bluuebunny/crossref_metadata_2025 huggingface dataset:
1583 Atypical Presentation of Calcified Fecalith
Authors: Hoskere Dhanush , Ramasamy Kovil , Dedousis John
Published: October 2019

INTRODUCTION:

Fecaliths are generally classified by the degree of calcification and presence of solid material in the stool. Fecaliths can cause complications such as hemorrhage, perforation, intussusception, and bowel obstruction. However, no documented cases of solid fecaliths associated with diarrhea exist.

CASE DESCRIPTION/METHODS:

63-year-old male with past medical history of hypertension, diabetes mellitus type II, gastroparesis, chronic kidney disease, and hyperlipidemia presented to the hospital with subjective fever, dull epigastric pain, belching, episodes of non-bloody and non-bilious vomiting, and non-bloody diarrhea for 2 weeks. He denied any recent travel history, new food consumption, or alcohol use. On exam, patient had diffuse tenderness of the abdomen but did not have any guarding, rebound, or distension. Lipase and liver function tests were within normal limits. Abdominal CT revealed no evidence of bowel incarceration or obstruction. Colonoscopy was performed for further evaluation which showed a large polyp covered with stool prolapsing into the cecum. Stool was removed with irrigation, which exposed a solid egg-shell like calcification. The calcification was cold-snared to expose the normal colonic mucosa underneath and was subsequently removed. This egg-shell like calcification likely represented fecalith which had calcified around a mucosal fold in the cecum. After the endoscopy, patient's symptoms improved, and he was discharged from the hospital.

DISCUSSION:

Fecaliths are common in clinical practice. The hardness of a fecalith is usually classified by the degree of calcification and presence of solid materials. Usually, fecaliths are managed conservatively with digital disimpaction, low residue diet, and administration of enemas and laxatives. Fecaliths can be broken down with colonoscopic methods such as a water jet or mechanical lithotripsy prior to removal. In this case, water jet only cleaned the liquid stool off of the calcified fecalith. This is one of the first cases reported using cold snare to break and dislodge calcified fecalith. It is also one of the first cases where fecalith was shaped around mucosa forming an egg-shell like calcification. In addition, fecaliths have been known to cause constipation through bowel obstruction; however, this case shows that there may also be an association with diarrhea as fecaliths may cause irritation of the mucosa leading to increased colonic transit. Further research will have to be done to assess for the validity of this theory.
1585 Chronic Constipation With Massive Acquired Megacolon in a 19-Year-Old Man
Authors: Abadir Alexander P. , Rombaoa Christopher , Park Sunhee
Published: October 2019

INTRODUCTION:

Acquired megacolon is a rarely diagnosed condition that may be a source of significant distress in the acutely hospitalized patient. It presents in either gender at any age. Symptoms, when present, are typically abdominal pain with distention, gas distress, and constipation. Reported cases are typically less than 10 cm on diagnostic imaging. Pathology findings vary greatly and include muscularis hypertrophy or degeneration of the smooth muscle, damaged or reduced ganglia, melanosis coli, or chronic inflammation.

CASE DESCRIPTION/METHODS:

A 19-year-old Hispanic US-born man presented to the ER with severe, progressively worsening abdominal pain and distention for one month and inability to urinate. His last bowel movement (BM) was 3 weeks ago, small and liquid. He stated it was common for him to not have a BM for up to a month. This has occurred since he was six years old, when he began avoiding defecation due to pain he experienced when moving his bowels. Prior treatment with laxatives and enemas had been ineffective in inducing regular bowel movements. He has had difficulty gaining weight. Initial labs were significant for severe iron deficiency anemia with MCV 65, Ferritin 2, TIBC 301, Iron 11, and percent saturation of 4%. CT imaging showed a markedly distended colon and rectum measuring up to 17 cm in the sigmoid colon. There was severe stool burden in the rectum and the distended colon. The colon was causing mass effect and crowding of other organs, including a distended bladder. Initial inpatient management with enemas, disimpaction, and frequent laxatives failed to cause significant reduction in the colonic distention. Under anesthesia, rectal examination found normal rectal tone and required disimpaction and lavage. Full-thickness rectal biopsies were obtained which revealed mild erosion, indeterminate colitis, and hyperplasia of the muscularis mucosa. Calretinin was positive for nerve fibers, however no ganglia were seen. A diverting Brooke ileostomy was created without immediate complications. On 1 month follow up the patient reported significant weight gain, no further abdominal pain, and adequate ostomy output.

