal conditions.

CASE DESCRIPTION/METHODS:

A 28-year-old African American female with a remote history of intussusception and small bowel resection presented with 5 days of epigastric pain. An EGD and colonoscopy from years prior reportedly revealed multiple benign polyps. There was no family history of PJS, gastrointestinal, ovarian, or endometrial cancer. On exam, right lower abdomen was tender and oral mucosa revealed hyperpigmentation. Labs were notable for iron deficiency anemia with a hemoglobin of 8.3 g/dL. Abdominal CT revealed a left lower quadrant enteroenteric intussusception with a 2.3 cm small bowel tumor functioning as a lead point and a 3 cm cecal mass. Retrograde enteroscopy to evaluate the small bowel tumor revealed ileal nodules, no intraluminal cecal mass, and 2 ileal polyps that were resected. Pathology showed polypoid fragments of ileal mucosa with marked submucosal lymphoid aggregates. Upright abdominal Xray was obtained for worsening abdominal pain and peritoneal signs, which showed an air fluid level in the small bowel, concerning for obstruction. She underwent a diagnostic laparoscopy revealing a cecal mass and ileal intussusception. She had an ileocecectomy and small bowel resection with a large polypoid mass in the resected ileum. Histology of the cecal mass revealed a cystic nodule of benign small bowel mucosa and the ileal polypoid mass demonstrated a hamartomatous polyp with ectopic extension into the muscularis propria, suggestive of PJS. Subsequent STK11 gene analysis revealed an exonic deletion, confirming the diagnosis.

DISCUSSION:

Up to 69% of patients with PJS experience intussusception. The risk of intussusception reaches 50% by age 20 in these patients. Although the association of PJS with intussusception is well-known due to polyps functioning as lead points, PJS is rarely diagnosed on recurrence of intussusception. Endoscopic polyp removal is recommended in these patients to avoid complications of surgery but surgical resection remains the definitive treatment in most cases. Recurrent intussusception in adult patients is a finding that should elicit consideration of PJS in patients with a history of polyps and no significant family history.
2632 Balloon Dilation via Colonoscopy to Treat Small Bowel Obstruction as a Complication of Surgical Resection of Carcinoid Tumor
Authors: Patel Pratik , Phan Ethan , Jampala Nannaya , Mudireddy Prashant
Published: October 2019

INTRODUCTION:

Metastatic neuroendocrine neoplasms (NENs) are prevalent at initial prognosis. Surgery with the aim to cure is the current recommended guideline. However, there is not data in supporting therapy for complications from surgery. We successfully treated anastomotic stricture using endoscopic dilation, a modality recommended for treating of Crohn’s Disease stricture.

CASE DESCRIPTION/METHODS:

69-year-old female with a history of HTN, hypothyroidism and metastatic Small Bowel Carcinoid Tumor s/p small bowel resection complicated by post-op ileus and now high grade small bowel obstruction (SBO). Initially diagnosed with carcinoid with imaging showing 2.2 × 1.4 cm nodularity in small bowel and mesenteric nodal involvement with elevated chromogranin and 5-HIAA. PET scan showed ileocolic mesenteric adenopathy with no hypermetabolic activity noted. Pathology from small bowel resection revealed high grade carcinoid tumor, for which octreotide therapy was initiated. Patient later developed a high grade SBO at the anastomotic site. She underwent colonoscopy and anastomotic stricture with severe stenosis of 3 mm was noted 10 cm from the ileocecal valve. A Visiglide wire was successfully passed through the stricture under fluoroscopic guidance. She was then serially dilated to 12 mm using a pyloric balloon dilator. Improvement in luminal narrowing was noted after dilation. Output from nasogastric tube began to decrease and her abdominal pain slowly improved. A few days later she began moving her bowels and nasogastric tube was removed. She was advanced from liquid to soft diet and was discharged in stable condition.

