bluuebunny/crossref_metadata_2025 huggingface dataset:
1436 Extreme Elevation of Pancreatic Enzymes in Severe Acute Renal Failure
Authors: Saliaj Merjona , Llukani Elton , Saeed Mariam , Bachan Moses
Published: October 2019

INTRODUCTION:

Serum amylase and lipase are important biomarkers to diagnose acute pancreatitis with a specificity of 89 and 93%, and sensitivity of 72% and 79%, respectively. Their elevation is common in pathologies such as acute cholecystitis, ketoacidosis, inflammatory intestinal disease, sepsis and renal insufficiency.

CASE DESCRIPTION/METHODS:

58 y/o male with type 2 diabetes mellitus, hypertension, and hyperlipidemia was admitted with generalized weakness, dizziness and multiple episodes of non-bloody watery diarrhea for one week. Physical exam was remarkable for left lower quadrant (LLQ) abdominal tenderness, bilateral lower extremity edema, and pulmonary congestion. Laboratory tests showed pre-renal acute kidney injury (AKI) with creatinine of 10.3, BUN of 121, metabolic acidosis, and hyperkalemia requiring emergent hemodialysis, leukocytosis of 17 per nL, and stool studies were positive for clostridium difficile infection (CDI). Interestingly he also had extremely elevated lipase of 3913 U/L and amylase of 1046 U/L in the absence of clinical and radiographic findings (CT and ultrasound abdomen) of acute pancreatitis. CDI was successfully treated with oral vancomycin. After a prolonged hospital course patient, his kidney function improved, and he did not require additional dialysis upon discharge.

DISCUSSION:

The diagnosis of pancreatitis requires the presence of two out three criteria including elevation of pancreatic enzymes 3 times or more above the upper normal limit (UNL), clinical presentation and radiologic findings suggestive of pancreatitis. Up to 10% of acute pancreatitis patients lack classic epigastric pain. In our patient the abdominal pain was located on the LLQ, likely related to CDI. The only suspicion for acute pancreatitis in this clinical case was the impressive 60 folds elevation of lipase and 10 fold elevation of amylase. In AKI, amylase has been shown to increase up to 10 folds the upper normal limit, while the lipase increase is usually less dramatic, reaching 3-5 folds the UNL. To identify the pancreas-originated enzyme increase we can perform additional tests including isoenzymes (isoamylase and isolipase), trypsin, and elastase levels. Elastase 1 is a highly specific enzyme for pancreatitis, not affected by reduced renal clearance found in AKI. In conclusion, an extreme elevation of amylase and lipase in the setting of severe AKI can be noted in the absence of acute pancreatitis. Interpretation of these laboratory values must be correlated with the clinical presentation.
1448 Acute Pancreatitis in a Patient With Left-Sided Diverticulitis
Authors: Ahmad Minhaz , Bella Saif , Saleem Atif
Published: October 2019

INTRODUCTION:

Acute pancreatitis is a leading gastrointestinal cause of hospitalization. Several conditions are associated with pancreatitis, with gallstones and chronic alcohol abuse causing approximately two-thirds of cases. In rare instances, acute pancreatitis has been associated with intraluminal or periampullary duodenal diverticulitis and right-sided colonic diverticulitis. We present a case of acute pancreatitis associated with left-sided colonic diverticulitis.

CASE DESCRIPTION/METHODS:

43-year-old non-alcoholic female with history of sigmoid diverticulosis presented to the ambulatory clinic with worsening epigastric pain radiating to the neck and back. Epigastric tenderness was evident on physical examination. Initially, she was treated empirically with proton-pump inhibitor for presumed gastritis. Her symptoms persisted for one month and was associated with hematochezia. CT of the abdomen and pelvis with contrast revealed inflammatory change within proximal descending colon, with ovoid fluid distended structure consistent with acute diverticulitis and fat stranding of the pancreatic tail. She was admitted to the hospital where labs revealed serum lipase of 1202, Calcium 9.2, liver biochemical tests were within normal range. Further workup showed triglycerides and immunoglobulins were unremarkable, tissue transglutaminase reported being negative, calprotectin was elevated to 380 mcg/g. Ultrasound showed no evidence of cholelithiasis. In addition to bowel rest, she was treated with IV antibiotics for diverticulitis and IV Ringer's Lactate for pancreatitis. Later on, symptoms resolved. CT abdomen-pelvis with contrast was repeated and demonstrated resolution of the inflammatory changes in both the colon and pancreas. Outpatient endoscopy showed a small hiatal hernia, non-erosive gastritis and normal duodenum. Colonoscopy showed moderate diverticulosis in the descending colon and sigmoid colon. Gastric, duodenal and colonic biopsy did not show any abnormality. Her acute pancreatitis may be associated with diverticulitis of the proximal descending colon.

DISCUSSION:

There have been many cases of duodenal diverticulitis associated with acute pancreatitis. There has been one case report of acute pancreatitis associated with right-sided colonic diverticulosis. There is no case report available with any association of acute pancreatitis and left-sided diverticulitis. Pancreatitis may also be associated with left-sided diverticulitis.
1451 A Caroli Look-Alike
Authors: Rodriguez-Berrios Frances , Santiago Loscar , Acosta Eduardo , Class-Vazquez Walisbeth
Published: October 2019

INTRODUCTION:

Peribiliary cysts are a rare entity usually found in patients with chronic liver disease and polycystic kidney disease. Patients are mostly asymptomatic therefore it is identified at times incidentally by abdominal imaging. Differential diagnosis include cholangiocarcinoma, Caroli disease and primary biliary cirrhosis. Awareness is essential to avoid misdiagnosis and unnecessary procedures including biopsies and surgeries.