DISCUSSION:

This case demonstrates a severe example of acquired megacolon in a young man due to chronic constipation. Surgery is typically required for very distended cases, but surgical options vary considerably and have been poorly studied. In this patient, due to the extreme nature of his megacolon, surgical diversion was performed to allow eventual resection.
1586 A Classic Presentation of Cowden Syndrome
Authors: Hanna David , Pedroso Claire , Pluskota Christopher , McKee Jessica
Published: October 2019

INTRODUCTION:

Cowden syndrome (CS) is a rare autosomal dominant hereditary multiple hamartoma syndrome characterized by benign and malignant tumors. CS is one of the four subtypes of phosphatase and tensin homolog (PTEN) hamartoma tumor syndrome (PHTS). The National Comprehensive Cancer Network utilizes consensus diagnostic criteria, where one must have ≥3 major criteria or 2 major plus 3 minor criteria. Major criteria include breast cancer, endometrial cancer, follicular thyroid cancer, GI hamartomas including ganglioneuromas, Lhermitte-Duclos disease, macrocephaly, macular pigmentation of the glans penis, and multiple mucocutaneous lesions. Minor criteria include autism, colon cancer, esophageal glycogenic acanthoses, lipomas, intellectual disability, renal cell carcinoma, testicular lipomatosis, papillary thyroid cancer, thyroid structural lesions, and vascular anomalies.

CASE DESCRIPTION/METHODS:

A 59-year-old male with macrocephaly presented for a screening colonoscopy. He was found to have 30 polyps ranging in size from 3-15 mm. Pathology revealed serrated adenomas, hyperplastic polyps and moderately differentiated invasive adenocarcinoma arising in a tubular adenoma. Subsequent PET/CT revealed marked enlargement and heterogeneity in the thyroid gland. He underwent a total colectomy with ileorectal anastomosis and ultimately a total thyroidectomy. The resected colon showed adenomatous polyps, multiple lipomas, and a ganglioneuroma. Pathology from the thyroid revealed a 2.5 cm nodule with follicular carcinoma and a 6 mm nodule with papillary micro-carcinoma, follicular variant. Our patient met 3 major criteria (macrocephaly, GI hamartomas including ganglioneuromas, follicular thyroid carcinoma) and 1 minor criterion (colon cancer). The clinical presentation prompted genetic testing.

DISCUSSION:

Early onset colorectal cancer has been reported in patients with CS due to malignant transformation of adenomatous and hamartomatous polyps. Management includes annual thyroid ultrasound, renal ultrasound at age 40 every 1-2 years, dermatologic assessment, and discussion regarding risk to relatives. Colonoscopy is recommended at age 35 and then at least every 5 years; more frequent in patients who are symptomatic, have family history of colon cancer, personal history of polyps or colon cancer. Recognition of pertinent medical history, family history and physical manifestations are critical for accurate diagnosis, risk assessment, genetic testing and medical management.
1588 A Case of Suspected Adalimumab-Induced Apoptotic Colonopathy
Authors: Rojas Patricia Guzman , Gonzaga Ernesto Robalino , Vergeli-Rojas Jeannette , Parikh Jignesh
Published: October 2019

INTRODUCTION:

Adalimumab is an anti-TNFa monoclonal antibody used for the treatment of multiple autoimmune diseases including IBD. Although it has shown a great benefit minimizing the burden of symptoms, it carries multiple side effects such as headache, nausea, vomiting, abdominal pain, rash, gastrointestinal hemorrhage and even diverticulitis. We present a rare side effect associated to this immune modulator.

CASE DESCRIPTION/METHODS:

A 40-year-old female with a PMH of Crohn's disease presented for a routine visit to the GI clinic. The patient had been undergoing treatment with adalimumab for past eight months, with non-adherence to treatment. She reported one loose bowel movement per day but denied any tenesmus, urgency, abdominal pain, bleeding or extra-intestinal manifestations. A follow-up colonoscopy showed a stricture in the ileo-cecal valve and a 0.5 centimeter aphthous ulcer in the ascending colon (Figure 1). Biopsies of the ileocecal valve and rectal area showed active chronic inflammation, while the ascending, transverse and descending colon showed inactive chronic colitis. Furthermore, the biopsy of the ileocecal and ascending colon revealed drug-induced apoptosis (Figure 2). She was switched to infliximab due to mentioned histopathological findings of apoptotic colopathy. She was also referred to colorectal surgery for evaluation of stricture and fistula formation.