DISCUSSION:

Metastatic intestinal and pancreatic NENs represent 40–50% at initial diagnosis. Besides systemic therapies, current consensus guideline for metastatic NENs recommends for surgical resection with locoregional or ablative therapies. One complication of surgical resection is the development of anastomotic strictures. Strictures in the small bowel are commonly seen in Crohn's Disease. Literature has shown great success with endoscopic balloon dilation for the management of Crohn’s associated strictures. However, small bowel strictures as a complication of surgical resection of carcinoid tumors is not well documented. Our case illustrates how using an endoscopic technique known to manage Crohn’s complications can be novel to cases with similar pathophysiology but different etiology.
2640 Intractable Celiac Disease in IgA Deficiency
Authors: Gonzalez Lisandro , Lewis Megan , Kataria Archish , Gondin Lyan , Parker Allan L.
Published: October 2019

INTRODUCTION:

Celiac disease is an immune-mediated disorder triggered by a reaction to gluten with elevated levels of IgA antibodies. Symptoms typically resolve with a gluten free diet. However, refractory cases have been reported despite dietary adherence. Our discussion involves an elderly woman with severe, refractory celiac disease with concomitant IgA deficiency.

CASE DESCRIPTION/METHODS:

An 80-year-old woman presented our clinic with exacerbation of chronic, non-bloody diarrhea. She has a history of celiac disease diagnosed 20 years ago after an episode of acute pancreatitis. She also has IgA deficiency and her total IgA level remains low at 37, despite infusions 3 times per week. She is strictly adherent to a gluten free diet, but continues to have multiple episodes of diarrhea and has lost over 100 pounds since her diagnosis. Patient had bidirectional endoscopy notable for antral gastropathy as well as fissures and flattening of the duodenal mucosa. Biopsies were consistent with celiac sprue. Capsule endoscopy showed diffuse flattening of the small bowel villi with erythema and cracked, scalloped mucosa as well as multiple, small, aphthous ulcers throughout the bowel (Figures 1, 2, and 3). Patient has had an extensive workup, but everything else have been unrevealing. Steroids have been initiated as a last-ditch effort, but she continues to have “more bad days than good days” despite being on a high dose prednisone.

DISCUSSION:

The diagnosis and treatment of celiac disease can be complicated by coexisting immunodeficiencies. Usually, titers of tissue transglutaminase IgA will be elevated and are involved in the immune reaction that causes damage to the lining of the small bowel with characteristic flattening of the villi as well as chronic diarrhea and malabsorption. A connection between IgA deficiency and celiac disease has been well established and likely contributes to the refractory nature of our patient’s disease. In patients with IgA deficiency it is important to utilize other forms of serologic testing, typically with IgG tissue transglutaminase, in addition to duodenal biopsies. Symptoms typically resolve with a gluten free diet. However, refractory cases have been reported with persistent diarrhea and villous atrophy for over 1–2 years. Symptom management can be difficult for these patients and may require the use of steroids as the last resource.
2648 A Case of Amebiasis in a Patient With Familial Hypertriglyceridemia Complicated by Recurrent Pancreatitis
Authors: Sang Jessica , Lewis Jason
Published: October 2019

INTRODUCTION:

Amebiasis disproportionately affects people in developing countries because poor sanitation conditions increase the risk for pathogen acquisition. In the United States, individuals who travel to endemic areas and men who have sex with men are two groups at higher risk of exposure. The following case highlights the importance of exposure history and avoiding anchoring bias. The patient’s constellation of symptoms could be explained by his history of chronic pancreatitis and pancreatic insufficiency, but upon further investigation he was also found have an infective enteritis.

CASE DESCRIPTION/METHODS:

A 44-year-old man with a past medical history significant for type 2 diabetes mellitus, idiopathic small fiber neuropathy, and familial hypertriglyceridemia complicated by recurrent pancreatitis was admitted for recurrent symptoms of nausea, vomiting, non-bloody diarrhea, and abdominal pain. Within the previous year, the patient had a PEG-J tube placement for nutritional support in the setting of severe pancreatitis complicated by acute fluid collections. On arrival to the emergency department, he was tachycardic and labs revealed a leukocytosis of 18 × 103 µL, lipase of 510 U/L, and normal LFTs. The CT scan showed a stable pancreatic pseudocyst and no suggestion of acute pancreatitis. Imaging did reveal mild thickening and dilated loops of small bowel consistent with enteritis in the left mid and left lower abdomen. Stool pathogen panel sent during previous admission had returned positive for Entamoeba histolytica (E. histolytica). The patient endorsed drinking well water from his backyard and using it to flush his PEG-J tube.

