bluuebunny/crossref_metadata_2025 huggingface dataset:
1863 The Mouth Is More Than Just an Entry Path to the Esophagus: A Rare Site of Breast Cancer Metastasis
Authors: Malik Neena , Brandt Lawrence , Timsar Ali Kazerouni
Published: October 2019

INTRODUCTION:

The following case highlights a rare site for breast cancer metastasis, as well as demonstrates the importance of careful attention to all structures including the oral cavity, during endoscopy.

CASE DESCRIPTION/METHODS:

A 53-year-old woman with a history of a recent dental abscess presented with weakness. She reported that 2 weeks before presentation she developed a dental abscess that required drainage. Upon further questioning, she also recalled a 2-month history of right breast pain and swelling. CT abdomen and pelvis obtained raised concern for infiltrative breast cancer with metastases to the liver, lung, bone, and brain. Prior to dedicated breast imaging and biopsy, the patient developed large-volume hematemesis and urgent endoscopy was performed. As the endoscope was advanced into the mouth, a 15 mm soft, friable polypoid mass was seen on the hard palate off the midline, as well as a cratered lesion with rounded walls in the gastric body. These lesions were biopsied with pathology showing poorly differentiated carcinoma composed of nests of malignant cells with marked atypia and pleomorphism, positive for pancytokeratin, GATA3 and CK7. The morphology and immunoprofile supported the diagnosis of metastatic carcinoma of breast origin.

DISCUSSION:

Breast cancer most often metastasizes to the liver, lung, bone, and brain. Gastric metastases are infrequent, with an estimated incidence rate of approximately 0.3%. Metastasis of malignant tumors to the oral cavity is exceedingly rare and accounts for approximately 1% of all malignant oral tumors. There are insufficient data to account for the true incidence for breast cancer metastasis to the oral cavity. Management of metastatic breast carcinomas of the oral cavity is primarily palliative, as prognosis for patients with these metastatic lesions is generally poor. As gastroenterologists, we are often focused solely on the proximal gastrointestinal tract during upper endoscopy, but we have the ability to fully evaluate and detect abnormalities of a number of other structures, including the oral cavity, oropharynx, and larynx. We should take full advantage of this opportunity to view these structures in an attempt to aid in early detection of what would otherwise be neglected disease. This case not only demonstrates the need for awareness of the oral cavity as a potential site for metastasis of breast cancer and its associated poor prognosis, but it also highlights the key principle of conducting a thorough endoscopic evaluation.
1866 “I am Choking:” An Unusual Late Complication of a Gunshot Injury
Authors: Kulkarni Deepika , Kulkarni Prasad
Published: October 2019

INTRODUCTION:

Benign tracheo-esophageal fistulas (TEF) in adults are an uncommon entity. We present the case of a patient who presented with dysphagia, was diagnosed with a benign TEF, and was successfully managed with endoscopic clipping with complete resolution.

CASE DESCRIPTION/METHODS:

A 64-year-old male veteran was referred to gastroenterology clinic for evaluation of dysphagia, specifically coughing and choking when eating. Previous history included stable pulmonary nodules, PET-avid mediastinal lymphadenopathy of unclear etiology, and GERD. Patient reported a gunshot wound to the throat over 30 years prior to presentation, which had required a left posterior thoracotomy. Barium esophagram showed a 6 mm diverticulum of the proximal esophagus, with extravasation of contrast into the trachea. EGD was performed, which identified a diverticulum with a small fistula at 20 cm from the incisors. The remainder of the esophagus appeared to be unremarkable, with no evidence of masses. Three hemoclips were deployed, with successful closure of the defect. Repeat barium esophagram 6 weeks post-procedure noted no contrast in the trachea, with the patient reporting improvement of symptoms. Repeat EGD 6 months post-procedure showed no evidence of diverticulum, fistula, nor clips.

DISCUSSION:

Nonmalignant TEF in adults are uncommon entities. Most acquired benign TEF are secondary to endotracheal cuff injury from prolonged mechanical intubation, but may be due to trauma, prior surgeries, foreign bodies, and mediastinal infections. Classical treatments for acquired TEF include surgical approaches with single or multistage procedures. Endoscopic therapies are increasingly studied with high technical and clinical success rates. While management of TEF is often performed with esophageal stents, tracheal stents, or a combination of both, literature review shows that patients may be successfully managed with endoscopic clips, or stents with a combination of sutures and cautery. For patients with persistent dysphagia and unexplained pulmonary findings, a high index of suspicion must be maintained for a benign TEF, and endoscopic interventions may be critical for clinical resolution. References Silon, Bryan, et al. “Endoscopic management of esophago-respiratory fistulas: a multicenter retrospective study of techniques and outcomes.” Digestive diseases and sciences 62.2 (2017): 424-431. Santosham, Rajan. “Management of acquired benign tracheoesophageal fistulae.” Thoracic surgery clinics 28.3 (2018): 385-392.
1868 Novel Use of Overtube for Rectal Foreign Body to “Clean” Out the Colon: Extraction of Large Tide-To-Go Pen
Authors: Shao Paul , Grewal Jasleen , Perumpail Ryan , Leung Felix
Published: October 2019

INTRODUCTION:

The rate of colorectal foreign bodies is rising. This poses an interesting challenge to endoscopists as there is great variability in object size, shape, and surface characteristics. This heterogeneity requires endoscopists to have a diverse range of techniques at their disposal to safely remove colorectal foreign bodies in a minimally invasive manner. We present a case of the novel use of an esophageal overtube to aid in the removal of a difficult-to-remove Tide To Go cap.