CASE DESCRIPTION/METHODS:

A 67-year-old female with cirrhosis secondary to NASH and portal hypertension, among other comorbidities was evaluated at GI clinics. Abdominal sonogram performed for hepatocellular carcinoma surveillance showed right and left intrahepatic biliary ductal dilatation. The common bile duct measured 0.35 cm and the gallbladder showed intraluminar posterior acoustic shadows suggestive of cholelithiasis without wall thickening or pericholecystitic fluid collections. Patient denied fever, chills, abdominal pain, nausea or vomits. Abdomen was benign. Laboratories remarkable for baseline thrombocytopenia of 71, normal ALT and AST, elevation of alkaline phosphatase to 171 and hyperbilirubinemia of 3. MRCP was performed for further evaluation which showed multiple hyperintense rounded lesions tracking along the intrahepatic and extrahepatic biliary as seen with peribiliary cysts.

DISCUSSION:

Peribiliary cyst are usually associated to alcoholic cirrhosis with a prevalence of 9%; while in they have not been described in NASH. Pathophysiology may be due to intrahepatic circulatory disturbances of the portal venous system. Possible complications include biliary tract dilatation, obstructive jaundice and cholangitis.
1456 A Case of Syphilitic Proctitis in a Newly Diagnosed Patient With HIV
Authors: Agrawal Rohit , Attar Bashar M. , Mutneja Hemant , Majeed Muhammad , Randhawa Tejinder , Omar Yazan Abu , Chicas Oscar Rivas
Published: October 2019

INTRODUCTION:

Rectal pain and hematochezia are common symptoms of anorectal pathology. Sexually transmitted infections such as gonorrhea, chlamydia and syphilis are often implicated as infectious etiologies of such symptoms in men who have sex with men. We report a case of young male who presented with rectal pain, hematochezia and weight loss and was concomitantly diagnosed with syphilitic proctitis and HIV.

CASE DESCRIPTION/METHODS:

A 35-year-old bisexual male presented with a 9 months history of rectal pain, hematochezia and involuntary 30 pounds weight loss. Initial laboratory tests revealed normocytic anemia with a hemoglobin of 9.2 gm/dl, ferritin of 81.1 ng/ml, a positive HIV test with CD4 count of 50 cells/microL. Colonoscopy demonstrated large, semi-circumferential ulcers around 10 cm from the anal verge (Figure 1). Biopsy of the ulcerated lesions revealed chronic active colitis with cryptitis, crypt abscess and destruction. Numerous spirochetes were identified on Warthin-Starry and Steiner stains in the ulcerated mucosa and random biopsies of colon (Figure 2). Enzyme immunoassay (EIA) and rapid plasma reagin (RPR) for syphilis were positive with a RPR titer of 1:256. He was treated with benzathine penicillin 2.4 million units intramuscularly once a week for 3 weeks for syphilits proctitis along with anti-retroviral medications. He had resolvement of symptoms on subsequent follow up visit at 6 months with a repeat RPR of 1:64 suggesting an adequate serological response.

DISCUSSION:

Anorectal syphilis can either present as a chancer in primary infection or proctocolitis as a manifestation of secondary infection. Establishing a diagnosis often requires endoscopy for visualization of colonic inflammation, histopathology for documentation of spirochetes and serological test such as EIA and RPR to identify Treponema palladium. The histopathological features of syphilitic proctitis can mimic that of inflammatory bowel disease in which case the microbiological stains such as Warthin-Starry and Steiner aid in diagnosis. As proctocolitis is a manifestation of secondary syphilis, treatment includes Penicillin G benzathine 2.4 million units IM once. With the rise in the MSM population, cases of syphilis are more frequently being encountered and therefore syphilitic proctitis should be a common differential in such patients presenting with lower gastrointestinal symptoms.
1458 Colon Cancer Metastatic to the Pancreas Presenting as DKA
Authors: Bush Allison , Humes Ross , Young Patrick
Published: October 2019

INTRODUCTION:

New onset diabetes mellitus (DM) in the setting of a pancreatic mass has been described, primarily with adenocarcinomas, due to the secretion of diabetogenic substances. DM related to pancreatic metastases is rarely seen. We present a case of colon cancer metastatic to the pancreas presenting as diabetic ketoacidosis (DKA).

CASE DESCRIPTION/METHODS:

A 69-year-old male with a 70 pack-year tobacco history and hypertension presented to the emergency department with fatigue, weight loss, and abdominal pain. Laboratory tests demonstrated a white blood cell count of 11.8 109/L, a hemoglobin of 8.0 g/dL, sodium of 125 mmol/L, carbon dioxide of 18 mmol/L, and a glucose of 656 mg/dL with positive serum ketones indicating diabetic ketoacidosis. He was admitted to the hospital and treated with insulin and IV crystalloids. A chest x-ray showed multiple lung nodules. A CT scan of the chest, abdomen, and pelvis revealed bilateral lung masses, an uncinate process pancreatic mass, multiple hypodense liver lesions, and thickening of the sigmoid colon. Bronchoscopy was performed and cytology revealed metastatic adenocarcinoma with suspected source of colonic, hepatobiliary, or upper gastrointestinal source. EUS/FNA was performed on the pancreatic mass and demonstrated poorly differentiated carcinoma of unclear primary source. Flexible sigmoidoscopy discovered a friable mass in the sigmoid colon. Biopsies were taken revealing adenocarcinoma on the background of high grade dysplasia consistent with a primary colon cancer. Given the widely metastatic nature of his disease he was offered FOLFOX + Bevacizumab as well as a palliative care referral.