DISCUSSION:

The majority of amebiasis cases are asymptomatic, however 10% are associated with significant morbidity and mortality. E. histolytica is one of four species of intestinal amebae and the one related most to symptomatic disease. Malnutrition, which was present in our patient, is a risk factor for severe disease. Studies have shown that interaction between the host’s intestinal flora and E. histolytica may influence pathogenic behavior. Our patient's treatment regimen consisted of metronidazole, which is active against the trophozoite stage, and paromomycin, which eliminates intraluminal cysts. His source of exposure was likely the well water which was uncovered through a detailed exposure history.
2649 A Case of Primary Intestinal Lymphangiectasia in an African American Adult Male With Intermittent Abdominal Pain and Diarrhea
Authors: Abdallah Abdallah , Karim Ahmed , Alnakshabendi Imad , Alnakhabendi Ibrahim
Published: October 2019

INTRODUCTION:

Primary intestinal lymphangiectasia is a rare type of protein losing enteropathy in which there is a localized or diffuse ectasia of the enteric lymphatic causing leakage of protein into the intestinal lumen. Here, we describe a case of Primary Intestinal Lymphangeictasia in a patient presenting with chronic intermittent abdominal pain and diarrhea.

CASE DESCRIPTION/METHODS:

Patient is a 56-year-old African-American male with history of COPD, DM, morbid obesity, GERD who presented to our office as a referral after hospitalization for for evaluation of abdominal pain and diarrhea. Patient was hospitalized for 3 day duration of epigastric pain and watery diarrhea. There, he was noted to have hypocalcemia, hypoalbuminemia, and trace urine proteinuria. Lactate was normal. CT abdomen pelvis showed nonspecific Jujenitis. He was treated empirically with Intravenous antibiotics and discharged home. During follow up visits, initial comprehensive workup for inflammatory bowel disease, celiac disease, stool pathogens, thyroid panel, lipid panel, Alpha-1-Antitrypsin stool clearance, and HIV were all unremarkable. Patient subsequently underwent colonoscopy and EGD. Colonoscopy revealed sigmoid diverticulosis and internal hemorrhoids. EGD revealed nonspecific jejunitis. He had yet another hospitalization for worsening similar acute abdominal pain. During his second hospitalization, labs showed mild leukocytosis, CT abdomen and pelvis revealed jejunal edema. He was taken for diagnostic laparoscopy which only showed mild ascites and thickening of the jejunum. Surgical pathology unfortunately was inconclusive. Patient followed up again as an outpatient and underwent small capsule endoscopy which revealed lymphangiectasia at the jejunum. Patient was referred to a dietitian where he was placed on high protein and Medium chain triglycerides diet.

DISCUSSION:

Primary Intestinal Lymphangeictasia is a rare cause of protein losing enteropathy that can manifest as non-specific abdominal pain and diarrhea. In this case, the patient had chronic intermittent abdominal pain and diarrhea which required capsule endoscopy in order to diagnose and was missed on surgical pathology. Much like an Inflammatory Bowel disease which can take several studies and biopsies in order to diagnose, albeit different pathophysiology, Primary intestinal lymphaniectasia is a rare cause of abdominal pain that should be on the differential when evaluating chronic intermittent severe abdominal pain and diarrhea of unknown etiology.
2654 Metastatic Squamous Cell Carcinoma to the Small Bowel Masquerading as Crohn’s Disease: A Diagnostic Dilemma
Authors: Mony Shruti , Patel Krishen , Taunk Pushpak
Published: October 2019

INTRODUCTION:

Head and neck squamous cell carcinoma (HNSCC) is the sixth most common type of cancer in the world. The presence of distant metastasis after the initial treatment of head and neck cancers is associated with a poor prognosis. The most frequent site for distant metastasis of HNSCC is lung, followed by mediastinal lymph nodes, bone and liver. Metastatic squamous cell carcinoma (SCC) to the small bowel is an extremely rare occurrence. We present a unique case of a patient with HNSCC who presented with small bowel obstruction and concern for Crohn’s disease (CD) but was ultimately diagnosed with metastatic SCC.