CASE DESCRIPTION/METHODS:

The patient was a 55-year-old male who presented to the ED about 24 hours after inserting a smooth plastic Tide To go pen into his rectum. When he attempted to remove the pen, the cap was left behind. He denied any pain, hematochezia, fevers or chills. In the ED he underwent a CT scan which showed a well circumscribed air-containing elongated and conelike region occupying the rectum and rectosigmoid with mild thickening of the rectal wall without extraluminal air. We initially gave him 4L of Golytely to flush the object, but he did not pass the object on his own. During flexible sigmoidoscopy we could appreciate a very strictured and erythematous rectum and a smooth, white, plastic object lodged in the rectosigmoid colon. Multiple attempts at pulling the object out with rat-tooth forceps, snare, and Roth net were all futile as we could not pull the object through the narrowed rectum. We then inserted a heavily lubricated esophageal overtube through the rectum and pulled the object into the overtube and removed the cap and overtube together. The overtube helped dilate and straighten the rectum while allowinging the object to be secured into the overtube.

DISCUSSION:

The incidence of patients presenting to emergency departments with rectal foreign bodies is increasing, particularly in males. Recurrent episodes of rectal foreign body insertion requiring repeat endoscopic and surgical interventions for extraction can lead to anorectal stricturing. The alteration of anatomy may, as in this case, result in difficulty with foreign body extraction despite endoscopic access to the object. Stenting of the overlying mucosa and straightening of the rectum with overtube placement may facilitate successful retrieval of the rectal foreign body.
1871 Rare Case of Endoscopic Erosive Ulcerations in Celiac Disease
Authors: Rezaie Aida , Ahmed Shifat , Goldberg Aaron
Published: October 2019

INTRODUCTION:

Celiac disease is a common disorder of the small intestine caused by an autoimmune reaction to dietary gluten in the setting of genetic predisposition. Patients can present with a variety of symptoms ranging from diarrhea and unintentional weight loss to extraintestinal signs such as iron deficiency anemia and dermatitis. The diagnosis is confirmed with serologies and duodenal biopsies while a patient is on a gluten-containing diet. Histopathology of the small bowel demonstrates characteristic villous atrophy, mucosal inflammation, or crypt hyperplasia with increased intraepithelial lymphocytes. Gross endoscopic findings are typically normal with occasional endoscopies can show gastritis or atrophy. This is the first case of celiac disease with gross endoscopic findings consistent with non-bleeding erosive gastropathy.

CASE DESCRIPTION/METHODS:

A 68-year-old Veteran male presents for evaluation of weight loss, left lower quadrant discomfort and chronic loose stools. He denied any dietary changes, changes in appetite, nausea, vomiting, skin lesions, joint pain or recent travel. Endoscopy was performed demonstrating petechial gastropathy in the proximal stomach, mild duodenal bulb erosions with marked transverse-oriented erosions from the second part of the duodenum to proximal jejunum. Jejunal and duodenal biopsies were consistent with Celiac disease without H pylori, intestinal dysplasia or metaplasia. Serum TSH was 0.876, IgA was 276 (normal 58-484 mg/dL), Tissue transglutaminase IgA >100 U/mL and gastrin <15 pg/mL.

DISCUSSION:

The chronic lymphocytic infiltration triggered by the ingestion of gluten causes the classic histopathological findings. However, endoscopically, celiac disease has not been shown to have significant features outside of scalloped duodenal folds, fissures and grooves. This is the first documented case that presents an endoscopic pattern of erosive ulcerations consistent both histologically and serologically with celiac disease. While biopsy remains the standard of care, further exploration into diagnosing this disease through gross pathology is warranted.
1872 Mycobacterium Avium Complex Colitis in a Patient With AIDS
Authors: Rezaie Aida , Pradhan Faruq , Wadas Darrell
Published: October 2019

INTRODUCTION:

Disseminated mycobacterium avium complex (MAC) is an uncommon diagnosis with the advent of highly active anti-retroviral therapy (HAART). The International Antiviral Society-USA Panel and the US Department of Health and Human services recently changed their guidelines recommending against routine MAC prophylaxis in patients on HAART. Gastrointestinal manifestations of MAC typically result in diarrhea, fever, weight loss, and abdominal pain. The diagnosis is clinically challenging as radiographic findings are non-specific and cultures can be negative for up to 2 weeks. Upper endoscopy with biopsy is required to make the diagnosis. We present a rare case of MAC colitis in a patient with AIDS with only focal subtle endoscopic changes.

CASE DESCRIPTION/METHODS:

A 31-year-old male was admitted for fevers, chills, diarrhea and rectal pain for 1 week. The patient was diagnosed with HIV 1 year prior and declined HAART. On admission, the patient had a benign abdominal exam with tender inguinal lymphadenopathy. Computed tomography (CT) of the abdomen/pelvis without contrast demonstrated subtle wall thickening in the rectosigmoid consistent with proctocolitis. His absolute CD4 count was 38 cells/uL, unfortunately an HIV viral load was not checked. Stool culture with shiga toxin, clostridioides difficile, coccidioides, stool giardia/ova and parasites/cryptosporidium were negative. Cytomegalovirus (CMV) serum PCR was positive at 15,400 IU/mL. Colonoscopy showed normal mucosa throughout the colon and terminal ileum, except for a single, subtle, erosion of the rectum 2 mm in length. Biopsies taken of the solitary erosion were notable for acid fast bacilli concerning for intestinal MAC, CMV was negative. An interferon gamma release study was indeterminate. The patient was discharged on therapy for CMV viremia.

