bluuebunny/crossref_metadata_2025 huggingface dataset:
1660 Malakoplakia of the Rectum Masquerading as a Tumor: A Case Report
Authors: Mashiana Simran , Ambelil Manju , Nair Varsha , Ko Huaibin Mabel , Harpaz Noam
Published: October 2019

INTRODUCTION:

Malakoplakia is a rare inflammatory disorder that occurs in the clinical setting of persistent infections, immunosuppression and tumors. The most common sites of involvement are the urinary, gastrointestinal and respiratory tracts, skin, brain and lymph nodes where they can mimic malignancies.

CASE DESCRIPTION/METHODS:

A 60-year-old woman with myasthenia gravis and stage IV metastatic thymoma (status-post resection and chemo-radiation) presented with persistent weight loss, bloating, nausea, tenesmus and hematochezia. Her recent history included treatment-resistant Giardia lambia infection for one year as well as recently diagnosed Norovirus and Enteroaggregative Escherichia coli, diagnosed by stool pathogen PCR testing. On colonoscopy, the rectum contained a 7 cm region of polypoid, non-circumferential, non-obstructing nodules (Figure 1) which were highly suspicious for tumor. Microscopically, biopsies revealed rectal lamina propria infiltration by epithelioid cells with small central nuclei, eosinophilic cytoplasm (Figure 2) and lamellated cytoplasmic calcifications (Figure 3). The cells expressed cytoplasmic CD68 (Figure 2) and Von Kossa stain highlighted the calcifications, consistent with Michaelis-Gutmann bodies (Figure 3). Immunostain for pancytokeratin and Ziehl-Neelsen and Gomori's methenamine silver stains were negative. The final diagnosis was malakoplakia. A re-biopsy of the lesion showed positivity for Cytomegalovirus (CMV) immunostain and high levels of CMV viremia (1010IU/mL), for which she was treated with Gancyclovir.

DISCUSSION:

Malakoplakia is a rare gastrointestinal disorder without specific symptoms, endoscopic features or gross findings and tends to masquerade as a tumor. As illustrated herein, it is often an unexpected diagnosis that depends on pathological recognition of characteristic microscopic features. The correct diagnosis is critical to avoid inappropriate radical treatment. Various micro-organisms have been implicated in its development including bacteria, most commonly E. coli, viruses, fungi and even protozoa such as Taeniaspecies and it is characterized by defective bactericidal activity of the macrophages. Pathologists should be aware that malakoplakia can coexist with malignancy and tuberculosis, therefore, thorough sampling of mass lesions and appropriate adjunctive stains are advisable. Risk factors in our case included an immunocompromised state, multiple concurrent infections, and advanced malignancy, although no malignancy was identified in the biopsies.
1661 Colo-Colic Intussusception Secondary to a Large Submucosal Colonic Lipoma
Authors: Fazeli Cameron , Patel Harsh D. , Camero Alfredo , Gonzalez Lisandro , Campi Haisar Dao , Rosenkranz Laura
Published: October 2019

INTRODUCTION:

Intussusception is telescoping of a proximal segment of bowel into the lumen of the adjacent distal segment of bowel. This condition is usually seen in the pediatric population and is most often due to a benign pathologic lead point. Intussusception remains a rare condition in adults, representing approximately 1–5% of mechanical bowel obstructions typically due to malignancy. We present a rare case of Colo-colic intussusception secondary to a sub-mucosal benign lipoma.

CASE DESCRIPTION/METHODS:

A 33-year-old Caucasian woman with no past medical or surgical history, presented with one month of intermittent left-sided and mid-abdominal cramping, which intensified the week prior to presentation. She reported increasing post-prandial pain with associated nausea and bloating. Physical exam revealed stable hemodynamics, and diffuse abdominal tenderness to palpation. Laboratory testing was unremarkable, including a serum pregnancy test. Contrasted CT Abdomen/Pelvis revealed intussusception of the mesenteric tissues and transverse colon into the descending colon with a discrete mass lesion as the lead point (Figure 1). A colonoscopy revealed a large, non-obstructing, hard, negative pillow sign, subepithelial mass, with a short stalk at the hepatic flexure was encountered (Figure 2). The patient underwent laparotomy by colorectal surgeon. A proximal transverse colon intussusception was identified and a right hemicolectomy with ileocolonic anastomosis was completed. Surgical pathology results revealed a 6.5 cm submucosal lipoma without evidence of dysplasia or malignancy (Figure 3). The patient recovered well post-operatively and was discharged.

DISCUSSION:

In adults, the diagnosis of intussusception can be difficult to make based on clinical presentation alone due to the rarity and non-specific complaints. The condition is commonly related to malignancy. Generally, colo-colic intussusceptions are the least common. Cross sectional imaging, such as CT scans with IV contrast are the most sensitive diagnostic tests. Our case identifies an uncommon cause of abdominal pain in an adult patient with the CT scan and diagnostic laparotomy revealing a colo-colic intussusception. In this fortunate case, pathology revealed a benign lesion as the lead point. Although colonic lipomas are common this patient has low risk factors such as age and no metabolic syndrome, they are often asymptomatic and have been rarely reported to cause similar presentations as they increase in size ( >4 cm).
1665 A Baffling Case of Gastrocolitis
Authors: Penninti Pranav , Lewis Megan , Diallo Souleymane Y. , Malakouti Mazyar , Echavarria Juan , Brady Charles
Published: October 2019

INTRODUCTION:

Chronic mesenteric ischemia often has a subtle presentation requiring a high index of suspicion. Average time to diagnosis is 10.7 months, often delayed due to the vague nature of complaints. We present a challenging case of severe chronic mesenteric ischemia in a young woman.