CASE DESCRIPTION/METHODS:

A 67 year old Caucasian male with a history of SCC of the left pinna and epiglottis on cisplatin chemotherapy and radiation therapy, presented with 2 weeks of intractable nausea, vomiting, and peri-umbilical abdominal pain. Lab work revealed leukocytosis with WBC 16,000. CT abdomen and pelvis was notable for dilated small bowel loops and a long segment thickening of the distal ileum causing a partial small bowel obstruction (Figure 1).  His symptoms persisted despite nasogastric decompressiontube and antibiotics. An abdominal MRI showed similar findings of long discontinuous segments of diffuse distal small bowel thickening, luminal narrowing and mural enhancement with concern for small bowel CD. Given these findings, an empiric course of steroids was initiated. Patient’s symptoms improved and he was discharged from the hospital..To further evaluate the small bowel, he underwent a retrograde balloon enteroscopy, which showed subtle findings of multiple sub-centimeter distal ileal nodules (Figure 2), but no other abnormalities. Biopsies of the nodules returned as metastatic poorly differentiated squamous cell carcinoma (Figure 3).

DISCUSSION:

Small bowel metastasis represents less than 10% of malignant tumors of the small bowel. Small bowel metastasis from HNSCC is an unusually rare occurrence and to date, there is minimal literature on it’s occurrence. Clinical presentation is variable with acute or sub-acute intestinal obstruction, ileus, gastrointestinal hemorrhage or bowel perforation. Here, we present an unusual case of small bowel metastasis from HNSCC, which is unique given the initial radiologic findings suggestive of CD. Thus, clinicians must be cognizant of the metastatic potential of squamous cell cancer in order to prevent delayed diagnosis and avoid devastating consequences.
2664 You're Breaking My Heart: Carcinoid Heart Disease
Authors: Biglin Mary , Swanson Garth
Published: October 2019

INTRODUCTION:

Neuroendocrine tumors (NET) are rare tumors affecting the gastrointestinal tract and lungs with ∼8,000 cases diagnosed in the US each year. About 80% of small intestinal NET have metastasized to the liver and present as carcinoid syndrome with flushing, diarrhea, bronchospasm and heart failure, as the liver is unable to metabolize vasoactive substances. Carcinoid heart disease can occur in ∼60% of patients with carcinoid syndrome and is a late complication that can be associated with significant morbidity due to right sided heart failure.

CASE DESCRIPTION/METHODS:

A 60 year old female with anxiety and breast cancer presented to an outside clinic with chronic diarrhea. She began experiencing 10–20 watery stools daily for over a year but lost 8 pounds over the last four months. An upper and lower endoscopy done for evaluation of chronic diarrhea was normal. Stool studies revealed a negative stool culture, clostridium difficile PCR and normal fecal elastase, but laboratory studies showed an elevated chromogranin A (23,940 ng/ml), serotonin (1668 ng/ml) and urinary 5-HIAA (112 mg/day). A CT of the abdomen revealed multiple liver lesions. Liver biopsy was non-diagnostic. Four months later she sought a second opinion but soon after developed new onset ascites and lower extremity edema so was admitted to the hospital for further evaluation. Echocardiogram showed severe tricuspid regurgitation with the leaflets tethered and fixed in an open position. Cardiac MRI showed late gadolinium enhancement of tricuspid valve leaflets which was consistent with carcinoid heart disease. Repeat liver biopsy revealed grade 2 well differentiated NET, with presumed small bowel origin. She received octreotide and underwent mechanical tricuspid valve replacement.

DISCUSSION:

Carcinoid syndrome is a rare finding but is important in the differential of chronic diarrhea. This case also portrays the prolonged natural history of carcinoid syndrome with the late complication of carcinoid heart disease. Inability of upper and lower endoscopy to locate small bowel carcinoids can lead to a delay in diagnosis, and in 18% of small bowel carcinoids the primary location is not identified. Early identification and treatment of NET tumors can avoid late morbid conditions such as carcinoid heart syndrome.
2667 Can't You GIST Move Over?
Authors: Likhtshteyn Michelle , Arroyo-Mercado Fray Martin M. , Iqbal Sadat , Botti Evan , Diks John , Anklesaria Ava
Published: October 2019

INTRODUCTION:

Gastrointestinal stromal tumors (GISTs) are a common mesenchymal tumor of the GI tract. Here we present a case of a 60-year-old male with a 33.5 × 27 cm GIST arising from the greater stomach curvature, increased in size from 18.1 × 13.4 cm in five months; an alarming growth rate for a tumor known to grow slowly.