DISCUSSION:

The incidence of disseminated mycobacterium avium infection has decreased to 2 cases per 1000 person-years with the use of HAART. However, the risk of infection increases with high HIV viral loads >1000 copies/mL, previous or concurrent opportunistic infections, and CD4 count <50 cells/uL. Gastrointestinal MAC is rare, and when identified is most commonly found in the small bowel. Endoscopically, this is associated with granular, erythematous mucosa with ulcerations. Identification of the pathogen can be difficult unless direct biopsies of suspicious lesions are obtained on endoscopy.
1876 A Rare Case of Giardia Duodenalis on Duodenal Biopsy in a Patient With Chronic Abdominal Pain
Authors: Moore Andrew , Lee Salina , Jakate Shriram
Published: October 2019

INTRODUCTION:

Giardia duodenalis is an intestinal flagellated protozoan parasite and is the most common parasitic infection in the GI tract, having been estimated to effect as much as 2-5% of the population in developed countries. Symptoms of giardiasis in children include diarrhea, flatulence, abdominal cramping, nausea, and dehydration; however, in adults the symptoms are often absent or short-lived. Giardiasis is typically diagnosed by identification of cysts or trophozoites with a test for ova and parasites in the stool of infected patients. Here we present a rare care of a patient with chronic abdominal pain who was diagnosed with giardiasis via duodenal biopsy.

CASE DESCRIPTION/METHODS:

A 65-year-old male with a past medical history of COPD, HTN, and depression was evaluated for abdominal pain that had been ongoing for the last two years. The pain was primarily epigastric with occasional radiation to the upper quadrants, worse after eating, and often occurred at night, awakening him from sleep. He denied any constipation, diarrhea, hematochezia, melana, or weight loss. He did not take any PPIs or H2 blockers. His last colonoscopy was in 2015 and was notable only for a few polyps. Physical exam was notable for mild tenderness in the upper quadrants and epigastric area. Esophagogastroduodenoscopy (EGD) showed mild dilation in the distal esophagus, nodularity in the gastric corpus, patchy erythema and erosions in the antrum of the stomach. Duodenum was notable for diffuse erythema and friability in the bulb. The second portion of the duodenum appeared normal. Pathology was notable for multiple pieces of the duodenal mucosa showing numerous Giardia parasites and focal acute erosive duodenitis (Figure 1). Multiple pieces of gastric mucosa showed chronic gastritis and numerous H. pylori organisms. Moderate esophagitis compatible with reflux was also observed. Presidential Poster AwardThe patient was prescribed triple therapy with omeprazole 20mg BID, amoxicillin 1g TID, and metronidazole 500mg TID for 10 days to cover both H. pylori and Giardia duodenalis and then was instructed to continue on omeprazole 20mg daily.

DISCUSSION:

For patients in whom Giardia or other infectious etiology is suspected, stool O&P are routinely ordered. However, the sensitivity of examining one stool specimen is only 50-70%. This case demonstrates the utility of EGD as a more sensitive diagnostic tool when there is strong clinical suspicion but stool studies fail to reveal a definitive diagnosis.
1886 Endoscopic Management of Tubulovillous Adenoma Within a Diverticulum: Report of a Case and Review of Literature
Authors: Hawa Fadi , Tworek Joseph A. , Catanzaro Andrew T. , Gunaratnam Naresh T.
Published: October 2019

INTRODUCTION:

Colonic polyps within a diverticulum are technically challenging to resect as the polyp might be difficult to access if it is buried within the diverticulum. There is also an increased risk of perforation upon endoscopic resection owing to the lack of muscularis propria in the wall of the diverticulum. We describe an endoscopic technique for management of a rare case of tubulovillous adenoma within a diverticulum with review of literature.

CASE DESCRIPTION/METHODS:

A 74-year-old male underwent screening colonoscopy which identified a 15 mm polyp within a sigmoid colon diverticulum. Attempted resection was unsuccessful despite sub-mucosal injection with saline and the use of multiple snares. Therefore, the endoscopist elected to use a variceal band ligator. The polyp was then suctioned into the band ligator cap and 2 bands were deployed which exposed a clearly defined 15 mm polyp. This was followed by endoscopic resection using hot snare polypectomy. Histopathology revealed a tubulovillous adenoma. Inspection of the resection site demonstrated a 3 mm perforation which was closed using 4 endoscopic clips. The patient was admitted overnight for observation and was discharged the following day without complications.

DISCUSSION:

Colonic polyps within a diverticulum are technically challenging to resect given that the majority of the polyp might be buried within the diverticulum. Suction over the polyp using a variceal banding device and deploying bands across the base was an effective method for exposing and resecting the entire polyp in this case. However, it was complicated by a small iatrogenic perforation likely due to the lack of a muscularis propria within the wall of the diverticulum. Review of literature revealed three other cases which reported endoscopic management of colonic polyps within a diverticulum. Two of the cases utilized an over the scope clip at the base of the suctioned polyp prior to resection with a hot snare to reduce the risk of iatrogenic perforation. The third case allowed for natural sloughing of the polyp to occur without tissue retrieval as a result of tissue ischemia from the band. In conclusion, colonic polyps within a diverticulum can be successfully removed by using a band ligator and/or over the scope clip to isolate the polyp. The polyp can then be resected using hot snare polypectomy to ensure tissue retrieval. However, an over the scope clip should be used prophylactically to prevent a perforation or a perforation can be closed with endoscopic clips.
1892 Stomach Where the Sun Don’t Shine: A Rare Case of Gastric Adenocarcinoma Metastasizing to the Colon
Authors: Houston Trevor , Lim Diego , Andraws Nevene , Vennalaganti Prashanth
Published: October 2019

INTRODUCTION:

Gastric cancer has been known to have a poor prognosis worldwide. It frequently leads to a metastatic disease, but rarely to the colon.