CASE DESCRIPTION/METHODS:

A 42-year-old female smoker presented with abdominal pain, constipation, and >70-lb weight loss. She had developed black, watery stools one week prior. Vital signs were normal, BMI was 12.6. She was cachectic, had abdominal distention and tenderness worse in the right lower quadrant. A contrasted CT scan revealed a distended colon and large stool burden. She failed conservative management. Endoscopy revealed multiple Forrest III gastric ulcers (Figure 1) and deep cecal ulcerations (Figure 2) with normal TI. Biopsies showed inflammation with granulation tissue. Work up was negative for vasculitis and infection. She failed a steroid trial for a presumptive diagnosis of Crohn’s disease. CT enterography was normal. Repeat endoscopy showed persistent gastric ulcers. Biopsies revealed ischemic gastritis with associated ulceration and submucosal blood vessels with fibrin thrombi. A CT angiogram showed severe stenosis of the celiac artery and chronic occlusion of the superior mesenteric artery (Figure 3.) Endovascular celiac and SMA stenting failed requiring surgically-placed retrograde celiac and SMA stents. Her symptoms recurred due to celiac stent thrombosis and SMA stent migration to the left iliac artery. Finally, an antegrade supraceliac to celiac and SMA bypass was performed with excellent results.

DISCUSSION:

A high index of suspicion is required to diagnose chronic mesenteric ischemia. Risk factors include age > 60, female gender, history of PAD, CVD, or CAD. Typical symptoms include weight loss, postprandial pain, and diarrhea though most people are asymptomatic or present with atypical symptoms including nausea, vomiting, early satiety, or bleeding which often lead to misdiagnosis or delayed diagnosis. Management is aimed at preventing further bowel infarction via endovascular or open revascularization. Patients who fail stenting or angioplasty have a much higher risk of perioperative mortality during open repair (15% vs. 2%.) Our patient’s young age, normal initial CT abdomen, gastric and cecal ulcerations with lack of vascular disease history blurred the clinical picture. A high index of suspicion is required in patients with an initial negative work up.
1669 Cancer Within the Family Tree: The Risks, Diagnosis, and Treatment of Juvenile Polyposis Syndrome
Authors: Kozacek Kyler , Abdo Michael , Hudspath Caleb , Oroian Tudor , Manibusan Pedro , Goldwire Franklin
Published: October 2019

INTRODUCTION:

Juvenile Polyposis Syndrome (JPS) is characterized by the development of numerous hamartomatous polyps in the GI tract, increasing individuals’ risk of colorectal and gastric cancer by as much as 68% by age 60. These odds are further compounded by the syndrome’s autosomal dominant (AD) mode of inheritance, placing children at a 50% risk of transmission from an affected parent. Bone Morphogenic Protein Receptor type-1A (BMPR1A) genes located on chromosome 10q22-23 are strongly associated with JPS, with nearly 60% of cases testing positive for the mutation. Effects of this anomaly cascade down the transforming growth factor-beta (TGF-beta) pathway, resulting in patients developing tens to hundreds of polyps within their lifetime, often by the first decade. Mutations in SMAD4 proteins can also lead to JPS and Hereditary Hemorrhagic Telangiectasia (HHT) as they are also vital in TGF-beta signaling. JPS is clinically diagnosed by the absence of other hamartomatous polyposis syndromes (eg, Peutz-Jeghers or Cowden) and the presence of either >5 juvenile polyps in the colorectum, multiple juvenile polyps elsewhere in GI tract, or any polyps with a family history of juvenile polyps.

CASE DESCRIPTION/METHODS:

A 41-year-old female with intermittent IBS symptoms presented for colon cancer screening. Two years earlier, the patient’s mother had been diagnosed at age 64 with multiple juvenile colon polyps and colon cancer testing positive for BMPR1A gene mutation. Patient’s initial colonoscopy revealed multiple 3–4 cm irregularly shaped pedunculated polyps, many less than 1cm and an irregularly shaped mass in the mid-ascending colon. The mass was circumferential, broad-based at 4–5 cm and nearly completely obstructing. Polyps removed revealed tubular adenomas and tubular villous adenomas. Though none of these were documented as juvenile polyps, the patient did test positive for BMPR1A mutation suggestive of JPS. The patient was referred to general surgery for resection of the mass and upper endoscopy.

DISCUSSION:

JPS is a rare polyposis syndrome with AD inheritance. In at-risk patients, it is imperative that genetic testing be performed to determine appropriate cancer screening. Testing should include both SMAD4 and BMPR1A gene mutations, with positive SMAD4 mutations undergoing evaluation for HHT. Current guidelines recommend screening the stomach and colon early, as the length of time to diagnosis remains the single most influenceable and impacting factor in the outcomes of patients and their families.
1672 Appearances Are Glimpse of the Unseen
Authors: Bhandari Sawina , Iqbal Sara , Hosseini-Carroll Pegah
Published: October 2019

INTRODUCTION:

Breast cancer metastasis is seen in nearly 30% of cases. It most commonly spreads to the liver, brain, bones and lungs1,2. Gastrointestinal tract (GI) especially large bowel involvement is rare3,4. Usually diagnosed because of obstructive symptoms or bleeding. Endoscopic evaluation usually demonstrates obvious ulcerations, masses or stenosis. Finding a normal looking colon infiltrated by metastatic breast cancer cells is unique with incidence unknown5.