CASE DESCRIPTION/METHODS:

60-year-old male with history of GIST and HTN presented to the hospital with abdominal pain and shortness of breath. Physical exam revealed decreased bowel sounds and diffuse tenderness to palpation in the right and left lower quadrants. Patient had previously been diagnosed with a 18.1 × 13.4 cm GIST 5 months prior, and was positive for CKIT (CD117) and DOG1, with 6 mitotic figures/21 HPFs (Figure 1). The patient was lost to follow up and never started on Imatinib. Over a span of five months, the necrotic mass had doubled in size with a repeat CT scan on admission showing a 33.5 × 27 cm GIST (Figures 2 and 3) arising from the greater stomach curvature, invading the left hepatic lobe and compressing the inferior vena cava (IVC). During this admission, he was also found to have bilateral pulmonary embolism, with large clot burden and right heart strain. An IVC filter would have been ideal for prevention of further clot migration, however the compression of the IVC by enlarging GIST prevented intervention. Patient was treated with heparin and started on Imatinib as an outpatient, patient is doing well and following with oncology.

DISCUSSION:

GISTs can be found in any part of the gastrointestinal tract, with predominance in the stomach. GISTs are often asymptomatic and diagnosed incidentally or they may present with nonspecific symptoms such as early satiety, abdominal pain, anemia, GI bleed or gastric outlet obstruction. Treatment options are dictated by risk of progression which is determined by size (≥3 cm), location, and mitotic count. [1] While the exact rate of tumor growth is unknown, studies have shown a range of 1.2 to 50.7% per annum [2]. On representation to the hospital five months after initial diagnosis, our patients’ mass had increased in size by 54% which surpasses documented growth rates. His mass also created significant compression and prevented integral placement of an IVC filter. While GIST tumors are traditionally thought to be slow growing tumors our case highlights the importance of earlier intervention in high-risk patients; metastatic and compressive complications could have been avoided for this patient had he returned for initial follow-up.
2674 Laying a Gastric Wall Abscess to Rest
Authors: Haberstroh William , Steinberg Joshua M. , Benjamin Stanley , Palese Caren
Published: October 2019

INTRODUCTION:

Gastric wall abscess (GWA) or localized suppurative gastritis is a purulent inflammatory process of the submucosa of the stomach associated with high mortality rates. GWA can be a rare complication of subepithelial lesions (SEL), such as ectopic pancreas (pancreatic rest), GIST, and leiomyosarcoma. Our report is the fourth demonstrated case of pancreatic rest associated GWA and the first in an extensive literature search with successful treatment without adjunctive surgical resection.

CASE DESCRIPTION/METHODS:

38-year-old healthy female presented to our Gastroenterology clinic for persistent abdominal pain with nausea and vomiting after being evaluated 3 days ago at an outside hospital (OSH) (Table 1). She was diagnosed with gastritis and sent home on omeprazole. At our institution, she described her pain as sharp, constant, non-radiating and diffuse, but worst in the epigastrium postprandially. Social history was remarkable for 1-2 drinks per day and recent travel to Peru 3-4 weeks prior. As she appeared acutely ill, the patient was referred to ED, with initial work up remarkable for blood pressure of 93/54 and WBC of 13.5. EGD revealed a large submucosal gastric mass in the distal gastric antrum with central umbilication and expressible white purulent material (Figure 1). She was started on pip/tazo and ID was consulted. Micro was largely negative; however, culture of purulent material was unable to be processed. Pathology showed active gastritis, focal ulceration, and necro-inflammatory tissue without evidence of malignancy. Cytology revealed purulent exudate associated with bacterial colonies consistent with abscess. The patient clinically improved and was discharged home on Augmentin. In outpatient follow up, patient reported continued improvement. Follow up EGD revealed resolution of abscess, however pancreatic rest was seen in the gastric antrum (Figure 2).