DISCUSSION:

The majority of malignant pancreatic lesions are primary pancreatic tumors, with a small percentage due to metastases. The most common tumor to metastasize to the pancreas is renal cell carcinoma. Few cases of metastatic colon cancer to the pancreas have been reported. DKA as a first presentation of pancreatic adenocarcinoma is a very rare phenomenon with more typical presenting symptoms including abdominal pain, nausea and jaundice. Our case features two rare findings; metastatic colon cancer to the pancreas and DKA as the initial presentation of a pancreatic mass. This highlights the need to consider uncommon metastatic lesions in cases of symptomatic pancreatic masses.
1461 Pseudomembranous Colitis, Bowel Ischemia, and Phentermine: A Case Report
Authors: Gollol Raju Narasimha Swamy , Jayananda Sriraksha , Ali Eslam , Harvin Glenn
Published: October 2019

INTRODUCTION:

Pseudomembranous colitis, though classically associated with Clostridium difficile infection, can be a consequence of other disease processes including severe ischemic colitis. Several drugs have been proposed to predispose to colonic ischemia including the appetite suppressant phentermine. We present a case of pseudomembranous colitis from severe bowel ischemia that likely was compounded by concomitant phentermine use.

CASE DESCRIPTION/METHODS:

A 55-year-old obese Caucasian female with hypertension presented with a week of abdominal pain and progressively worsening diarrhea that had subsequently turned bloody. She was a former smoker. Medication history was significant for using a family member's weight loss medication Phentermine 37.5 mg daily for several days prior to developing gastrointestinal symptoms. At presentation she was mildly hypotensive needing fluid resuscitation and brief vasopressor support. Laboratory profile was significant for acute kidney injury with creatinine 8.86 mg/dl, lactic acid 3.2 mmol/L and white blood cell count 12.3 k/uL. A non-contrast CT abdomen showed findings suggestive of acute colitis involving the splenic flexure and descending colon (Figure 1). Supportive care and broad-spectrum antibiotics were continued. Multiple stool studies were negative for clostridium difficile infection, bacterial cultures, and assays for ova and parasites. Antineutrophil antibodies and antineutrophil cytoplasmic antibodies were negative as well. Flexible sigmoidoscopy revealed severe ulcerations covered by thick exudate of the rectum and sigmoid colon (Figure 2). Histopathology of biopsy specimens showed colonic mucosa with fibrinopurulent surface adherent exudate with abundant neutrophils consistent with pseudomembranous colitis (Figure 3). Patient recovered with supportive care alone and was subsequently discharged with instructions not to use Phentermine again.

DISCUSSION:

Our patient, with risks for vascular disease, had several days of abdominal pain with diarrhea. At the time of her initial hospital presentation, she was hypotensive likely from gastrointestinal volume loss. The inciting event for her colonic ischemia is unclear. Possibilities include Phentermine induced colonic ischemia that was further compounded by volume loss vs prodrome of gastroenteritis leading to volume loss and hypovolemia with subsequent colonic ischemia compounded by patient's Phentermine use. Phentermine use in this patient would have been contraindicated secondary to her vascular risk factors.
1464 Malignant Perivascular Epithelioid Cell Neoplasm of Colon in Young Male
Authors: Karanfilian Briette , Jackson Ryan , Bhagat Vicky , Cristelli Ryan , Chekmareva Marina , Sarkar Avik
Published: October 2019

INTRODUCTION:

Perivascular epithelioid cell neoplasms (PEComas) are a rare type of mesenchymal tumor that can be found in various visceral and soft tissues in the body. Approximately fifty cases have been reported in the gastrointestinal (GI) tract. Typically, management of these lesions is laparoscopic or open surgical resection followed by chemotherapy if there is metastatic disease. The majority of GI PEComas are benign, colonic masses in middle-aged females. This case describes a malignant, colonic PEComa in a 16-year-old male. To the best of our knowledge, this is the largest malignant, colonic PEComa in an adolescent, and this is the first case to demonstrate successful endoscopic mucosal resection (EMR) of a PEComa.

CASE DESCRIPTION/METHODS:

A 16-year-old male with history of IgA vasculitis during childhood presented with acute onset of bilious emesis in the setting of severe, intermittent, left lower quadrant abdominal pain and constipation for one month. Lab testing was unremarkable. Computed tomography revealed a non-obstructing, nodular mass in the transverse colon. The patient underwent colonoscopy, during which the 6-cm large, semi-sessile, broad-based polyp was removed by piecemeal EMR. EMR was technically challenging due to the size, broad base, and location of the mass. Histology of the tissue showed a predominance of fascicular spindled cells, scattered areas with epithelioid morphology, and prominent vasculature, consistent with a PEComa. The tissue stained positive for HMB-45, MART-1, and cathepsin. Based on the size (>5 cm), nuclear atypia, and high mitotic activity, the lesion was defined as malignant. Though the lesion was removed to the submucosa, there was concern for deeper extension, so he underwent laparoscopic transverse colectomy with primary anastomosis. Pathology confirmed there was not any residual tumor in the resected colon or metastasis to lymph nodes. Positron emission tomography did not show metastasis. Fifteen months have elapsed and the patient has not had recurrence on imaging.

DISCUSSION:

There are few cases of GI PEComas. This case demonstrates a rare presentation of a large, malignant GI PEComa in a young male and is the first case of successful endoscopic removal of a malignant PEComa. The surgical specimen revealed no evidence of residual PEComa, and the patient has not had evidence of recurrence on imaging, verifying successful removal of his PEComa. This supports the notion that EMR should be considered for definitive management in patients with these lesions.
1472 Hypokalemia-Induced Rhabdomyolysis From Budesonide Therapy in Crohn's Disease: A Case Report and Review of the Pathophysiology
Authors: Mandiga Pujyitha , Mansour Ramy , Thigpin Derek
Published: October 2019

INTRODUCTION:

Here we present the case of a 71-year-old white male with active ileocolonic Crohn's disease, recently started on budesonide therapy, who presents with extreme weakness and muscle aches. He was diagnosed with hypokalemia induced rhabdomyolysis, three weeks after starting budesonide therapy.