CASE DESCRIPTION/METHODS:

We report a case of a 69-year-old African American female with Stage 4 Invasive lobular left breast carcinoma with metastasis to bone and chronic disseminated intravascular coagulation who was admitted for GI bleeding. She underwent upper and lower endoscopies which were unrevealing for the cause of bleeding. Her upper scope revealed erythema in the stomach and duodenal villous blunting both of which were biopsied. Colonic mucosa looked congested and ulcerations were found in the terminal ileum which were also biopsied. These findings are not per literature review typical of metastatic breast cancer. To our surprise biopsies revealed metastatic lobular breast cancer infiltration in all samples collected from stomach, duodenum, terminal ileum and colon.

DISCUSSION:

Lobular breast carcinoma more commonly metastasizes to the gastrointestinal tract6 as compared to infiltrating ductal breast cancer. In instances that it does metastasize to the colon it shows obvious endoscopic findings which was not the case in our patient. Hence we purpose that vigilant sampling of tissue be performed in patients inflicted with this disease even with subtle findings on endoscopy.
1673 Multitarget Stool DNA Test (Cologuard™): A Double-Edged Sword
Authors: Mulat Baruh , Boroda Konstantin , Hertan Hilary
Published: October 2019

INTRODUCTION:

Colorectal cancer (CRC) is the third most common cancer diagnosed in both men and women in the United States. Fortunately, early, precancerous lesions, can be caught early with proper screening, however, only approximately 60% of the US population gets screened. The multitarget stool DNA test (Cologuard™) is an alternative to colonoscopy that might help reach more patients. We present two cases of patients with positive Cologuard tests and unexpected outcomes which posed clinical challenges.

CASE DESCRIPTION/METHODS:

Case 1: A 63-year-old male who declined colonoscopy in the past opted for Cologuard, which was positive. Subsequent colonoscopy revealed several polyps including one measuring 3.5 cm in the proximal transverse colon, which was thought to be cancerous, so it was only biopsied and not removed (Figure 1). Biopsy of this polyp revealed hyperplastic changes necessitating another colonoscopy. However the patient remains lost to follow up. Case 2: A 75-year-old male, with history of stroke, ischemic heart disease, chronic constipation and no family history of CRC presented to gastroenterology clinic after he had a positive Cologuard test. Colonoscopy was performed revealing a normal colon without mass or polyps.

DISCUSSION:

The multitarget stool DNA (Cologuard™) is highly sensitive for detecting CRC at 92%. It is a convenient alternative for patients who do not want to undergo colonoscopy, however it can sometimes create clinical dilemmas as exhibited by our cases. In our first case Cologuard™ was able to detect a large right-sided polyp, the sensitivity for such polyps is 42%. This patient was very reluctant to undergo colonoscopy in the first place. He agreed to a noninvasive test, but it has proven difficult to get him back for another colonoscopy. This illustrates the potential ethical and medicolegal dilemmas that can arise when patients with positive stool-based tests are lost to follow up. These patients may be prone to defer colonoscopy due their initial reservations about the procedure. In our second case, the positive Cologuard™ with normal colonoscopy raises concern for a neoplasm elsewhere in the GI tract. Some gastroenterologists perform an EGD in this situation, while others do not. The reported false positive rate for Cologuard™ is 45%, however there are no guidelines for what should be done after a false-positive result. This is an area where further research is needed.
1674 Primary Anal Melanoma
Authors: Elfiky Ahmed , Krzyzak Michael , Mukherjee Indraneil , Holmes Nathaniel
Published: October 2019

INTRODUCTION:

Primary anal melanoma is a rare and aggressive form of neoplasm account <2 % of all melanomas and <2 % of all anal tumors. Metastatic lesions from primary skin tumor are more common. In either case, diagnosis is challenging because often misdiagnosed as hemorrhoid. Surgical excision is the treatment of choice. We present a case of primary anal melanoma that treated with wide local excision and chemotherapy.

CASE DESCRIPTION/METHODS:

A 71-year-old Caucasian smoker male with history of hypertension, and bladder cancer in remission presented with anal discharge and tenesmus of two-month duration, not related to bowel movement. Pt denies pain, bleeding, change in bowel habits or diet. Physical exam including anoscopy revealed grade 2 internal hemorrhoid, external hemorrhoid, with 2 × 6 cm pedunculated freely mobile black rectal mass. Last colonoscopy was 8 years prior to the presentation within normal limits. Patient underwent a wide local excision of the mass. Pathology revealed invasive nodular melanoma. Patient underwent colonoscopy with endoscopic ultrasound that revealed no regional lymphadenopathy. patient was started on chemo therapy and adjuvant immunotherapy by oncologist. Patient was seen in follow up visit after eight months with negative metastatic work up.