CASE DESCRIPTION/METHODS:

A 73-year-old male presented for a routine surveillance colonoscopy. He reported new onset constipation over the last 6-8 months that was not relieved by over-the-counter laxatives. He was found to have a stricture approximately 30 cm from the anal verge (Figure 1). This stricture was not seen on previous colonoscopy in 2014. He had a history of gastric adenocarcinoma 4 years ago, underwent a subtotal gastrectomy followed by chemotherapy and radiation and was closely followed in the oncology clinic. In addition, he also had a gastrointestinal stromal tumor (GIST) in the stomach. Histopathology was consistent with gastric adenocarcinoma (Figure 2). Widespread metastatic disease was found on PET scan (Figure 3).

DISCUSSION:

Although gastric cancer metastasizes to the liver, peritoneum and distant lymph nodes commonly, colon metastasis is rare and even rarer is sigmoid metastasis. We report a case of a patient with a change on bowel habits and was found to have gastric adenocarcinoma that has metastasized to the sigmoid colon causing a structuring lesion. In addition, both gastric adenocarcinoma and a concurrent GIST have been reported in literature. It has been suggested that C-KIT or PDGFR-a mutations can lead to both cancer types but more information on this subject is lacking in current literature. It appears though that having both types of cancers do not significantly influences symptoms or disease outcome.
1895 “The First Burn Is the Deepest:” A Cautionary Tale in Superficial APC Therapy for Radiation Proctopathy
Authors: Pineles David , Vareedayah Ashley , Poppers David
Published: October 2019

INTRODUCTION:

Globally, prostate cancer is the most commonly diagnosed cancer in men. Radiation therapy remains a mainstay in the armamentarium in the treatment of this disease. Radiation proctopathy is a common side effect of this treatment modality with an incidence in patients treated with brachytherapy alone estimated to range from 8 to 13%, and up to 21% in combination with other modalities [2]. Radiation proctopathy typically presents with diarrhea, mucoid discharge, urgency, tenesmus, and bleeding. Argon plasma coagulation (APC) has become the primary therapeutic modality in the management of radiation injury. It is essential that physicians of all specialties (as well as others who care for these patients) be aware of the multiple complications of this therapy. More severe adverse events, notably rectal ulcers following APC therapy are not uncommon, with an incidence ranging from 3 to 16%.

CASE DESCRIPTION/METHODS:

A 67-year-old man with a history of prostate cancer treated with radiation therapy one year prior presented with intermittent rectal bleeding for one and a half months. A colonoscopy was performed, which revealed a small area near the dentate line characterized by slightly oozing neovascularized tissue consistent with radiation proctopathy. This area was treated with APC with good effect. Biopsies of this area revealed hyperplastic crypts, lamina propria fibrosis, and vascular ectasias compatible with radiation injury. Three months following treatment, the patient developed recurrent rectal bleeding. A flexible sigmoidoscopy revealed a deep non-bleeding ulcer in the rectum. Subsequent CT enterography and MRI of the pelvis demonstrated a deep rectal ulcer with abutment of a 1.5cm peri-prostatic abscess. The patient was followed closely over the next several months in concert with colorectal surgical colleagues, with serial imaging and subsequent resolution of the peri-prostatic abscess as well as cessation of rectal bleeding.

DISCUSSION:

As more patients with prostate cancer are treated with radiation therapy the incidence of radiation proctopathy is increasing. Although argon plasma coagulation has been shown to be an effective therapy for this issue, providers must consider and discuss with patients the potential complications of this otherwise effective and generally well-tolerated mode of treatment.
1897 Endoscopic Closure of GastroColoCutaneous Fistula: A Rare Complication of Percutaneous Endoscopic Gastrostomy Tube Placement
Authors: Zia Hassaan , Hayat Maham , Guild Ralph
Published: October 2019

INTRODUCTION:

Percutaneous endoscopic gastrostomy (PEG) tube placement is an indispensable method for enteral nutrition. The incidence of complications ranges from 0.4% to 40% .These include buried bumper syndrome, infection, tube dislodgement, malfunction, peristomal leakage, bleeding and colonic perforation. We report a rare complication of colonic perforation presenting as a gastrocolocutaneous fistula.

CASE DESCRIPTION/METHODS:

55-year-old male with Stage IV gastroesophageal junction neuroendocrine carcinoma with ongoing chemoradiotherapy had a PEG tube placed for dysphagia. There were no post procedural complications. Two months post procedure, patient presented with pancytopenia and a two-week history of persistent diarrhea, malodorous peristomal drainage and weight loss. Computerized tomography (CT) imaging with intravenous (IV) contrast confirmed the presence of a gastrocolocutaneous fistula (Image A, left) with internal bolster located in the transverse colon. Due to immunocompromised status, endoscopic closure was pursued with a colonoscopy and esophagogastroduodenoscopy (EGD). A pediatric colonoscope with distal cap attachment was used, an internal bolster with colocutaneous fistula with no cologastric fistula was seen. (Image B). The site was tattooed with 6mL of Spot (carbon black). The gastrostomy tube was removed, and three hemostatic clips were used for closure (Image C, left). No air leak was noted over the exterior abdominal wall. This was followed by EGD, the residual gastrocolic fistula was closed by a mini over the scope clip (OTSC) OVESCO 10/3t (Image C, right). A CT scan with oral contrast demonstrated no residual leak/fistula. (Image A, right) Total parenteral nutrition (TPN) was initiated. Patient continued to do well, and post-procedural hospital stay was uneventful.