DISCUSSION:

Apoptotic enteropathy describes a type of injury to the gastrointestinal mucosa, characterized by epithelial cell apoptosis. This characteristic histological feature can be caused by different etiologies like GI Graft versus host disease (GVHD), infections (CMV, adenovirus and cryptosporidiosis in AIDS patients) and drug induced injury. Medications linked to these histopathological changes are mainly immuno modulators: MMF, CTLA-4 inhibitors (ipilimumab), anti-PD-1 (nivolumab, pembrolizumab and avelumab), idelalisib, tumor necrosis alpha inhibitors (etanercept, infliximab) and anti-metabolites (methotrexate, capecitabine). Furthermore, there is only one case report elucidating the relation between adalimumab with apoptotic colopathy, which showed affectation of the right colon, being the same location of our patient's injury. We present this case to make physicians aware of this entity, since is an important feature to monitor in patients needing biologics. Furthermore, a repeated endoscopic evaluation should be done in order to assess resolution of pathology.
1592 Treatment of Severe Clostridioides difficile Infection With Intravenous Immunoglobulin
Authors: Park Connie , Chun Alexander
Published: October 2019

INTRODUCTION:

Clostridioides difficile infection or C. diff (CDI) is the most common cause of health-care associated diarrhea. Despite interventions directed at decreasing transmission, the incidence of CDI remains high. Its morbidity, mortality, and overall burden on health care necessitate alternative therapies. As such, we report a case of severe CDI successfully treated with intravenous immunoglobulin (IVIG), a pooled blood product primarily used to treat antibody deficiencies or autoimmune diseases.

CASE DESCRIPTION/METHODS:

An 86-year-old female with diabetes and atrial fibrillation presented to our hospital with bloody stools. Her hospital course was long and complicated, requiring trials of multiple antibiotics: ceftriaxone, metronidazole, piperacillin-tazobactam, and ertapenem. One month into her hospitalization, she became septic with diarrhea and abdominal pain: temperature 101.3 F (38.5 C), white blood cell count 17K, creatinine 0.9 (baseline 0.7), BUN 25, albumin 1.7. Stool was positive for C. diff toxin. Despite 5 days of oral vancomycin, symptoms did not regress. Abdominal computed tomography (CT) imaging revealed pancolitis. Vancomycin was discontinued. Fidaxomicin was started. After 6 days of fidaxomicin, symptoms were unchanged. 25 grams of IVIG was given (347 mg/kg) as an adjunct to fidaxomicin. The next day, her stool count decreased from an average of 9 per day to 5. After once daily 25-gram IVIG treatment for 3 consecutive days, the patient had complete resolution of her abdominal pain and diarrhea.

DISCUSSION:

Inflammation and disease in CDI are mediated by toxins. Some studies documented poor immune response to C. diff toxins in patients with severe or refractory disease. IVIG addresses this issue, as it contains C. diff antitoxin antibodies that act as passive immunity to neutralize the toxins and help with disease resolution. This report is one of several documenting success with IVIG in severe CDI. However, IVIG use in C. diff is limited, partly due to its high cost but perhaps in larger part due to small-sample retrospective analyses deeming its benefits statistically insignificant. Larger prospective controlled studies investigating different doses, duration, and timing of IVIG therapy are necessary to fully clarify IVIG's role in CDI. Moreover, IVIG may prove to be cost-effective by preventing severe or recurrent disease. In cases of CDI refractory to standard antibiotic treatment, passive immunity with IVIG may be a reasonable adjunct to standard therapy.
1594 A Rare Case of Nivolumab-Induced Colitis
Authors: Kang Gurjeet , Venu Lakshminarasimhan , Quinn Michael , Orpiano Christopher L. , Staffetti Joseph , Ghanekar Dilip
Published: October 2019

INTRODUCTION:

Over the past decade immune-checkpoint inhibitors have been playing an increasing role in cancer treatment. One of the targets of these therapies is the Programmed Death (PD-1) protein; a protein that prevents T cells from recognizing and attacking inflamed tissues and cancer cells. Our reports describes a case in which a patient treated with nivolumab, a PD-1 inhibitor, presented with endoscopic findings characteristic of ulcerative colitis (UC).

CASE DESCRIPTION/METHODS:

Our case involves a 69-year-old male with past medical history of metastatic melanoma who presented with complaints of diarrhea rectal bleeding. Patient was on nivolumab 3 mg/kg every 2 weeks which was started 5 months ago. He reported lower abdominal cramping, bright rectal bleeding and diarrhea ongoing for 4 days. Physical examination was significant for moderate tenderness to palpation in lower abdomen. Initial abnormal laboratory results including hemoglobin of 11.2 g/dL otherwise unremarkable comprehensive metabolic panel. On computed tomography (CT) of abdomen and pelvis he was noted to have marked colitis involving the ascending, transverse and descending colon. All the following stool testing was negative for clostridium difficile, stool cultures camplyobacter, salmonella, shigella, ova and parasite. Patient was noted to have pancolitis on colonoscopy and pathology showed acute and chronic inflammation with superficial ulceration. Nivolumab was stopped and he was started on IV methylprednisolone 80 mg TID. Patient had little improvement over the next three days and hemoglobin decreased to 8.0 g/dL. Therefore he was given a dose of infliximab 5 mg/kg. His symptoms improved and he was in complete clinical remission soon after discharge. Patient was continued on oral prednisone 100 mg daily and instructed to taper slowly over the coming months.