DISCUSSION:

Malignant melanomas are the fifth leading cancer in men and the sixth in women in the United States. They are mostly cutaneous with non-cutaneous tumors being rare. Melanoma constitute 1% to 3% of all GI malignancies. It remains controversial as to whether these tumors are true primary tumor or they are metastases from unrevealed or regressed primary cutaneous melanomas. It is important to differentiate primary malignant melanoma from secondary lesions because of the worse prognosis of the first one; they are more aggressive and are usually diagnosed late. due to non specific presenting symptoms, more than 50% of patients have metastatic disease upon presentation. Surgical treatment remains the standard of care with controversy regarding the approach (wide local excision Vs. Abdominoperitoneal excision) depending on the stage of the disease.
1676 EFTR as a Means for Complete Resection for Adenomas
Authors: Yarra Pradeep , Kudaravalli Praneeth , Gabr Moamen
Published: October 2019

INTRODUCTION:

Endoscopic full thickness resection (EFTR) is an alternative to Endoscopic Mucosal Resection (EMR) and Endoscopic Sub-mucosal Dissection (ESD) for non-lifting lesions or flat lesions and residual adenomas. The current guidelines dictate that any patient able to undergo endoscopic curative treatment should consider it as the first line it is safer and less costly while being equally effacious. Here we describe a case of a non-lifting lesion in the ascending colon at 22 millimeters (mm) of size whose resection was previously attempted by EMR.

CASE DESCRIPTION/METHODS:

66-year-old male with a past medical history of CAD s/p CABG, hypertension, hyperlipidemia, liver cirrhosis and diabetes mellitus presented for surveillance colonoscopy. Three months prior to this he had a piece meal EMR of a 22 mm flat Tubulo-villous Adenoma in the proximal ascending colon. After this a Colonscope was passed under direct vision. EFTR device was passed and when it reached the proximal ascending colon, the previously placed tattoo was seen. A post-polypectomy scar was found between the tattoos. This was a non-lifting lesion and was granular lateral spreading and 22 mm in size. Thermal marking was placed and an Ovesco clip was now passed. Ovesco clip was deployed and using a snare within cap technique a full thickness resection of 22 mm was performed.

DISCUSSION:

ESD and EMR have enabled en bloc R0 curative interventions. FTRD is useful in situations where ESD and ESR fail to achieve a R0 resection. Recent study published by Kuellmer et al showed a technical success rate of 90% and a R0 resection rate of 77%. The limitation in terms of size is the most important one where the snare cannot be used as effectively for lesions more than 20 mm of size. Improvements in FTRD technology in regards to the snare size in the future will allow clinicians to pursue FTRD in these cases. We suggest close follow up for any patient who has a lesion resected on scar tissue due to the reoccurrence at sites where FTRD was done as was seen in the study published by Kuellmer et al.
1695 Removal of a Retained Biliary Stent in a Liver Transplant Patient Secondary to Biliary Cast Syndrome Using Digital Cholangioscopy and Electrohydraulic Lithotripsy
Authors: Koneru Gopala K. , Shah Ishani , Kantamaneni Vamsi , Gavini Hemanth , Peck Joshua R.
Published: October 2019

INTRODUCTION:

We describe the use of electrohydraulic lithotripsy(EHL) in conjunction with digital cholangioscopy which was used effectively to treat a retained intraoperative biliary stent in a liver transplant patient due to biliary cast which spared the patient from surgery.

CASE DESCRIPTION/METHODS:

A 72-year-old male who received an orthotopic liver transplant for end stage liver failure secondary to cirrhosis due to nonalcoholic steatohepatitis and hepatocellular carcinoma which was complicated by hepatic artery thrombus that ultimately required a second liver transplant with a pediatric feeding tube placed intraoperatively as an internal stent to prevent anastomotic stricture of the bile duct. Approximately eight years later, the patient presented to an ER with altered mental status and elevated liver enzymes. A computed tomography of abdomen and later a magnetic resonance cholangiopancreatography was done which showed an intra and extrahepatic biliary ductal dilation of the common hepatic and duct debris indicative of obstruction (Figure 1a,b). Endoscopy showed an enlarged prominent major duodenal papilla with a biliary stent which was visibly occluded (Figure 2). Attempted removal of stent was unsuccessful and a new plastic biliary stent was placed beside the impacted stent to relieve the obstruction. One month later, the new plastic biliary stent was removed and digital cholangioscopy was used to visualize the the bile duct which showed the endobiliary stent was embedded in stony material that was adherent the duct walls. Cholangioscope was slowly advanced from distally to proximally along the encased stent with the use of EHL which sequentially broke up the surrounding stony material. One half of the stent was stripped and the process was repeated on the other side until the stent was free floating. The stent was then successfully removed using rat-toothed forceps (Figure 3).

DISCUSSION:

This case demonstrated that cholangioscopy with lithotripsy can be used to treat an impacted stent in a liver transplant patient due to biliary cast. This is an unusual case as the intraoperative stent was found to be retained and the timeline of 8 years since liver transplant till presentation of biliary cast syndrome is one of the longest reported in the literature. We demonstrated a novel technique by fragmenting the cast of the encased stent from distally to proximally in order to disimpact the stent and this technique used may be applied to other challenging cases where standard methods have failed.

Watch the video: http://bit.ly/32zEMOY.
1710 Symptomatic Concomitant Sarcina Associated Erosive Esophagitis and Refractory Helicobacter pylori Gastritis
Authors: Chan Matthew , Jain Deepanshu , Minimo Corrado , Platt Alison
Published: October 2019

INTRODUCTION:

Sarcina is a gram-positive, non-motile, anaerobic cocci that was first identified in the gastric contents of humans by John Goodsir in 1842. Since then, its precise pathogenetic role in humans still remains unclear, as clinical observations have ranged from asymptomatic to life-threatening complications such as gastric perforation and emphysematous gastritis. Our review of literature yielded a total of 7 case reports which reported 8 patients with Sarcina on esophageal biopsies. Two of these had concomitant H. pylori gastritis. We report the third case of Sarcina of the esophagus associated with H. pylori gastritis.