DISCUSSION:

Gastrocolocutaneous fistula after PEG placement has an incidence of 0.5%–3%. Risk factors include lax mesentery, prior abdominal surgery leading to adhesions and improper insufflation of the stomach. Peritoneal signs represent acute presentations, delayed presentations manifest as feculent peristomal leakage, persistent diarrhea and weight loss. Diagnosis can be made with oral and IV enhanced imaging. Conservative management includes removal and allowing fistula healing. Surgical intervention is warranted when systemic signs or persistent fistulous tract is present. Endoscopic closure with OTSC is described as a treatment option for uncomplicated patients.
1898 Successful Endoscopic Removal of a Long Lost Toothbrush: 15 Years Later!
Authors: Khalid Nida , Kothari Truptesh , Kaul Vivek , Kothari Shivangi
Published: October 2019

INTRODUCTION:

Toothbrush ingestion is uncommon and can sometimes be seen in patients with eating disorders or underlying psychiatric illness. Although some foreign bodies can pass spontaneously, due to its shape, spontaneous passage of toothbrush can be difficult and if left untreated can lead to abdominal pain, mucosal ulceration, bleeding and perforation. We report one such case of a toothbrush accidentally ingested 15 years ago and impacted in the gastric wall that was successfully removed endoscopically.

CASE DESCRIPTION/METHODS:

A 37-year-old female with past medical history of bulimia and accidental ingestion of tooth brush 15 years ago reported to her PCP with worsening abdominal pain. She had never reported or sought help for her ingested toothbrush all these years due to fear of being labelled mentally ill. Labs were relevant for mild anemia with Hb of 10.5 gm/dl. Initial attempt at endoscopic removal at outside center was unsuccessful. At repeat EGD at our center, a 20 cm long toothbrush was seen in the gastric body covered with significant debris (Figure 1). The distal end of the toothbrush was seen embedded in the proximal gastric wall (Figure 2). Attempts to free the distal end with a snare were not successful. A long overtube was then placed and gastroscope passed through it. Then using a rat tooth forceps the bristle part of the tooth brush was grasped and the brush was pulled into the antrum and the distal end was freed from the gastric wall. No frank perforation was seen at the site of impaction. The tooth brush was then grasped with a snare and brought into the overtube. The endoscope and overtube with the toothbrush were successfully removed (Figure 3). The patient was continued on PPI for 4 weeks and her abdominal pain resolved post procedure.

DISCUSSION:

Up to 80% of the ingested foreign bodies may pass through the gastrointestinal tract spontaneously. However long objects (>5 cm) cannot pass through the duodenum and need to be removed by endoscopy and rarely by surgery. Those that remain in gastrointestinal tract can be associated with serious complications such as perforation, bleeding, pressure necrosis or obstruction. Toothbrush ingestion is uncommon and requires prompt removal. However our patient sought help after 15 years of ingestion only after it caused abdominal pain. To the best of our knowledge this is the longest time period a toothbrush has been reported retained in the stomach and subsequently successfully retrieved by endoscopy.
1903 Esophageal Squamous Papilloma: A Rare Epithelial Tumor of Undetermined Significance
Authors: Takkouche Sahar , Hutton Anneka , Barakat Mohamed , Quintero Eduardo , Reddy Madhavi
Published: October 2019

INTRODUCTION:

Esophageal squamous papilloma (ESP) is an uncommon lesion with less than 200 cases described. Although typically a benign lesion, the etiology remains uncertain. Currently, no guidelines exist for the management of esophageal squamous papilloma.

CASE DESCRIPTION/METHODS:

A 59-year-old woman presented with dysphagia; she reported symptoms of acid reflux and globus sensation. One year prior, esophagogastroduodenoscopy (EGD) was performed for these symptoms and revealed atrophic changes consistent with gastritis. Biopsy at that time was negative for H. Pylori infection. She was treated with PPI therapy, however her symptoms persisted. She endorsed intermittent dysphagia but denied weight loss or poor appetite. Physical exam revealed no palpable thyromegaly or epigastric tenderness. Repeat upper EGD revealed a white, 7 mm frond-like pedunculated polyp located 20 cm from the incisors (Figure 1). Endoscopic ultrasound (EUS) was performed, the origin of the lesion appeared to be within the superficial mucosa. The endosonographic borders were well defined, intact interfaces between the mass and adjacent structures suggested a lack of submucosal invasion (Figure 2). No was lymphadenopathy seen. The polyp was excised endoscopically (Figure 3), pathological review identified the specimen as an esophageal squamous papilloma, positive for Ki67 and HPV marker P16. The patient tolerated the procedure well and had no recurrence of symptoms after polypectomy.

DISCUSSION:

Often an incidental finding on endoscopy, ESP are most commonly found in adults over age 50 and typically involve the middle and distal thirds of the esophagus. ESP may be associated with dyspepsia but rarely cause obstruction. Purported etiologies include mechanical, chemical and viral insult to mucosa but is likely multifactorial. The malignant potential of ESP remains uncertain; although rare, several reported cases have been complicated by carcinoma. Studies to detect HPV DNA in ESP show variable percentage of HPV positivity. If HPV infection predisposes to ESP, this may explain cases of malignant conversion as HPV is a known cause of squamous cell cancer. ESP should be considered in patients over 50 years old presenting with dysphagia or GERD resistant to medical therapy. We recommend early recognition and removal of esophageal squamous papilloma due to ambiguity regarding malignant potential.
1904 Multiple Facets of CMV-Related Gastrointestinal Disease: From Top to Bottom
Authors: Magrath Melissa , Chauhan Kirtan , Vargas Alejandro , Tzimas Demetrios , Villanueva Gerald , Malter Lisa
Published: October 2019

INTRODUCTION:

Cytomegalovirus (CMV) primarily affects immunocompromised patients, and has multiple manifestations in the gastrointestinal (GI) tract. The incidence of CMV-related GI disease has decreased since the advent of antiretroviral therapy (ART) for HIV. This, along with varied and nonspecific symptoms, makes it difficult to diagnose.