DISCUSSION:

The PD-1 pathway will continue to be manipulated in future cancer treatments. Inhibition of PD-1 pathway in mice has resulted in various autoimmune diseases. In a safety profile study with 576 patients on nivolumab dosing of 3 mg/kg the most common adverse effect was noted to be a fatigue in 25% of patients. The incidence of grade 3 or 4 colitis was noted to be present in 0.7% of patients or 4 in total. Although the incidence of severe colitis may be low, infectious etiology must be ruled out prior to initiating immunosuppressive therapy. Patients with corticosteroid resistant colitis should have prompt initiation of infliximab therapy.
1595 Kayexalate-Induced Colitis: A Rare Cause of Acute Abdomen!
Authors: Shahid Tamoor , Abbas Syed Hassan , Hertan Hilary
Published: October 2019

INTRODUCTION:

Sodium polystyrene sulfonate (kayexalate) combined with sorbitol is a resin that exchanges sodium for potassium primarily in the colonic mucosa to treat hyperkalemia. It has been associated with ischemic colitis.

CASE DESCRIPTION/METHODS:

We present a case of a 78-year-old female with a medical history of renal disease requiring hemodialysis and heart failure, admitted with an ischemic right lower limb. She was started on an intravenous heparin drip as per vascular surgery recommendations. Overnight her potassium level was noted to be 5.9 mg/dL for which she was medically treated with dextrose solution, regular insulin along with three doses of oral 15 mg kayexalate. The next morning she complained of sudden onset abdominal pain. CT imaging showed pneumatosis along with asymmetric mural thickening of the cecum, concerning for cecal ischemia. The patient underwent emergent exploratory laparotomy which revealed ischemia of the cecum and ascending colon. A right hemicolectomy was done and the patient eventually made a complete recovery. Later, pathology revealed findings of ischemic colitis with detached purple refractile material in the colon consistent with kayexalate crystals.

DISCUSSION:

Colonic necrosis after the use of kayexalate is a rare and an under-recognized complication. Incidence of colonic necrosis is reported to be around 0.27% which increases to 1.8% in uremic patients. It often presents with nonspecific symptoms such as constipation, fecal impaction, obstruction, gastrointestinal bleeding, bezoars and rarely, acute abdomen as in our patient. Previously addition of sorbitol to kayexalate was thought to be the main culprit leading to colonic necrosis but cases have been reported in patients taking sorbitol free kayexalate. The exact mechanism of action remains unclear with a few possibilities such as a direct toxic effect, elevated prostaglandin levels and hyperreninemia in patients with renal insufficiency, leading to nonocclusive mesenteric ischemia, have been suggested. Endoscopically it presents as ulcerated lesions with a definitive diagnosis made after seeing kayexalate crystals on the histological exam. Patients without signs of peritonitis are usually managed medically with intravenous fluid resuscitation, use of supplemental oxygen, bowel rest and broad-spectrum antibiotics. Clinicians must be cautious in prescribing kayexalate to patients and keep kayexalate induced colitis in one of the differentials in patients presenting with signs and symptoms of colitis.
1599 Cronkhite Canada Syndrome: A Rare Cause of Dysgeusia and Protein Losing Enteropathy
Authors: Yalamanchili Silpa , Leroy Kyley , Heightchew Kimberly , Newman Gary
Published: October 2019

INTRODUCTION:

Cronkhite Canada syndrome (CCS) is a rare, acquired polyposis syndrome associated with serious complications and a high mortality rate. Awareness regarding presenting symptoms, endoscopic findings, and pathologic features leads to early diagnosis and treatment, and improved survival.