CASE DESCRIPTION/METHODS:

A 70-year-old woman presented to the Gastroenterology clinic with an increase in abdominal discomfort, nausea, and vomiting over the past several months. She had previously been taking Omeprazole for reflux symptoms without relief and Naproxen for joint pain. She underwent an EGD, which showed erythematous mucosa in the distal esophagus, gastropathy, and a hiatal hernia. Targeted esophageal and gastric mucosal biopsies showed erosive esophagitis with many colonies of Sarcina species and chronic gastritis with H. pylori infection, respectively. Patient was prescribed tetracycline, metronidazole, and bismuth subsalicylate for two weeks and her omeprazole increased to twice daily for treatment of both infections. After completing the treatment regimen, the patient reported having little improvement in symptoms. Repeat EGD showed normal appearing mucosa of the esophagus, stomach, and duodenum. Esophageal biopsies showed normal squamous mucosa. Gastric biopsies showed persistent H. pylori gastritis. She was started on a salvage treatment regimen of levofloxacin, amoxicillin, and omeprazole for two weeks. Repeat testing was noted for persistent H. pylori infection.

DISCUSSION:

In our case, we treated our patient with antibiotics and a proton pump inhibitor, which covered for both Sarcina and H. pylori infections. However, minimal improvement in our patient's symptoms despite successful Sarcina eradication and persistent H. pylori infection suggests that although there was endoscopic and histologic evidence of esophagitis, the majority of patient symptoms were likely due to H. pylori or non-infective etiology. This finding supports those who favor Sarcina to being a benign pathogen in the GI tract. It is unclear if H. pylori gastritis in any way can be associated with Sarcina esophagitis, but this case definitely raises a question.
1712 Detection of Sub-Surface High-Grade Dysplasia Following Radiofrequency Ablation (RFA) of Barrett’s Esophagus
Authors: Bsrat Makda , Kassim Gassan , Hershman Melissa , Tan Amy , Rubinov Jason , Alialy Roshanak , Smith Michael S.
Published: October 2019

INTRODUCTION:

Barrett's esophagus (BE) occurs when intestinal epithelium replaces squamous epithelium normally lining the distal esophagus. BE is associated with an increased risk of esophageal adenocarcinoma (EAC). While traditionally associated with Caucasian males, prevalence of BE and EAC in Asian populations is projected to rise, associated with increasing prevalence of gastroesophageal reflux disease (GERD), which is associated with obesity and hiatal hernia. Radiofrequency ablation (RFA) is an endoscopic treatment modality shown to be safe and effective in inducing reversion to squamous epithelium, with a treatment depth of 500-1000 microns. We present a case of BE with high-grade dysplasia identified on random forceps biopsy after RFA for BE with low grade dysplasia, after which significant sub-surface disease was detected by volumetric laser endomicroscopy (VLE).

CASE DESCRIPTION/METHODS:

A 72 yo Chinese male was diagnosed with short-segment BE containing low grade dysplasia, and was treated with 2 sessions of focal RFA 5 months apart. He was lost to follow up and re-established care two years later. At presentation, the patient denied any heartburn, dysphagia or weight loss. Surveillance endoscopy with white light and narrow band imaging (Figure 1) revealed short tongues of salmon-colored mucosa suspicious for residual BE. Forceps biopsy confirmed BE with high grade dysplasia at the 12:00 position. Repeat endoscopy using VLE demonstrated suspicious-appearing glands, primarily sub-surface, which were laser marked and resected with band ligation and snare instead of forceps biopsy (Figure 2). Pathology results confirmed high-grade dysplasia within BE (Figure 3). Due to the presence of dysplasia deeper into the epithelium, in the setting of prior RFA, the patient was referred for liquid nitrogen spray cryotherapy.

DISCUSSION:

Residual or recurrent BE following RFA is a relatively common finding, but it is uncommon to see disease with a higher dysplasia grade than what was found pre-treatment. In this case, the use of VLE to evaluate these findings identified deeper disease that may not have been amenable to initial RFA treatment, with the lesion becoming “buried” after incomplete ablation. VLE, which visualizes the esophageal wall to a depth of 3 mm, should be considered as part of the evaluation of residual BE, especially when dysplasia is present. Its use may improve patient outcomes by leading to an alternate approach to both tissue sampling and further treatment selection.
1713 Dark Side of the Esophagus
Authors: Makedon Alan , Botros Youssef , Volfson Ariy
Published: October 2019

INTRODUCTION:

Esophageal melanosis a rare disease of the digestive system which is characterized by melanocytic proliferation in the squamous epithelium of the esophagus and melanin accumulation of esophageal mucosa (EM). It was first described by De la Pava in 1963. The disease is extremely rare in Western countries and most of the previously reported cases were diagnosed in Japan and India. Despite an unclear pathogenesis, esophageal melanosis hypothesized to arise from chronic irritation of the esophageal mucosa that stimulate keratinocyte differentiation and subsequent hyperplasia in the basal epithelial layer of EM. Differential diagnoses of esophageal melanocytosis from its histologic mimics include benign melanocytic nevi and malignant melanoma. Esophageal melanosis has been reported to be the precursor lesion for esophageal melanoma. We report a case of esophageal melanosis in a 61-year-old woman who had esophagogastroduodenoscopy (EGD) done for dyspepsia.