CASE DESCRIPTION/METHODS:

We present the case of a 71-year-old male with hypertension and ileocolonic stricturing crohn's disease (CD) presents with severe muscle weakness and malaise. He presented for a five-month history of worsening watery diarrhea and unintentional weight loss. Colonoscopy to neoterminal ileum revealed Rutgeerts score of i3. He was started on oral 9 mg budesonide and began to experience weakness and muscle aches to a point where he was unable to walk or lift his arms above his head. He presented to the hospital and labs revealed hypomagnesemia 0.8 mg/dL, hypokalemia of potassium 1.7 mmol/L, creatinine 1.52 mg/dL, creatine phosphokinase (CPK) 15913 IU/L, hypocalcemia 7.1 mg/dL, normal albumin 3.7 g/dL. Urinalysis showed 3+ blood and 0-3 red blood cells. Labs two months prior were unremarkable (Table 1). He was diagnosed with rhabdomyolysis.

DISCUSSION:

Budesonide has long been accepted as induction therapy for mild-to-moderate CD. Hypokalemia induced rhabdomyolysis is due to laxative abuse, chronic diarrhea, renal tubular acidosis, diuretics use is well reported. Hypokalemia is a known side effect of budesonide.
1
Rhabdomyolysis is a syndrome which is characterized by muscle necrosis with CPK four times more than the upper limit of normal.
1
During a muscle contraction, potassium is released from the intracellular to extracellular space mediating the vasodilation and more blood flow to the muscle. When a patient has hypokalemia, there is a decrease in blood flow to the contracting muscles. This leads to constriction of arterioles causing ischemia of the muscles and myocytes destruction. The breakdown of the myofibril causes muscle necrosis and an increase in intracellular CPK and myoglobin, which is released into the blood circulation.
2
In this patient, several factors were taken into account for the cause of hypokalemia induced rhabdomyolysis. The patient rapidly responded to intervenous fluid and discontinuation of the budesonide.
1480 Colonic Spirochetosis Causing Ulcerative Proctitis
Authors: Durney Philip A. , Henry Christopher
Published: October 2019

INTRODUCTION:

Intestinal spirochetosis is a rare infectious diarrheal illness. Here we present a case of colonic spirochetosis initially diagnosed and treated as ulcerative proctitis.

CASE DESCRIPTION/METHODS:

A 57-year-old male presented to the office with 2 months of diarrhea occurring over 10 times per day with urgency and bleeding. The patient had an unremarkable past medical and family history. On social history, he practiced high risk sexual behavior with unprotected anal intercourse. Initial work-up showed mild elevation of ESR/CRP and an elevated calprotectin. Colonoscopy revealed ulcerative proctitis extending to 15 cm with normal colonic mucosa proximally. Rectal biopsies showed moderately active chronic colitis, remaining biopsies of colon were normal. He was started on mesalamine with improvement and subsequent sigmoidoscopy showed remission. Eight weeks later the patient presented to the ED with blurry vision. He was seen by ophthalmology who identified left optic nerve edema. An RPR was sent and resulted with a titer of 1:1024. He was referred to Infectious Disease with high suspicion for ocular syphilis and completed 14 days of IV penicillin G. Lumbar puncture showed no neurologic involvement. His RPR titers downtrended and visual changes improved. One month later, the patient developed large volume loose stools. Again stool studies were negative. Pathology was contacted to conduct repeat histochemical stains on earlier specimens, which showed spirochetes in the colonic mucosa. He was given metronidazole for 14 days for intestinal spirochetosis with improvement. With suspicion that proctitis may have originally been infectious the mesalamine therapy was weaned.

DISCUSSION:

Clinical manifestations of colonic spirochetosis can vary from asymptomatic to watery diarrhea. Rectal ulcerations are an uncommon presentation of primary syphilitic infection when compared to other mucosal sites. A literature review revealed a range of endoscopic findings from normal mucosa to erythema, friability, and polypoid lesions. To our knowledge the development of multiple ulcers has not been reported. It is necessary to maintain a high clinical suspicion because the diagnosis can be missed on a histologic level without appropriate additional staining. Given the increasing prevalence of syphilis, this case highlights the importance of collecting a thorough sexual history as to not delay the diagnosis and prevent the progression of disease, especially since early disease can frequently be asymptomatic.
1481 Synchronous Esophageal and Colon Adenocarcinoma: A Case Report
Authors: Bierle Lindsey A. , Reddy Shravani , Kesar Varun , Chitnavis Vikas , Grider Douglas J.
Published: October 2019

INTRODUCTION:

Synchronous carcinomas in the same patient were first elucidated in the early 1930s. Following this initial recognition, awareness of synchronous carcinomas coupled with advancements in medical technology have made diagnosis of two primary carcinomas from separate sites in the same time interval possible. We present a case of newly diagnosed synchronous primary esophageal and ascending colon adenocarcinomas in a patient presenting with lower gastrointestinal bleed.