DISCUSSION:

GWA is a rare and highly morbid condition commonly located in the antrum or pylorus. Exact pathogenesis may be due to direct bacterial seeding or hematogenous spread. Strep species are the most commonly isolated bacteria. GWA is rarely also associated with a SEL, in our case being a pancreatic rest, or ectopic pancreatic tissue. Treatment for SEL associated GWA has traditionally been surgical removal with either partial gastrectomy or wedge resection. Our case report demonstrates the safety and efficacy of drainage and medical management alone.
2676 An Extranodal Presentation of Peripheral T-Cell Lymphoma, Not Otherwise Specified as Primary Gastric Lymphoma, With Coexistence of HTLV-1
Authors: Bandaru Praneeth , Barakat Mohamed , John Febin , Aamar Ali , Quintero Eduardo
Published: October 2019

INTRODUCTION:

Peripheral T- Cell Lymphoma, not otherwise specified ( PTCL-NOS) is a subtype of T-cell lymphoma that typically presents as primary nodal lymphoma, however can rarely present as primary extranodal lymphomas with stomach being the most common extranodal site. Here we present a unique case of PTCL-NOS gastric lymphoma with coexistence of HTLV-1, which is usually associated with Adult T-cell lymphoma/leukemia.

CASE DESCRIPTION/METHODS:

A 58 year old man with known hypertension and a chief complaint of abdominal discomfort, fatigue, occasional black stools and unintentional 10 lb weight loss of 2 months duration was seen in clinic. Vital signs, physical exam were normal except for conjunctival pallor. Labs revealed Hb of 7 gm/dL and elevated LDH. CT scan of the abdomen revealed an 11 × 12 × 12.6 cm poorly defined inseperable mass, in the left upper abdomen (Figure 1). Upper endoscopy (EGD) with Endoscopic ultrasound (EUS) revealed a large, ulcerated, nearly circumferencial, fungating mass that appeared to erode through the cardia of the stomach. Biopsy and immunohistochemical (IHC) staining revealed pleomorphic lymphocyte cells positive for CD2, CD3, CD5, CD4(70%), CD7 (20%), CD8 (30%), CD43 and CD45 (20%) (Figure 2). KI-67 index was 80% suggestive of high grade PTCL-NOS, with necrosis (Figure 3). H. pylori and HTLV-1 antibody were positive. Pretreatment PET scan and bone marrow biopsy did not reveal additional site involvement. He was subsequently started on CHOEP regimen and triple therapy for H.Pylori. Repeat imaging after the 4th cycle revealed an interval decrease in the size of the stomach mass with no new lesions.

DISCUSSION:

Primary Gastric lymphomas account for 3-4% of all the stomach malignancies, mostly B-cell (85-90%) in origin followed by PTCL-NOS. Biopsy is obtained by EGD in most cases and EUS is being increasingly used to evaluate for locoregional spread. Early diagnosis and initiation of treatment with CHOP/CHOEP regimen is crucial for better outcomes. Pan imaging, FDG PET, bone marrow biopsy are critical for staging, tumour activity and for followup to check for response. Radiation, surgery, bone marrow transplantation are used as adjuvant to chemotheraphy in select patients. Coexistence of HTLV-1 in a PTCL-NOS patient make our case unique and this gives scope for further research to verify if there is any association exists between PTCL-NOS and HTLV-1.
2678 To the Heart of the Matter: A Case of Left Ventricular Assist Device Erosion at the Texas Heart Institute
Authors: Pathan Sabina , Sparkman Jordan , Kaur Manreet
Published: October 2019

INTRODUCTION:

Left ventricular assist devices (LVADs) are used in patients with advanced systolic heart failure as a bridge to cardiac transplant or as destination therapy. LVADs provide a survival benefit in this population but pose a significant risk of infection, typically of the driveline. Gastrointestinal-related infectious complications of LVADs, including erosion into the GI tract, or a device-related enteric fistula are less common. Here we present a case of enteric LVAD erosion discovered while investigating unusual blood culture results.