CASE DESCRIPTION/METHODS:

68 yo female with a history of alopecia totalis presented with 6 months of non-bloody diarrhea, 30 lb weight loss, and dysgeusia. Physical examination revealed complete alopecia, pitting lower extremity edema, and thinning and splitting of the fingernails. Diagnostic workup yielded marked hypoalbuminemia (albumin 1.1 g/dL), positive SS-a antinuclear antibody (titer 1:160), and elevated serum total IgG level (1,750 mg/dL). CT was notable for a thickened stomach with edematous rugae, and focal segmental colitis involving the cecum and ascending colon. Push enteroscopy showed diffusely edematous mucosa in the gastric antrum and duodenum with denuded appearing vili throughout the small bowel. Colonoscopy revealed diffuse polyposis throughout the entire colon and terminal ileum, with edematous underlying colonic mucosa. Biopsies of affected areas showed diffuse cystic dilation, edema of the lamina propria, and presence of plasma cells, compatible with CCS. The patient was initiated on total parenteral nutrition, prednisone 40 mg daily, and Imuran 75 mg daily. In follow up, she reported complete resolution of dysgeusia, reduction in diarrheal symptoms, weight gain, and improved energy level. Serum albumin level improved to 2.92 g/dL.

DISCUSSION:

Cronkhite Canada syndrome is a sporadic, acquired polyposis syndrome characterized by diffuse gastrointestinal polyposis and ectodermal features. It carries a 5-year mortality rate of 55% despite therapy, due to a high rate of serious complications, including malabsorption, infection, heart failure, and GI bleeding. Patients are at high risk of gastric and colorectal malignancies (10.4% and 25%, respectively), necessitating annual screening examinations. A combination of nutritional support and immunosuppression with prednisone (tapered dosing) and imuran (2 mg/kg) helps in achieving clinical remission and avoiding relapse. Expedited diagnosis and application of therapy has led to improvement in patient survival and achievement of clinical response. Therefore, improved clinician awareness of disease manifestations, pathologic findings, and treatment regimen is necessary to modify the disease course for this syndrome.
1601 Cecal Granular Cell Tumour: An Uncommon Site of an Uncommon Tumour
Authors: Bandaru Praneeth , Ofosu Andrew , John Febin , Reddy Madhavi
Published: October 2019

INTRODUCTION:

Granular Cell Tumors (GCTs) are tumors arising from Schwann cells of the nerve sheath. They occur at an incidence of about 0.03% and have a predilection for the skin, oral cavity, and breasts. Only 6-8% of all GCTs occur in the GI tract with the esophagus (65%) being the most common site, followed by the colorectum (25%). Less than 20 cases of cecal GCTs have been reported so far. Owing to its rarity, we report a case of an asymptomatic cecal GCT found incidentally during screening colonoscopy.

CASE DESCRIPTION/METHODS:

A 58-year-old male with no known past medical history presented to the Gastrointestinal (GI) clinic for screening colonoscopy. History was negative for alarm symptoms, including no family history of GI cancers. He had no prior Upper endoscopy or colonoscopy. Physical examination and labs were unremarkable. Colonoscopy revealed an 8mm yellowish, sessile, subepithelial nodule with normal overlying mucosa in the cecum (Figure 1). Biopsy showed clusters of cells with granular cytoplasm that was Periodic acid–Schiff (PAS) positive suggestive of GCT (Figure 2). Immunohistochemical staining was positive for S100, CD 68, calretinin thus confirming the diagnosis of GCT (Figure 3). The patient has since been scheduled for Endoscopic ultrasound (EUS) for further evaluation.

DISCUSSION:

Colorectal GCTs account for up to 25% of all GI GCTs, with most affecting the right sided colon (cecum and ascending colon). Mostly benign and solitary, but about 2% are known to have malignant potential with poor prognosis. More common in females and in African Americans between ages 40-60 years. Generally asymptomatic and found incidentally during a screening colonoscopy, however in a few cases, patients have presented with hematochezia, abdominal pain, and change in bowel habits. EUS is invaluable in differentiating GCTs from other subepithelial tumors, in determining the size, and depth of invasion. Definitive diagnosis is by histopathology and immunohistochemical staining. There is no general consensus on the management of colorectal GCTs. Conservative management is recommended for tumors < 1cm, asymptomatic, with no deep tissue invasion or malignancy. However, resection is warranted for symptomatic tumors, tumors >1 cm in size, deep tissue invasion or malignancy. Endoscopic removal is preferred over surgery for tumors without deep tissue infiltration or malignancy. Endoscopic and histologic surveillance every 1-2 years is recommended.
1605 Typhoid Fever: GI Bleed From an Ancient Disease
Authors: Curtis Stephen , Young Patrick
Published: October 2019

INTRODUCTION:

Gastroenterologists periodically encounter ileocecal wall thickening in a patient with abdominal pain, fevers and gastrointestinal bleeding in an inpatient setting. A unifying diagnosis for a patient with these radiologic findings and symptoms could include inflammatory, infectious, or malignant etiologies. We present a case of a patient presenting in this way, who has found to have salmonella bacteremia as well as colonic and ileocecal valve ulcers on endoscopy.