CASE DESCRIPTION/METHODS:

A 61-year- old female with past medical history of hypertension presented to the gastroenterology service for persistent dyspepsia. She had a 10 pack-year smoking history. She had no history of acid reflux. Physical examination and blood work were unremarkable. EGD was performed and showed a pigmented (black) flat mucosal lesion in the middle third of the esophagus. Multiple biopsies were obtained. Histopathology showed squamous mucosa, with an organized cellular architecture, surface maturation, and lack of cellular atypia but with an increased lymphocytic infiltrate of the epithelium, with an increase in melanocytosis consistent with the features of esophageal melanosis. The patient was started on a proton-pump inhibitor with recommendations to repeat EGD in 1 year.

DISCUSSION:

Currently, one theory of esophageal melanosis pathogenesis implicates aberrant melanocyte migration during fetal development. Another theory suggests that esophageal melanosis arises from keratinocytic differentiation and subsequent hyperplasia in the basal epithelial layer of EM as a result of chronic acid reflux, Addison’s Disease, or chronic inappropriate eating. It is possible that combination of both conditions is likely to be stronger. Chronic alcohol use, cigarette smoking, diet and hereditary factors might also be associated with development of esophageal melanosis. Recognition of this lesion on endoscopy is important given the potential differential diagnosis including esophageal melanoma.
1714 A Case of a Primary Large Cell Neuroendocrine Carcinoma of the Esophagus Disguised as a Food Impaction
Authors: Patel Harsh D. , Beck Jared , Kataria Archish , Echavarria Juan
Published: October 2019

INTRODUCTION:

Neuroendocrine carcinomas (NECs) are defined epithelial neoplasms with predominant neuroendocrine differentiation. They primarily arise from the gut and bronchopulmonary systems with the possibility of distant metastasis. We present a case of an esophageal neuroendocrine neoplasm with unique endoscopic/radiographic features on presentation disguised as a food impaction.

CASE DESCRIPTION/METHODS:

A 50-year-old Caucasian male with past medical history of tobacco dependence; presented to the ED with complaints of solid food dysphagia for 1.5 months with unintentional weight loss of 15 lbs and intractable hiccups. On arrival, he was hemodynamically stable. Physical exam was unremarkable. Laboratory testing revealed mild normocytic anemia of 12.3, otherwise unremarkable. An upper endoscopy was performed revealing a large amount of meat in the mid-esophagus; however, after further manipulation there appeared to be bleeding from the mucosa (Figure 1). Upon closer inspection, a mass originating from the lateral esophageal wall was caked with food debris giving it the appearance of meat. CT Chest was performed showing a large heterogenous esophageal mass (8.1 cm v 5.7 cm) extending from the mid-esophagus to the GE junction with no evidence of direct invasion (Figure 2). Biopsies returned positive for large cell neuro-endocrine carcinoma with diffuse synaptophysin and Ki67 positivity. PET-CT performed as outpatient showed prominent peri-gastric lymphadenopathy. EUS was attempted but failed due to inability to pass the ultrasound scope. CT surgery subsequently performed a McKeown transthoracic esophagectomy for definitive therapy as outpatient. He recovered well from the procedure with positive radial margins and lymph nodes on pathology and is now undergoing adjuvant radiation and chemotherapy.

DISCUSSION:

Esophageal NEC is a rare entity with a generally dismal prognosis when high-grade. A study out of a large volume, tertiary center reported approximately 40 cases over a 20-year period. Given the sparsity of esophageal NECs, most studies are retrospective case series and are from outside the USA. It is reported that esophageal NECs represent only 0.4-1.4% of the gastrointestinal NECs a majority of which arise from the mid-esophagus. To our knowledge, there is no reports of a single case with similar endoscopic and radiographic findings which makes it unique. There is also limited data reported on the endoscopic/phenotypic appearance of large cell neuroendocrine carcinomas of the esophagus.
1716 Esophageal Squamous Cell Carcinoma-Associated Dancing Eye Syndrome in an Adult: Negative Paraneoplastic Antibodies Screen and Rapid Response to Intravenous Immunoglobulin and Methylprednisolone
Authors: Hammami Muhammad B. , Aboushaar Reem , Azhar Mishah , Musmar Ahmad , Miller Stephen M. , Salomon Peter
Published: October 2019

INTRODUCTION:

Dancing eye or opsoclonus-myoclonus syndrome is a rare paraneoplastic syndrome that has been mostly associated with small cell lung cancer. It was reported in association with esophageal cancer in one case. Here we report a second case.

CASE DESCRIPTION/METHODS:

A 59-year-old man presented with 5 weeks of rapidly worsening vertigo and gait difficulty that lead to frequent falls and inability to perform daily activities. About 5 weeks prior to presentation, he completed three rounds of cisplatin and 5-FU for recently diagnosed squamous cell carcinoma of the esophagus. He had long standing hypertension treated with hydrochlorothiazide, lisinopril, and carvedilol, and diabetes mellitus treated with glipizide, glyxambi, and sitagliptin. He denied alcohol, tobacco, or illicit drug use and recent viral infection. He was fully alert and oriented and afebrile. He had spontaneous, involuntary, arrhythmic, conjugate, multidirectional saccades occurring in all directions of gaze without a saccadic interval and pronounced ataxia on standing associated with unsteadiness. Complete blood count and routine chemistry were unremarkable. Brain MRI with and without contrast revealed no evidence of intracranial hemorrhage, mass lesion, acute infarct or pathologic enhancement. HIV screen was negative. Hepatits C virus antibody was non-reactive. Paraneoplastic autoantibodies screening was negative. He received 5 day course of 0.4g/kg/day intravenous immunoglobulin (IVIG) and 250 mg BID methylprednisolone with marked improvement of rhythmic eye beating at rest, coordination of multidirectional eye movements, ataxia, and vertigo by day 3. He was discharged to acute rehabilitation facility on day 8.