CASE DESCRIPTION/METHODS:

A 74-year-old female with a history of abdominal aortic aneurysm repair on dual-antiplatelet therapy, chronic obstructive pulmonary disease (COPD) on continuous supplemental oxygen at four liters per minute, and tobacco abuse presented with complaints of bright red blood per rectum. Hemoglobin on presentation was 12.5 g/dL, down-trending to 9.0 g/dL the following day. Esophagogastroduodenoscopy (EGD) revealed a nodule in esophageal mucosa, a submucosal lesion in the esophageal body, 30 centimeters from the incisors, and a small hiatal hernia with initial pathology showing high grade dysplasia in Barrett mucosa. There was no active bleeding site and hemoglobin was stable. Patient was discharged with plan for repeat EGD for evaluation of dysplastic Barrett mucosa and complete work up for anemia. Repeat EGD with endoscopic mucosal resection showed Barrett esophagus and a distal esophageal mass at 30 cm. Colonoscopy showed an ascending colon mass. Histopathology with ancillary immunohistochemistry revealed synchronous primary esophageal adenocarcinoma and a second primary ascending colonic adenocarcinoma. The patient was then staged as esophageal adenocarcinoma T2N0 by endoscopic ultrasound with recommendations for esophageal resection and T2N0 colon adenocarcinoma with recommendations for hemicolectomy. Given comorbidities, she was deemed not a candidate for esophagectomy, however successfully underwent elective right hemicolectomy.

DISCUSSION:

Common synchronous carcinomas within the gastrointestinal tract include colon and appendiceal malignancies, followed by small bowel, gastric, and esophageal carcinomas. Colonic neoplasias (up to 20%) are the most common synchronous cancers in patients with primary gastric cancer; the incidence of esophageal and synchronous colon cancers is unknown, however, highlighting this case's uniqueness. Upon discovering multiple primary malignancies, accurate staging along with immunohistochemical analysis is key to distinguish each primary cancer and determine appropriate therapy.
1484 A Rare Case of Necrotizing Colitis in an Adult
Authors: Karim Syed S. , Jiyani Rucha , Jacob Bobby , Prasa Jarin , Rizvon Kaleem , Mustacchia Paul
Published: October 2019

INTRODUCTION:

Necrotizing colitis has historically been primarily a disease of premature infants, affecting about 3/1000 live births. Adult necrotizing enterocolitis (ANEC) has seldom been reported, and to our knowledge, only a few case reports exist. We present an adult with necrotizing colitis and hope to provide some insight about presentation, diagnosis, and management.

CASE DESCRIPTION/METHODS:

A 54-year-old male with history of gastroesophageal reflux disease and hyperlipidemia presented with abdominal pain associated with vomiting, fever, and bloody diarrhea. He had both an unremarkable upper endoscopy and colonoscopy 3 years ago. His abdomen was soft, but tender on the left, with no rebound or guarding. CT scan revealed infectious and inflammatory colitis. Stool studies for bacteria, parasites and clostridium difficile were negative. Initially, the patient deteriorated despite aggressive hydration and antibiotics. Colonoscopy showed extensive ulcerated friable boggy colon, and severe colitis with pseudomembranes. Pathology confirmed necrotizing inflammation suggestive of necrotizing colitis. Ischemic work up with CT angiography showed patent abdominal arteries. Surgery was premeditated, however the patient gradually improved with medical management alone and was eventually discharged.

DISCUSSION:

Although the exact mechanism of ANEC is unknown, two possible explanations include infectious agents and bowel perfusion disturbances. Infection is the main cause in neonates due to an underdeveloped immune system. Both gram negative bacteria and viruses are culprits, most commonly, E. Coli and Klebsiella. In ANEC, the primary insult may be hypoxia-reperfusion injury due to vasoconstriction of non occlusive mesenteric vessels and bacterial overgrowth as a secondary insult. Patients present with abdominal pain, vomiting and hematochezia. Xray and CT usually show nonspecific findings. CT angiography rules out mesenteric occlusion. Histological analysis demonstrating necrotizing inflammation finalizes the diagnosis. Our patient's diagnosis was based on histology and the exclusion of mesenteric occlusion. Although, stool studies did not identify a causative pathogen, our patient eventually improved with antibiotics. It is postulated that an initial ischemic damage contributed to the patient's clinical deterioration but the second insult of bacterial translocation was treated with antibiotics. Although rare, ANEC is being reported and clinicians need to keep high index of suspicion for timely management.
1489 “Bi-Morphic” Post-Transplant Lymphoproliferative Disorder Masquerading as Inflammatory Bowel Disease
Authors: Mussarat Saad , Yoo Buyng S. , Oldfield Edward C. , Parekh Parth J.
Published: October 2019

INTRODUCTION:

Post-transplant lymphoproliferative disorder (PTLD) is a serious complication occurring in up to 30% of post-transplant patients, usually within the first year; however, recurrent PTLD or development of multiple histologic subtypes is rare.1 Relevant to gastroenterologists, GI tract involvement can occur in up to 25% of cases and present as nonspecific clinical symptoms, abdominal pain, bleeding, or perforation.2

CASE DESCRIPTION/METHODS:

An 80-year-old African American male with a past medical history of living-donor kidney transplant presented to clinic to undergo surveillance colonoscopy. Nine months post-transplant, the patient was diagnosed with early PTLD on colonoscopy and treated with 4 cycles of rituximab without evidence of disease on repeat colonoscopy or PET scan. Follow up colonoscopy at 5 years did not show any recurrence of disease and the patient was recommended to undergo his next colonoscopy in another 5 years (10 years following PTLD treatment). Repeat colonoscopy at this time found multiple inflammatory polyps at the ileocecal valve and in the transverse and sigmoid colon. Additionally, the rectosigmoid colon showed evidence of moderate inflammation (Figure 1). Pathology reports indicated polyps of the ileocecal valve were consistent with polymorphic PTLD, whereas the biopsies of the rectosigmoid colon showed monomorphic PTLD (Figure 2). The patient was referred to Oncology and is currently undergoing repeat rituximab therapy for monomorphic PTLD and a dose reduction of immunosuppressants for polymorphic PTLD.