CASE DESCRIPTION/METHODS:

We report a 34-year-old man with AIDS (CD4 count 114 cells/µL) on ART presenting with five days of fevers. He was admitted to the ICU for sepsis and stabilized. His course was complicated by pulmonary embolism, recurrent fevers, and development of biopsy proven pyoderma gangrenosum. He also reported odynophagia, and was empirically treated for candida esophagitis with fluconazole. On hospital day 37, he developed massive hematochezia. An urgent esophagogastroduodenoscopy (EGD) did not reveal the source of bleeding, but showed a 5-cm linear esophageal scar, which appeared to be a healing tear. Sigmoidoscopy revealed a solitary rectal ulcer with a visible vessel, which was clipped for hemostasis. His bleeding resolved. The patient’s odynophagia persisted, significantly limiting his ability to tolerate oral intake. Repeat EGD revealed a large, cratered, non-bleeding esophageal ulcer which was biopsied. The same day, the patient developed hematochezia; repeat sigmoidoscopy showed a deeply cratered rectal ulcer with a visible vessel successfully treated with hemostatic clips. Esophageal biopsies returned positive for CMV; valganciclovir was initiated. His odynophagia improved after starting treatment and he had no further GI bleeding. Given the clinical response, the rectal ulcers were presumed to be due to CMV, making this a case of extensive CMV-related GI disease.

DISCUSSION:

This is a case of extensive CMV-related GI disease which eluded diagnosis during a prolonged and complicated hospitalization. CMV-related GI disease has varied presentations, most commonly affecting the esophagus, but has also been noted to manifest with gastritis, duodenitis, pancreatitis, and colitis. The most common endoscopic findings for esophageal involvement are discrete, shallow, punched-out ulcers surrounded by normal appearing mucosa. Clinical manifestations of colonic CMV include abdominal pain and diarrhea, while discrete ulceration causing bleeding is less commonly reported. This case highlights the importance of a high index of suspicion for CMV in immunocompromised patients with multiple, unexplained GI symptoms to avoid a delay in diagnosis and management.
1909 A Case of Severe Pseudomelanosis Duodeni
Authors: Zivari Kaveh , Yakubov Stanley , Iswara Kadirawelp , Rahmani Rabin
Published: October 2019

INTRODUCTION:

Melanosis in the gastrointestinal tract consists of black pigmentation of the mucosa. It is generally seen in colon, and extracolonic melanosis is rare. Duodenal Melanosis is a rare benign condition caused by idiosyncratic metabolism of benzene-ring-containing drugs resulting in the accumulation of pigment in the duodenal mucosa. It is thought to be related to folate deficiency, gastric ulcer, intestinal bleeding, hypertension, chronic heart failure, chronic renal failure, consumption of sulfur-containing antihypertensive agents, drugs containing cyclic compounds, anthracene laxatives, and ferrous sulfate.

CASE DESCRIPTION/METHODS:

80-year-old man with history of hypertension, chronic heart failure, chronic renal failure, and chronic anemia on iron supplementation, presented to the hospital with weakness, palpitations, and melena. He was found to have acute blood loss anemia. The patient had normal folate level of 16 ng/ml. Gastroduodenoscopy revealed 2 cm gastric ulcer with no active bleeding, and melanosis of duodenum. Pathology confirmed aggregates of macrophages in the lamina propria with CD 68 positive immunostaining, contain black granular material consistent with Pseudomelanosis Duodeni (PD). Iron stain and Melan-A were both negative.

DISCUSSION:

Pseudomelanosis Duodeni was first described in 1976. Although there has been increased reports of this condition, its pathogenesis and clinical significance are not yet known. It is postulated that iron deposition secondary to intramucosal hemorrhage or impaired intramucosal iron transport after oral ferrous sulfate supplementation, or impaired macrophage metabolism of drugs is to be blamed. PD does not require any specific treatment or recommended follow-up; However, in our patient a 1 year follow up showed the progression of his melanosis.
1912 Chronic Non-Healing Gastric Ulcer Caused by Eosinophilic Gastroenteritis
Authors: Mavilia Marianna , Perelman Alexander , Sao Rahul , Sachdev Rishabh , Curran Matthew , Rossi Lisa
Published: October 2019

INTRODUCTION:

Eosinophilic gastroenteritis (EG) occurs when eosinophils (eos) infiltrate the gastrointestinal (GI) tract leading to GI dysfunction. The prevalence of EG is 2.5 cases per 100,000 people in the US. The diagnosis is confirmed by histology with >20 eos per HPF. Common manifestations include abdominal pain, nausea, vomiting, and malabsorption. Ulcers are rarely seen in EG.