DISCUSSION:

Our patient has dancing eye or opsoclonus-myoclonus syndrome that followed the diagnosis of esophageal cancer and rapidly responded to IVIG and methylprednisolone, strongly suggesting a paraneoplastic association. Interestingly and consistent with the single case previously reported of this association, paraneoplastic autoantibodies screen was negative.
1717 “Dissec-ting” the Etiology
Authors: Rojas Patricia Guzman , Riestra Irene , Gonzaga Ernesto Robalino , Katukuri Vinay , Parikh Jignesh , Blonski Wojtek
Published: October 2019

INTRODUCTION:

Esophagitis dissecans superficialis (EDS) was first described in 1892. It is a rare and benign desquamative disorder characterized by sloughing of the esophageal mucosa. EDS has been linked to coronary artery disease, chronic kidney disease, autoimmune conditions (celiac disease and pemphigus vulgaris) and medications known to damage the gastrointestinal tract. However, most cases are idiopathic.

CASE DESCRIPTION/METHODS:

A 48-year-old male with a PMH of GERD presented to the Gastroenterology clinic with a 6-month history of esophageal dysphagia to solid foods. He denies any nausea, vomit, abdominal pain, hematemesis or episodes of melena. Esophagogram revealed delay of the barium tablet (Figure 1). The patient underwent an EGD showing sloughing of the mucosa in the entire esophagus along with LA grade C esophagitis (Figure 2). Biopsies were taken from the proximal and distal esophagus with findings compatible with esophagitis dissecans superficialis (Figure 3). Ranitidine and PPI were continued and he was scheduled for a follow appointment in 6 weeks.

DISCUSSION:

EDS is typically seen in middle aged women, and is commonly misdiagnosed due to the lack of diagnostic or histologic criteria. Endoscopic features consist of esophageal mucosa with multiple columns of strips that have whitish/pearly appearance andsloughs which are > 2 cm in length, and lack of ulcers in the surrounding mucosa. These findings can be mistaken with esophageal candidiasis, eosinophilic esophagitis, lichen planus and even squamous cell carcinoma. For this reason, the diagnosis is made through histopathologic findings such as parakeratosis and intraepithelial splitting above the basal layer. As in our patient, dysphagia is frequently reported, but nonspecific symptoms like nausea, vomiting or heartburn are also found. There are no specific treatment guidelines. Nevertheless, acid suppressants can be started to aid mucosa healing. Some patients can present with esophageal strictures, but this entity mainly follows a benign course as it shows self-resolution from 8 weeks to 4 months of diagnosis. This case shows the importance of recognizing EDS not only as an underreported cause for dysphagia, but also as an important differential diagnosis for esophageal diseases. It is important to obtain mucosal biopsies in order to get a proper diagnosis and avoid unnecessary treatments.
1719 Esophageal Adenocarcinoma Arising From <1 cm of Intestinal Metaplasia at the Gastroesophageal Junction: Is <1 cm Actually Low Risk?
Authors: Ahuja Amisha , Elden Andrew C. , Tofani Christina , Infantolino Anthony
Published: October 2019

INTRODUCTION:

Barrett’s esophagus (BE) is defined by length, which has been shown to correlate with the risk for esophageal adenocarcinoma (EAC). Although long-segment (>3 cm) and short-segment (between 1 and 3 cm) BE are well-established definitions, current ACG practice guidelines recommend against defining columnar goblet-cell metaplasia in the distal esophagus <1 cm as BE. This specific variation of metaplasia disease has been officially defined as “specialized IM of the esophagogastric junction” (SIM-EGJ) over alternatives such as ultra-short segment BE. Given the relatively low incidence of EAC in this group and the high degree of inter-observer variability in defining metaplasia of this length, current guidelines recommend against biopsy in this setting. Individual cases in practice however have demonstrated reasons to question this paradigm.

CASE DESCRIPTION/METHODS:

A 42 year old white man with obesity and 10 years of reflux symptoms was diagnosed with a GE junction nodule on index endoscopy. Cold forceps biopsy of the nodule revealed high grade dysplasia, prompting referral to the BE Treatment Center at Thomas Jefferson University Hospital (TJUH). His repeat EGD revealed salmon-colored mucosa suggestive of intestinal metaplasia in an area less than 1 cm in length (Z-line at 39 cm). An 8 mm nodule was identified in the area of abnormal mucosa and removed by endoscopic mucosal resection. Pathology of the nodule revealed a T1a moderately differentiated intramucosal adenocarcinoma arising in BE. All margins were negative for invasive carcinoma, dysplasia, and intestinal metaplasia. The patient patients underwent endoscopic eradication therapy (EET) with radiofrequency ablation at the GE junction and in subsequent endoscopy achieved complete eradication of intestinal metaplasia (CE-IM) and dysplasia (CE-D).