DISCUSSION:

Importantly, even though rates of PTLD are typically lowest for renal transplants (0.8-2.5%), early and recurrent PTLD is still possible in this population.3 Our patient, despite a previous response to rituximab, demonstrated evidence of rare, recurrent PTLD in addition to multiple pathologic subtypes spread diffusely throughout the colon. In particular, the emergence of monomorphic PTLD carries the worst prognosis with survival rates ranging from 25-60%.5,6 Given the frequency of GI tract involvement, it is essential gastroenterologists maintain high suspicion for PTLD in patients with prior transplantation and have a lower threshold for biopsy, as our case demonstrates advanced disease appearing endoscopically as inflammatory changes. Importantly, this recurrence was found 10 years after initial diagnosis, which signifies the importance of surveillance colonoscopy for early detection, monitoring for recurrence, and establishing disease prognosis in PTLD.
1492 Sporadic Colonic Hamartoma in an Adult Patient: A Rare Finding
Authors: Sehmbey Gurbir , Chuang Keng-Yu
Published: October 2019

INTRODUCTION:

Colonic hamartomas are non-neoplastic polypoid lesions that are rare in adults and most commonly encountered in children between the age of 1 and 7 years. They are histologically characterized by cystic dilation of mucus-filled glands, prominent bands of fibrous stroma, and a rich vascular network. Hamartomatous polyps are often diagnosed during endoscopy and require histological identification.

CASE DESCRIPTION/METHODS:

A 43-year-old male was referred due to intermittent rectal bleeding and positive fecal occult blood test (FOBT). He did endorse a positive family history of colon cancer in his mother. Colonoscopy was performed, revealing: 3 small sessile polyps <3 mm in size and a single 2 cm pedunculated polyp in the sigmoid colon (Figure 1). Polypectomy was performed for each noted polyp. Histopathological examination of the sigmoid polyp revealed a benign hamartomatous polyp with cystic dilation and focal crypt abscess (Figure 2). Pathology of rest of polyps revealed benign colonic mucosa with mild non-specific inflammation. The patient did well and remained symptom-free on follow up visit.

DISCUSSION:

Hamartomatous polyps are characterized by disorganized growth of tissue native to the organ in which it occurs. The reported prevalence of hamartomatous polyps in the adult population is around 0.15%. The prevalence of hamartomas in patients with colon polyps at index colonoscopy is 0.073%. Colonic hamartomas can occur sporadically or may present with distinct syndromic and hereditary features. The syndromes commonly associated with hamartomatous polyps are Peutz–Jeghers syndrome (PJS), juvenile polyposis, and phosphatase and tensin homolog (PTEN) hamartoma syndrome (PTHS). Endoscopically, these polyps can appear as pedunculated or sessile lesions making them indistinguishable from adenomatous polyps, which makes it prudent for the endoscopist to remove these lesions for histologic examination. In pediatric patients, hamartomas usually are localized to the rectum, the left colon, and may cause rectal bleeding, abdominal pain, and transanal prolapse. In adults, colonic hamartomas are most frequently found in the left colon and the rectosigmoid region. Patients are most commonly referred for colonoscopy due to positive FOBT or rectal bleeding. It is important to distinguish sporadic polyps from syndromic polyps as the sporadic polyps generally have a relatively benign course, while those associated with a syndrome have a higher lifetime malignancy risk.
1493 Large Fecalith Obstructing the Cecum in a Patient With Rectal Bleeding and Iron Deficiency Anemia
Authors: Rivera Arturo Suplee , Rapoport Grigoriy , Castano Juan J. , Zamir Asif
Published: October 2019

INTRODUCTION:

Fecal impaction as a result of fecalith formation can lead to rare but serious complications, such hemorrhage, perforation, intussusception and bowel obstruction. Fecaliths are stones made of feces and are a common finding in clinical practice. A fecaloma is a giant fecalith. Patients typically present with overflow diarrhea, constipation, and abdominal pain. Fecalomas are usually located in the sigmoid colon or rectum, but are rarely seen in the cecum. We present a case of a patient with a fecaloma obstructing the cecum, causing ischemic stricture.

CASE DESCRIPTION/METHODS:

The patient is a 79-year-old man without a significant past medical history who was referred to gastroenterology clinic for iron deficiency anemia, bloating, intermittent rectal bleeding, and chronic constipation. Home medications include ferrous sulfate. Patient's last colonoscopy was 7 years ago and was significant for internal hemorrhoids. No significant family history. Due to anemia and rectal bleeding he was scheduled for colonoscopy. Colonoscopy revealed the presence of a large, obstructing fecalith in the cecum, with evidence of luminal narrowing. After several attempts, it was removed endoscopically with a large 27 mm hexagonal snare. It was subsequently split into smaller pieces in the transverse colon due to concerns for obstruction. Iron supplementation was stopped. Follow-up colonoscopy revealed a smooth circumferential luminal narrowing of the right side of the colon likely due to ischemic changes from the pressure effect created by the fecalith. The patient was seen in clinic 2 weeks afterwards with significant improvement of his symptoms.

DISCUSSION:

Although fecaliths are a frequent finding in clinical practice, luminal obstruction and ischemic changes resulting in stricture formation are rare. The need for surgery in our patient was avoided due to successful removal of the fecalith. At this point we believe that iron supplementation caused the fecalith formation, resulting in obstruction and ischemic stricture. Our case illustrates an alternative non-invasive way to manage cecal fecaliths in symptomatic patients thus preventing the need for surgery.
1497 Signet Ring Cell Carcinoma of the Colon: A Rare Finding and Clinical Review
Authors: Law Jade , Singh Simi
Published: October 2019

INTRODUCTION:

Colorectal primary signet ring cell carcinoma (PSRCCR) accounts for less than 1% of colorectal cancer cases. PSRCCR most commonly arises in the stomach, but it can arise in the colon, prostate, rectum, and breast. Prognosis is poor as this cancer is usually advanced upon presentation. We present a rare case of PSRCCR diagnosed early and treated with hemicolectomy.