CASE DESCRIPTION/METHODS:

A 51-year-old man with a past medical history notable for bladder cancer status-post BCG treatment presented with a three day history of crampy abdominal pain and fevers. He denied any diarrhea or vomiting. Exam was notable for a temperature of 102.7 and mild tenderness to palpation in lower abdomen. Admission labs were notable for normal leukocyte count and mildly elevated hepatocellular enzymes (AST 63, ALT 97). Due to his high fever, blood cultures were drawn. CT scan was notable for marked wall thickening at the ileocecal junction with enlarged regional lymph nodes. On the day after admission, he had a melenic stool and was scheduled for EGD and colonoscopy. EGD was unremarkable, but his colonoscopy was notable for two 3-5mm ulcers in the ascending colon as well as an ulcerated and inflamed ileocecal valve, which was unable to be intubated. Concern was for infectious or malignant etiology of these findings. Multiple blood cultures returned positive for Salmonella enterica with Vi antigen, shortly thereafter. He was treated with ceftriaxone and metronidazole for his bacteremia, and later transitioned to ciprofloxacin, with improvement in symptoms. Biopsies of the ulcers showed chronic active colitis. They were also notable for B and T cell clones which were concerning for lymphoma. To follow up on these concerns, he had repeat colonoscopy three weeks later which noted resolution of his ascending colon ulcerations and ileocecal valve inflammation. His terminal ileum was intubated and appeared normal. Biopsies of the ileocecal valve revealed benign colonic mucosa. After completion of antibiotic therapy, the patient denied any further symptoms.

DISCUSSION:

This case illustrates the importance of maintaining a broad differential in a patient with colonic inflammation on imaging and ulcerations noted on endoscopy. Also, this case highlights key features of typhoid colitis which can include GI hemorrhage with a predilection for right-sided colonic involvement.
1607 The Hidden Parasite
Authors: Rodriguez-Berrios Frances , Figueroa Ivonne , Martin-Ortiz Jose , Rosado Katia
Published: October 2019

INTRODUCTION:

Parasite identification during routine colon cancer screening is unexpected and rather unusual. Schistosoma is a tropical parasite associated to freshwater snails; among which S. mansoni and S. japonicum species have been associated with intestinal tract infection. Although most patients are asymptomatic, identification is crucial to avoid possible complications like chronic intestinal schistosomiasis or hepatosplenic schistosomiasis.

CASE DESCRIPTION/METHODS:

A 57-year-old Puerto Rican Vietnam veteran with history of schizophrenia and chronic liver disease secondary to Hepatitis C underwent colonoscopy for average-risk colorectal cancer screening. During colonoscopy, a one-centimeter polyp at 15cm was completely removed by hot snare and six additional small sessile polyps in the rectum by cold forceps. Pathology was remarkable for a tubular adenoma, while one of the rectal polyps identified a non-necrotizing granuloma suggestive of schistosoma parasite. Patient had shown no GI symptoms or complaints and was treated with Praziquantel.

DISCUSSION:

Puerto Rico is an endemic area for schistosoma. Schistosomiasis is a chronic parasitic disease with significant cause of morbidity and mortality. Intestinal polyps and dysplasia can arise due to granulomatous inflammation surrounding eggs deposited in the bowel wall. Gastrointestinal manifestations may result in chronic abdominal pain, poor appetite, and diarrhea for which early identification is necessary for treatment even in the asymptomatic setting.
1610 Don't Let Your Past Determine Your Destiny
Authors: Pisipati Sailaja , Elliott Chistie , Crapko Matthew , Hsieh Ting Hui
Published: October 2019

INTRODUCTION:

Synovial sarcoma (SS) is a rare mesenchymal soft tissue sarcoma usually involving extremities close to large joints. SS of the GIT is uncommon; SS of the colon is extremely rare. Recognition and management of SS of the GIT can be very challenging. Here we report a rare case of asymptomatic SS of the rectosigmoid diagnosed as a surprising finding of surveillance colonoscopy.