DISCUSSION:

Although current guidelines advise against biopsying <1 cm of variability in Z line given its status as a relatively low risk lesion, data used to generate many of these risk predictions for EAC exclude visible lesions in their studies. Therefore in practice there may be under-evaluation of SIM-EGJ, potentially missing advanced dysplastic or cancerous disease. This case illustrates that the consideration BE risk factors and all endoscopic findings, such as nodules, need to be taken together when assessing abnormal mucosa at the GE junction, even with <1 cm variability of the Z line.
1723 Esophageal Granular Cell Tumour: An Unusual Polypoid Lesion
Authors: Bandaru Praneeth , John Febin , Tsipotis Evangelos , Etienne Denzil
Published: October 2019

INTRODUCTION:

Esophageal granular cell tumours (GCTs) account for 1% of all Esophageal tumors and up to two-third occur in the distal third of Esophagus. Since first reported in 1931 approximately 400 cases have been reported so far. We report a case of Esophageal GCT incidentally found on endoscopic evaluation for resistant GERD.

CASE DESCRIPTION/METHODS:

A 42-year-old Hispanic male was seen for evaluation of refractory GERD and occasional dysphagia to solids of 3-month duration. There were no alarm symptoms or use of NSAIDs. Physical examination and labs were unremarkable. EGD was performed that showed a 4mm yellowish, sessile, subepithelial nodule with intact mucosa in the distal Esophagus (Figure 1). Biopsy showed clusters of polygonal cells with abundant granular cytoplasm that was Periodic acid–Schiff (PAS) positive suggestive of GCT. Immunohistochemical staining was positive for S100, CD 68, CD56 and Vimentin, thus conforming the diagnosis of GCT (Figure 2). EUS performed subsequently showed a 4mm, submucosal, hypoechoic, homogenous mass with no extension into muscularis propria (Figure 3); completely removed by hot snare technique with pathological conformation. Patient was discharged home with close endoscopic surveillance.

DISCUSSION:

Granular Cell Tumors (GCTs) arise from Schwann cells of the nerve sheath with incidence of about 0.03% and has a predilection towards skin, oral cavity and breasts. Of all GCTs, 6-8% occur in the GI tract with esophagus (65%) being the most common site. It has predilection towards females and African Americans between 40-60 years of age. Generally asymptomatic and found incidentally during endoscopy. However, GERD and dysphagia are associated with GCTs of more than 2 cm in size. EUS is invaluable in differentiating GCTs from other subepithelial tumors, determining size, depth and invasion. Biopsy/FNA can be performed during the initial endoscopy or during EUS. Definitive diagnosis is by histopathology and immunohistochemical staining. The treatment of esophageal GCTs is controversial. Conservative management is recommended for tumors <1 cm, asymptomatic, no deep tissue invasion or malignancy. However, resection is warranted for symptomatic tumors, >1 cm size, with deep tissue invasion or malignancy. Endoscopic removal is preferred over surgery for tumors without deep tissue infiltration or malignant. Endoscopic and histologic surveillance every 1-2 years is recommended.
1726 A Tough Pill to Swallow: A Rare and Unusual Case of Recurrent Esophageal Candidiasis
Authors: McDonald Emmanuel , Trejoss Marisol , Choi David , Panicker Linoj , Frontela Odayls , Sobrado Javier
Published: October 2019

INTRODUCTION:

Esophageal candidiasis (EC) is one of the most common infections in immunocompromised individuals. Fungal infections, particularly in the esophagus, have been found in individuals with predisposing factors, such as uncontrolled diabetes mellitus, gastric acid suppression, malignant neoplasms, corticosteroids, antibiotics, or immunosuppressant use. Factors that suppress cellular immunity often cause opportunistic fungal infections; however, little is known regarding significant risk factors in individuals who are immunocompetent. For our study, we report a rare and unusual case of a 58 year old immunocompetent male who presented with recurrent esophageal candidiasis.

CASE DESCRIPTION/METHODS:

EC is not a rare complication for individuals who are immune compromised or who are uncontrolled diabetics; however, our case is unique and rare because our patient did not have the typical comorbidities associated with esophageal candidiasis. The patient had a PMHx of well-controlled DM type 2, HIV (-), diet controlled GERD who is not taking PPI therapy who presented with a 20 pound weight loss and dysphagia to solids. An EGD revealed a benign gastric mass and esophageal candida, then treated with Fluconazole. After completion of therapy, he returned with dysphagia, abdominal pain, weakness, and weight loss, requiring hospitalization. A repeat EGD revealed a second EC infection, this one an ulcerated EC infection, which was treated with IV Fluconazole. On outpatient follow up after discharge, the patient underwent CT scan of abdomen/pelvis. It showed moderately thickened and dilated esophageal walls, bullae, and migration of the stent into the stomach which had been placed previously. Additional findings on imaging include, bilateral renal masses, left para-aortic adenopathy, and loculated fluid collection in the abdomen. Consequently, the patient underwent another EGD to remove the stent and was sent to Oncology for further care.

DISCUSSION:

Our patient’s clinical manifestations, initial findings, and developmental course of the presenting illness in this patient makes this case particularly rare and unusual in terms of assessment and diagnosis. EC in an immunocompetent patient is rare; however, recurrent EC is even rarer. At this time there is limited data reported on attributable causes of EC, especially in individuals without predisposing factors. Thus, this case highlights the need for further investigation regarding the mechanisms of colonization and its development in such individuals are needed.