CASE DESCRIPTION/METHODS:

A 72-year-old male with myelodysplastic syndrome and hemochromatosis presented with a positive stool DNA test. Though he was asymptomatic, colonoscopy revealed a 30 mm sessile polyp in the ascending colon. Pathology of the polyp showed poorly differentiated signet-ring cell adenocarcinoma without lymphovascular invasion. Full body computed tomography (CT) scan found no evidence of metastatic disease. Carcinoembryonic antigen (CEA) was elevated at 5.3. He was treated for stage IIA disease with a right hemicolectomy. Two months later, PET-CT showed no recurrence, and CEA level was normal at 2.7.

DISCUSSION:

PSRCCR of the colon is a rare malignancy that is typically diagnosed at an advanced stage due to the late manifestation of symptoms. Colorectal cancer screening tests can help identify some of these individuals with sensitivities of 79% for fecal occult blood tests, 92% for stool DNA tests, and >95% for colonoscopies.
1
A third of PSRCCR patients have metastasis on presentation. One hypothesis for the late presentation of PSRCCR is that the cancer spreads through the mucosa and spares mucosal surfaces, leading to fewer symptoms in the early stages.
2
Treatment is focused on surgical resection, neoadjuvant radiotherapy, and adjuvant radiochemotherapy. In our case, the patient was diagnosed early at stage IIA without lymph node involvement or metastases. His early diagnosis enabled him to have surgical resection that will likely be curative. This remarkable case showcases a rare circumstance of early detection and treatment of PSRCCR.
1501 Double Whammy: Checkpoint Inhibitor and CMV-Induced Colitis
Authors: Paniz Graziella Rangel , Sharkey Sarah O. , Dean James T. , Lopez Portillo Glenda M.
Published: October 2019

INTRODUCTION:

Immune checkpoint inhibitors (ICIs) such as nivolumab have become a common treatment for several types of malignancies, especially metastatic disease. Diarrhea and enterocolitis are known side effects of these drugs. Here we present a case of a patient who developed ICI associated colitis who was later diagnosed with superimposed Cytomegalovirus colitis.

CASE DESCRIPTION/METHODS:

A 75-year-old male with past medical history pertinent for squamous cell carcinoma of the neck and base of tongue treated with nivolumab. His treatment was interrupted due to the development of chronic diarrhea possibly related to immune checkpoint inhibitor therapy (nivolumab). Immunotherapy was discontinued and the patient was started on a high dose of steroids with initial clinical response and symptom control. He was admitted to the hospital two months later with signs of shock with hematochezia and profound diarrhea. Computed Tomography (CT) of his abdomen upon admission showed severe colitis. Blood cultures were positive for Streptococcus infantarium (previously known as Streptococcus bovis) likely translocation from severe immunotherapy-induced colitis. His hemodynamics improved with fluid resuscitation and antibiotic therapy; however his diarrhea did not resolve. He then underwent colonoscopy which demonstrated circumferential, uninterrupted, extensive and severe inflammation (Figures 1 and 2) with the procedure terminated prematurely to avoid risk of perforation. Pathology of colonic biopsies showed positive immunostaining for Cytomegalovirus (CMV), and the patient tested positive for CMV DNA PCR, confirming acute active infection. He was started on valganciclovir and his steroid regimen was tapered with significant improvement of his diarrhea.

DISCUSSION:

Immune checkpoint inhibitors are monoclonal antibodies that target downregulators of the anti-neoplastic immune response. There are currently seven FDA approved ICIs, including Nivolumab. Immune-mediated colitis and diarrhea are the most common side effects associated with these drugs. One third of patients treated with ICIs will experience gastrointestinal adverse effects and 1-2% of patients on nivolumab will experience diarrhea. Although is not common, infection can coexist and in the setting of persistent and recurrent diarrhea it has to be ruled out.
1504 Case Report: A Rare Case of Community-Acquired Clostridium difficile Infection After Colonoscopy
Authors: Xu Binghong , Xie Bingru
Published: October 2019

INTRODUCTION:

Clostridium difficile (C.diff) infection (CDI) is commonly related to recent antibiotic use, usually occurring in hospitals and other health care facilities where a significantly higher percentage of people carry the bacteria. Here we reported a rare case of community acquired C.diff 3 days after colonoscopy in a low risk patient without a history of antibiotic use or recent hospitalization.

CASE DESCRIPTION/METHODS:

A 50-year-old healthy female with no past medical history presented for screening colonoscopy. She tolerated the bowel preparation regimen with polyethylene glycol well. The colonoscopy was unremarkable with one small tubular adenoma removed by snare polypectomy. Patient tolerated the procedure well without any complications. She ate raw blueberry from the local supermarket one day after colonoscopy. Then she presented with watery diarrhea up to 10 times per day with nocturnal symptoms 3 days after colonoscopy. Stool studies were ordered. Diarrhea gradually resolved with hydration and clear liquid diet after 3 days without antibiotics treatment. Stool studies came back with positive C. diff toxins. Patient has no risk factors include recent hospitalization, antibiotic use. She took proton pump inhibitor intermittently a few months prior to colonoscopy. All the other patients had procedures done on the same day in the endoscopy suite had no complications.