CASE DESCRIPTION/METHODS:

We describe a case of a 23 year old female with history of asthma presented with one month of severe epigastric pain, nausea and vomiting. Her pain was constant and exacerbated by eating. She took NSAIDs for 14 days without relief but denied melena, hematochezia, and hematemesis. She had no history of food intolerances, travel, smoking or alcohol use. Vitals and exam were unremarkable except for epigastric tenderness without rebound or guarding. Initial work up revealed WBC 8.0 K/UL with 16.7% eos, Hb 11.9 g/dL, MCV 80.6 fL, and ferritin 3 ng/mL. EGD revealed LA Grade A esophagitis, duodenitis, and a non-bleeding cratered antral ulcer, measuring 20 mm (Figure 1). Pathology revealed chronic gastritis without H. pylori. Pantoprazole 40 mg BID and sucralfate 1 g QID were initiated, but she continued to have symptoms and new onset hematemesis. Repeat EGD showed persistent 20 mm ulcer after 2 months of medical therapy. Biopsies showed marked eos in the esophagus, stomach, and duodenum, with >50 eos/HPF at the ulcer (Figure 2). Biopsies from a colonoscopy done at the time same revealed increased eos at the ileocecal valve. A workup for eosinophilia was negative for autoimmune or parasitic etiologies, gastrin level was normal, but serum IgE level was 1862 IU/mL. She was treated with prednisone and repeat EGD 2 months later revealed resolution of mucosal eosinophilia and decrease in ulcer size to 10 mm.

DISCUSSION:

Our patient was found to have diffuse eosinophilic infiltration throughout the GI tract as well as significant peripheral eosinophilia. While the ulcer may have been initially caused by NSAID use, it was refractory to treatment due to eosinophilic inflammation. Only after initiation of corticosteroids, did it begin to heal. The primary management for EG is elimination diet and avoidance of triggers. Systemic corticosteroids are effective in controlling symptoms if dietary modification is unsuccessful. There is limited evidence for the use of other medications including antihistamine, leukotriene, or IgE antagonists. In patients with ulcers refractory to conventional therapies, EG should be considered.
1917 Fatal Gastrointestinal Hemorrhage Secondary to Rare Aortoesophageal Fistula in a Patient With Esophageal Adenocarcinoma
Authors: Ratra Atul , Flannery Christopher
Published: October 2019

INTRODUCTION:

Aortoesophageal fistula (AEF) is a rare cause of upper gastrointestinal bleeding which is associated with extremely high mortality despite timely intervention. We present a fatal case of gastrointestinal hemorrhage from AEF in a patient with esophageal adenocarcinoma who had recently undergone esophageal stent placement and chemoradiation therapy.

CASE DESCRIPTION/METHODS:

A 77 year-old Caucasian man with a past medical history of cirrhosis and TNM stage IIIA hepatocellular carcinoma, status post Yttrium-90 radioembolization in April 2017, presented with progressive dysphagia in January 2018. Patient underwent esophagogastroduodenoscopy (EGD) revealing a partially obstructing, non-bleeding mass at the gastroesophageal (GE) junction (Figure 1) and placement of an esophageal stent. Dysphagia improved post stent placement. Biopsy was consistent with primary adenocarcinoma of the esophagus. He received concurrent chemoradiation therapy with paclitaxel and carboplatin. In April 2018, patient presented to the emergency department with presyncope, hematemesis and epigastric pain. He was hyptotensive with a blood pressure of 88/56 mm Hg and anemic with a hemoglobin of 7.6 g/dL. Repeat EGD was performed with unintentional migration of stent into stomach, revealing friable and ulcerated mucosa in the lower esophagus (Figure 2). Retrieval of the dislodged stent caused the ulcerated mucosa to bleed. Hemostatic clip could not adhere to inflamed mucosa and a stent was placed to minimize bleeding. Interventional radiology was consulted. Fluoroscopy revealed presence of a small aortoesophageal fistula at the site of active bleeding (Figure 3). Hemostasis was achieved with coil embolization. Unfortunately, a few hours later, patient had a recurrence of massive re-bleed and expired.

DISCUSSION:

Esophageal malignancy is one of the primary causes of AEF. Thoracic radiation as a standalone cause has also been documented in non-esophageal malignancies. Several reports also document that aortic grafts and esophageal stents increase the risk of AEF development in patients who undergo radiation. This case adds to the growing literature that presence of esophageal stent and subsequent radiation compounds risk of AEF development in patients with esophageal tumors. Further studies are warranted for risk stratification. Such patients presenting with hematemesis and syncope need immediate AEF evaluation and emergent intervention.
1920 Superior Mesenteric Arteriovenous Fistula Mimicking Hepatic Cirrhosis With Spontaneous Bacterial Peritonitis
Authors: Haddad Ibrahim , El Kurdi Bara , Babar Sumbal , Alomari Mohammad , El Iskandarani Mahmoud , Young Mark
Published: October 2019

INTRODUCTION:

Arteriovenous fistula of the superior mesenteric vasculature is a rare entity that was reported for this first time by Movitz and Finne in 1960. The majority of these cases are iatrogenic after surgical bowel resection. We present a 52-year-old male patient who had a spontaneous AFV of the superior mesenteric vasculature that presented as a chronic portal vein thrombosis.

CASE DESCRIPTION/METHODS:

A 52-year-old male patient with a past medical history significant for active hepatitis C infection. The patient presented to our institution complaining of progressive abdominal distention and chronic abdominal pain for 3 months. He had been diagnosed with cirrhosis two months prior to admission and was started on furosemide and spironolactone for ascites and underwent multiple therapeutic paracentesis. At presentation, the patient was found to have a normal platelet count and INR which were not consistent with cirrhosis calling the diagnosis into question. Further workup with ultrasound examination of the liver revealed portal vein thrombosis with extension to the proximal part of the splenic vein. This was followed by CT of the abdomen and pelvis with IV contrast which showed smooth liver surface, enlarged portal, superior and inferior mesenteric veins with clot seen in the left portal vein extending into the main portal vein (Figure 1).it also showed a fistula of the mid superior mesenteric artery with the superior mesenteric vein (Figure 2) which explained the prominence and the enlargement of the portal venous system. Upon diagnosis, the patient was transferred to a tertiary center for endovascular closure of the fistula.