CASE DESCRIPTION/METHODS:

A 52 year old man with history of alcohol-related cardiomyopathy now with LVAD and chronic driveline infections with Stenotrophomonas, E. cloacae, MRSA, and MSSA on suppressive antibiotics was admitted to our hospital after outpatient blood cultures grew C. albicans. He reported fatigue and forty-pound weight loss during the previous three months. He denied fevers, abdominal pain, nausea, vomiting, change in appetite or early satiety. On admission, the patient was afebrile. On physical exam, he was in no distress, the abdomen was soft and not tender. There was purulent drainage from the driveline site, unchanged from prior admissions. Given his unusual history of bloodstream infections with Lactobacillus, Enterobacter, E. coli, and now Candida, there was concern for a bowel connection to the LVAD. Cross-sectional imaging with PO contrast revealed expected positioning of the LVAD abutting the gastric body and significant hardware scatter artifact, limiting the examination (Figure 1). The patient therefore underwent bidirectional endoscopy and EGD revealed two areas of ulceration and exposed LVAD hardware eroding into the greater curvature of the gastric body (Figure 2). The patient underwent subsequent explant and replacement of the LVAD. Two defects in the gastric body, one near the cardia and the other near the antrum were repaired by omental flap placement and gastrorrhaphy. A peri-gastric abscess was also drained.

DISCUSSION:

LVADs have revolutionized the management of advanced heart failure, however one-half of patients will develop a device-related infection within nine months of implantation. Although less common, GI-related LVAD infections, including enteric erosion and fistula formation, require a high index of suspicion. Non-invasive testing is suboptimal given limitations of current imaging modalities. Therefore, these patients should undergo upper and lower endoscopy for direct visualization and timely diagnosis.
2679 An Unusual Presentation of Invasive Gastric Adenocarcinoma
Authors: Wankhade Charudatta , Kratzer Marykate , Jacob Bobby , Paz Sandra Gomez , Desai Jiten , Singh Davinder , Khan Nausheer
Published: October 2019

INTRODUCTION:

Gastric cancer rarely occurs before the age of 40, but it’s incidence rises thereafter and peaks in the seventh decade of life. Most patients with gastric cancer in the United States are symptomatic and already have advanced disease at the time of presentation. We present a case where neither the patient history nor physical exam provided any early indication to the diagnosis of gastric adenocarcinoma.

CASE DESCRIPTION/METHODS:

A 32-year old Jamaican female was admitted for right lower quadrant abdominal pain since five days. Pain was constant, sharp, radiating from the pelvis to lower back. Review of systems was positive for dyspnea on exertion and 35-pound weight loss over past 3 months. She denied any past medical or surgical history, alcohol and tobacco use. Family history was significant for breast cancer in an aunt. On physical exam patient was afebrile, blood pressure and pulse were 120/76 mmhg and 86/min respectively. She had right lower quadrant tenderness on deep palpation but rest of the physical exam was unremarkable. CT thorax, abdomen and pelvis was negative for PE but demonstrated mediastinal, hilar, retroperitoneal and mesenteric lymphadenopathy. Infectious and autoimmune workup were unremarkable. Endoscopic intervention revealed a 7 cm ulcerated friable gastric mass near the pylorus and internal hemorrhoids on colonoscopy. Biopsy of the mass revealed poorly differentiated gastric adenocarcinoma. Hospital course was complicated with pericardial tamponade. Pericardial biopsy revealed metastatic poorly differentiated carcinoma. Patient was not a candidate for chemotherapy as she was spiking fevers on antibiotics. After over a month long hospital course, patient succumbed to multi-organ dysfunction related to her malignancy.

DISCUSSION:

Greater than 50% of patients present with unresectable locally advanced or metastatic gastric adenocarcinoma. The American Society for Gastrointestinal Endoscopy recommends endoscopic surveillance for high-risk individuals. Mass endoscopic/radiologic screening is not recommended in United states. Patients with advanced stage IV disease as in our patient, are usually referred for palliative therapy depending on their functional status. Our case illustrates an unusual presentation of a primary gastric mass, however with careful history, physical examination and timely endoscopic intervention, we can possibly prevent the significant delay in diagnosis and allow for timely management of gastric adenocarcinoma.