DISCUSSION:

The risk factors of CDI include antibiotics use, advanced age (>65), gastrointestinal surgery, IBD and immunosuppression, etc. The effect of anti-acid use remains unsure because the C. diff spores are acid resistant. Recent studies reported a 7-fold and 13-fold increase in C. diff infection rate after colonoscopy for patients with Crohn's disease and ulcerative colitis compared with non-IBD patients. Another study reported the preoperative use of mechanical bowel preparation was not associated with increased risk of C. diff infection after colectomy. Generally, mechanical bowel preparation and colonoscopy are not risk factors of CDI for a healthy population. This is a rare case with no traditional risk factors acquired CDI by eating raw blueberry 3 days after colonoscopy. Bowel preparation might be a risk factor to disturb the normal gut flora, which increases the risk of CDI. The use of probiotics afterward to prevent C. diff colonization could be a safe and easily adoptable control strategy, but the routine use for prevention or treatment of active infection is not recommended.
1507 A Rare Case of Intestinal Endometriosis Mimicking Acute Appendicitis and Sigmoid Malignancy in a Five Year Time Span
Authors: Miao Chuan Long , Khuri Nadeem , Roberts Marigny , Broadwell Ronald
Published: October 2019

INTRODUCTION:

Endometriosis is characterized by implantation of endometrial epithelium outside the uterus. The prevalence is about 10-15% in women of reproductive age. The most common extra-pelvic site is the GI tract, affecting 4–37% of women with endometriosis. The sigmoid colon and rectum are the most common sites followed by the ileum, appendix and cecum.

CASE DESCRIPTION/METHODS:

Here we present a very rare case of severe intestinal endometriosis involving multiple GI sites including the terminal ileum, appendix and recto-sigmoid colon in the past 5 years. 4.5 years ago, the then 27 year old otherwise healthy female presented with worsening RLQ pain. She had leukocytosis of 15K WBC with CT scan showing a dilated and thickened distal appendix consistent with appendicitis. She underwent laparoscopic appendectomy without complications. Pathology reported endometriosis (Figure 1). After appendectomy, she continued to have diffuse abdominal pain with nausea and constipation. As part of GI workup, she underwent EGD and colonoscopy about 3 years ago with findings of two recto-sigmoid strictures with biopsies showing endometriosis. The patient was then lost followup until she was readmitted with multiple GI complaints including nausea/vomiting, abdominal pain, with alternating diarrhea and constipation. It appears that she had been treated for IBS and also received hormonal treatment for endometriosis in the past two years. On admission, she had leukocytosis of 16K and a CT scan showing a 3 cm focal apple-core lesion in the distal sigmoid colon. Colonoscopy showed a very severe stricture at the distal sigmoid colon with nodular mucosa in the proximal rectum. Pathology was negative for malignancy or endometriosis. She then underwent laproscopy with findings of 2 strictures in the recto-sigmoid colon together with another stricture 5 cm proximal to the IC valve in the distal ileum. Partial resection of the recto-sigmoid colon together with a right hemicolectomy was performed. Pathology of both TI and recto-sigmoid colon showed endometriosis (Figure 2). During the one-month post-op followup, she reported resolution of constipation.

DISCUSSION:

Our patient represents a rare case of symptomatic multi-focal gastrointestinal endometriosis with mucosal involvement at different times mimicking appendicitis and sigmoid malignancy. Endometriosis should be considered in the differential diagnosis in any young woman with lower GI symptoms.
1509 81 Colonic Polyps—An Incidental Finding and Clinical Dilemma
Authors: Franco Quintanilla Jose A. , Camero Alfredo , Patel Harsh D. , Schindler Amy E.
Published: October 2019

INTRODUCTION:

Colorectal polyposis syndromes are rare but, when present, can increase someone's risk of colorectal cancer up to 100%, such as in the setting of familial adenomatous polyposis. Advances in genomics have identified several well-established hereditary cancer syndromes; however, with ongoing research, many patients are left without a formal diagnosis. Clinical presentations vary widely. We present a case of a 62-year-old man with a polyposis syndrome found incidentally during workup for multiple myeloma and the clinical dilemma it presented.

CASE DESCRIPTION/METHODS:

A 62-year-old man undergoing staging workup for newly diagnosed multiple myeloma had abnormal computerized tomography (CT) and positron emission tomography (PET) imaging of the gastrointestinal (GI) tract. His CT scan demonstrated intraluminal densities in the rectosigmoid region and his PET scan showed increased FDG avidity of these lesions along with others in the descending colon (Figures 1 and 2). The patient had no symptoms related to the GI tract. He had no relevant surgical history, and there was no family history of colon cancer or other GI disease. He had a 46 pack-year smoking history. A colonoscopy was performed, which showed marked left-sided colonic polyposis. Two additional colonoscopies were performed over the next week, and a total of eighty-one polyps were removed. Most left-sided polyps were between 1-3 cm, and many had large pedunculated stalks (Figure 3). Pathology showed all polyps to be tubular adenomas with six of them having high-grade dysplasia. Genetic testing using a 17-gene panel for colorectal cancer predisposing mutations was negative.

DISCUSSION:

Our patient had clinical signs of a colorectal polyposis syndrome but was in a clinical conundrum, as he was only recently diagnosed with widespread multiple myeloma and was due to start potentially cytotoxic chemotherapy. Our decision to perform such extensive polypectomy was to decrease polyp burden, evaluate for high-risk features, and potentially diagnose early adenocarcinoma. Genetic testing did not identify a culprit gene, but with his clinical features and high-grade dysplasia colectomy was recommended. A multidisciplinary approach between hematology and colorectal surgery is being pursued after initial rounds of chemotherapy. This case highlights the variety in which polyposis syndromes can present, discussion of extent of polypectomy at time of colonoscopy, and importance of a multidisciplinary approach.