DISCUSSION:

Arteriovenous fistula of the superior mesenteric vasculature is a rare entity. Most cases are iatrogenic in origin occurring after bowel resection. The most common presentation is gastrointestinal bleeding due to portal hypertension and resulting variceal changes. Treatment with endovascular with coil embolization is often preferred over surgical repair. In summary, we discuss an unusual presentation of idiopathic arteriovenous fistula of the superior mesenteric vasculature with portal vein thrombosis, abdominal pain and ascites mimicking hepatic cirrhosis with spontaneous bacterial peritonitis.
1922 The Use of a New Hemostatic Powder in Refractory Pseudocyst Wall Bleeding
Authors: Cortez Nathaly , Berzosa Manuel , Mahfouz Mahmoud
Published: October 2019

INTRODUCTION:

Despite multiple endoscopic hemostatic devices available, GI bleeding can still be difficult to treat. A new hemostatic device was recently approved by the FDA as an non-surgical treatment option of upper and lower GI bleeding. The hemostatic powder forms a mechanical and adhesive barrier by absorbing water and promotes thrombus formation by concentrating and activating platelets and coagulation factors with high primary hemostasis rates. It has been reported as a successful hemostatic technique for common causes of GI bleed, but not for pseudocyst bleeding.

CASE DESCRIPTION/METHODS:

84-year-old male admitted to our institution ten days after a surgical cystgastrostomy with one day history of abdominal pain associated with nausea and vomiting. Hemoglobin decreased from 11 to 8 mg/dl after the surgery and occult blood in stool was positive. Initial CT angiogram revealed no active bleeding but a large complex fluid collection 13.1 × 11.6 × 12.9 cm from the pancreatic tail and involving the stomach. Gastroenterology was consulted to assess the cystgastrostomy patency and evaluate for GI bleeding as the cause of anemia. Endoscopy was performed and revealed that the pseudocyst gastrostomy in the proximal gastric body had stenosed to 0.5 cm from 6 cm and the pseudocyst cavity was filled with large clots but no evidence of active bleeding. Due to the stenosis, double pig tail plastic stents were placed. Patient developed melena and hemoglobin decreased again from 9 to 7 mg/dl. Repeated endoscopy revealed active bleeding within the pseudocyst wall near the anastomosis. The tissue was very friable. Epinephrine injection, coaptive coagulation with bipolar cap and hemostatic clip placement were all unsuccessful to stop the bleeding. Finally, hemostasis was achieved using a new hemostatic powder through endoscopic delivery catheter. The powder was sprayed successfully to the anastomosis and proximal cavity of the pseudocyst without complication or further bleeding. Follow up a month later did not showed any evidence of active bleeding. Repeat CT abdomen revealed decreased in size of the pancreatic pseudocyst with plastic stents still in place.

DISCUSSION:

To our knowledge, this is the first report of the use of hemostatic powder delivered via endoscopy outside the GI tract to achieve hemostasis from pancreatic pseudocyst wall bleeding. This device can be considered as a rescue modality for those cases where the standard treatment has failed. Further studies are needed to assess its safety in this setting.
1923 Bleeding Varices in a Non-Cirrhotic
Authors: Zarrin Arash , Choksi Vivek , Dave Kairavee , Kaplan Steven R.
Published: October 2019

INTRODUCTION:

Extra-hepatic portal vein obstruction (EHPVO) presents with manifestations of portal hypertension, including variceal bleed. Cirrhosis is the leading cause of portal hypertension (90%), and EHPVO can mask as cirrhosis, especially in a patient with risk factors such as alcohol abuse and incarceration.

CASE DESCRIPTION/METHODS:

37 y/o male with h/o DVT and alcohol abuse presented to our ER for abdominal pain and hematemesis. He was a chronic alcoholic but quit drinking 6 months prior. On admission, he was afebrile, mildly tachycardic but not hypotensive. Examination showed non-specific diffuse abdominal tenderness and jaundice. Labs showed Hb 5.8 g/dL, platelets 66/mcL, INR 2.13. Liver enzymes were normal, except T Bili of 5.1 mg/dL, and albumin 3.8 g/dL. Entire cirrhotic work-up was negative. CT abdomen showed nodular liver, splenomegaly, mild ascites, and gastroesophageal varices. Doppler US showed hepatopedal flow within the main portal vein. Triple-phase CT showed portal vein thrombosis (PVT) with cavernous transformation. EGD revealed large esophageal varices with red wale sign, which were banded. No gastric or duodenal varices. Colonoscopy revealed diffuse melena up to the terminal ileum, but no varices. Liver biopsy was negative for cirrhosis. The patient was found to have a heterozygous Factor V Leiden (FVL) gene mutation. Anticoagulation was not initiated due to recent bleed. He was re-admitted, unconscious after massive GI bleeding at home. Repeat banding was performed. SMA angiography and portography showed complete occlusion of the main SMA, splenic vein, and PV.

DISCUSSION:

For patients with portal hypertension secondary to portal vein thrombosis, the Bevano VI guidelines on portal hypertension recommend primary prophylaxis with non-selective beta-blockers and endoscopic variceal ligation. Failure of primary prophylaxis requires secondary prophylaxis with TIPS. However, surgical devascularization, such as the modified Sugiura procedure, is a great option with lower rates of re-bleeding and higher rates of survival compared to surgical shunts. Decompressive portal therapy is an important treatment aspect for our patient due to his need for lifelong anticoagulation in the setting of inherited thrombophilia.