CASE DESCRIPTION/METHODS:

A 59-year-old asymptomatic lady with past medical history of diabetes mellitus, morbid obesity, colon polyps was referred for surveillance colonoscopy. Prior colonoscopy six years ago revealed two sigmoid colonic tubular adenomas. Examination was unremarkable except for a BMI of 44. Thorough examination of the musculoskeletal system did not reveal any abnormalities. Colonoscopy revealed a large, 5 cm pedunculated and superficially ulcerated round mass in the rectosigmoid colon, filling most of the lumen with the distal end of the lesion being ∼15 cm above the anal verge. Biopsy demonstrated spindle cells with marked nuclear pleomorphism, high mitotic index rate, positive SS18 (SYT) gene rearrangement testing on FISH. Immunohistochemistry (IHC) was positive for TLE1, OSCAR, MCK, AE1/AE3, CK7 with Ki-67 of 70% and negative for desmin, CD117, DOG1, p63, CK5, CK6, S100, SMA. Findings were consistent with SS. Staging CT and PET-CT did not demonstrate distant spread. Robotic laparoscopic anterior resection with wide surgical resection margins and lymphadenectomy revealed T1N1 LN 2/20 stage 3 monophasic synovial sarcoma, with negative margins, 20% tumor necrosis and high mitotic rate. The patient was started on adjuvant chemotherapy with 5 cycles of Adriamycin 75 mg/m2 and Olaratumab on day 1 and day 8 of a 21-day cycle. A repeat PET-CT and a flexible sigmoidoscopy, six months later, did not reveal any tumor recurrence.

DISCUSSION:

Increasing number of cases of GIT SS are being reported. The majority of GI SS cases involved esophagus and stomach with pain, obstruction and bleeding being the common presenting symptoms; SS of the large intestine is extremely rare. Diagnosis is established by molecular genetics and IHC. Standardized treatment-guidelines are currently lacking. It is of paramount importance to i) consider SS on the list of differentials of colonic neoplasms, ii) report these unusual cases to better understand the pathophysiology, treatment options and success rates. This would facilitate more targeted and effective treatments for SS of the colon.
1613 A Case of Extreme Fatty Expulsion Per Rectum
Authors: Baloch Luqman , Carney Spencer
Published: October 2019

INTRODUCTION:

The purpose of colonoscopies (CLN) is primarily for the prevention & management of disease in the lower gastrointestinal (GI) tract. Colonoscopies can often find fleshy masses found to be benign polyps, colorectal cancer, and even lipomas. These masses are rarely passed through the GI tract. The mechanism of spontaneous expulsion is thought to be primarily from auto-amputation. This auto-amputation occurs when a polyp or mass on a pedunculated stalk twists upon itself. It continues to twist until becoming free from the mucosal layers inside the GI tract. This allows the mass to be free to pass into rectal vault & present as a bowel movement. Though this mechanism is known, spontaneous expulsion of such fleshy masses is thought to be quite rare.

CASE DESCRIPTION/METHODS:

A 48-year-old male with a past medical history of a partial small bowel obstruction & atrial fibrillation (AF) on rivaroxaban presented to ED with complaints of intermittent abdominal pain & an abnormal bloody bowel movement. Prior CLN in 2014 was negative except for benign polyps. Patient described his stool as an "abnormal mass.” On gross evaluation the stool was noted to be a large yellow/tan fatty mass measuring 4 × 3.4 × 5.3 cm. Histological examination showed benign adipose tissue separated by thin fibro-vascular septae. Evaluation with CLN showed an 18mm pedunculated polypoid lesion on a thick 15mm stalk in the descending colon. The head of the lesion was found to be erythematous with granulation tissue on its surface consistent with recent removal of a large polypoid lesion. Cold forceps were used to biopsy the lesion & revealed benign submucosal lipomatous neoplasm.

DISCUSSION:

Lipomas are non-malignant neoplasms composed of adipose tissue. They can often be found throughout the body and rarely present in the GI tract. If present in the GI tract they are often found to be submucosal & in the colon. Majority are asymptomatic but can produce symptoms if > 2 cm. This patient’s lipoma was noted to be > 4 cm. This patient presented with intermittent lower abdominal pain, changes in bowel habits, passage of fresh blood per rectum, recurrent AF episodes, along with passing a lipomatous mass. After expulsion of this mass the patient noted decreased episodes of AF. This case & its findings demonstrate that spontaneous expulsion of a lipoma can occur via similar mechanisms of auto-amputation for polyps as previous cases have shown. It also reminds us the relationship between abdominal pathologies & the propensity for AF.
1617 Colon Ischemia as Initial Presentation of Amyloidosis: A Rare and Challenging Diagnosis
Authors: Boktor Moheb , Saraiya Neeyma , Moore Samantha A. , Balani Jyoti , Alexander Jonathan , Burstein Ezra
Published: October 2019

INTRODUCTION:

Amyloidosis is a systemic disease rarely involving gastrointestinal tract (GIT) and requires a high index of suspicion to diagnose. GI presentations including abdominal pain, bleeding, malabsorption or protein losing enteropathy. Predisposing conditions are plasma cell dyscrasia, chronic inflammatory conditions or hemodialysis. We present case of Amyloidosis involving entire GIT presented with severe colon ischemia required total colectomy.

CASE DESCRIPTION/METHODS:

A 59-year-old man with 6 months history of abdominal pain, bloating and constipation. He tried laxatives with partial relief. A colonoscopy revealed ulcerations in the sigmoid colon with biopsies consistent with ischemic colitis. CT angiography of the abdomen showed patent vessels with no findings to explain ischemic changes. A colonoscopy repeated 3 months later showed persistent inflammation in the sigmoid colon. He, subsequently, was diagnosed with multiple myeloma and initiated on bortezomib and dexamethasone. A few weeks after initiating this treatment, he presented to ED with significantly worsened abdominal pain, distension and nausea. CT A/P revealed thickening from the rectum to the descending colon with proximal dilation, concerning for pneumatosis and ischemic colitis. He was taken emergently for a total colectomy with end ileostomy. Pathology revealed that he, in fact, had extensive amyloidosis (transmural, interstitial, and vascular involvement) with hemorrhage and necrosis throughout the removed colon as well as the removed portion of the ileum with positive margins. There have been prior reports of colonic ischemia after initiation of bortezomib however this does not appear to be culprit in this case given the patient’s findings on initial colonoscopy prior to starting the medication.

DISCUSSION:

Amyloid deposition infiltrates multiple organs. GIT involvement is common, rectal biopsy can confirm diagnosis. However, severe colon ischemia is uncommon presentation. Our patient presented with severe ischemic colitis and pneumatosis on CT scan. Prior to this, he had 2 colonoscopies, EGD, and abdominal fat biopsy all was non-diagnostic. He subsequently, had total colectomy, pathology revealed Amyloidosis. Duodenal biopsies confirmed small intestine amyloidosis. Colon ischemia due to Amyloidosis is rare. Diagnosis is challenging but can lead to detrimental consequences when it is delayed. Early diagnosis is critical in preventing progressive disease and potentially fatal complications.
1618 TB or Not to Be: What’s Truly Going On?
Authors: Debesai Meron , Oak Rachana , Mikityanskiy Yevgeniy , Trillo John , Thomas Jessen
Published: October 2019

INTRODUCTION:

Granulomatous disease of the colon has a constellation of symptoms that is usually attributed to an inflammatory condition such as ulcerative or crohn's colitis. Generally, suspicion for Mycobacterium Tuberculosis (TB) or Mycobacterium Avium (MAC) colitis is low and diagnosis can be difficult. We present a case of abdominal pain in a young individual found to be MAC colitis.

CASE DESCRIPTION/METHODS:

Our patient was a 29-year-old male with history of hemorrhoids and appendectomy 1 month prior who presented with complaints of recurrent and diffuse abdominal pain. Patient stated the pain had been ongoing for the last two months, denying constitutional symptoms but endorsed alternating constipation and diarrhea with episodic blood in the stool for ten years. He denied any family history of inflammatory bowel disease or malignancy and recently immigrated from Pakistan 4 years ago. Physical examination only exhibited abdominal tenderness upon palpation. Review of pathology report from recent appendectomy showed granulomatous appendicitis suggestive of TB. Investigations revealed a positive beta-quantiferon with mild elevation of fecal calprotein, ASCA, and normal inflammatory markers. Stool studies were negative for infectious organisms but showed growth of acid-fast bacilli with Mycobacterium Avium Complex being isolated. CT scan of abdomen displayed extensive colitis of ascending colon and cecum with dilatation of the terminal ileum. Patient underwent colonoscopy revealing a polypoid mass in the cecum with biopsy consistent with prolapse of mucosa.

DISCUSSION:

Mycobacterium tuberculosis and Avium Complex are infections predominantly seen in immuno-deficient individuals and in those from developing countries. Diagnosis can be difficult because there are no specific symptoms for colonic infection and less than a quarter of cases have radiological evidence of active or healed pulmonary infection. TB infections of the abdomen comprises roughly 5% of worldwide TB infections with mycobacterium avium being the rarest. Predominatly infections in the GI tract are seen within the terminal ileum due to the bacilli’s affinity for lymphoid tissue with large colon infection being uncommon. Although, TB has been labeled “the great imitator,” other disease states such as MAC colitis may also present as possible IBD versus TB and a broader differential should be considered.
1619 Not All Intra-Peritoneal Free Air Is Created Equal. Pneumatosis Cystoides Intestinalis Causing Massive Pneumoperitoneum After a Colonoscopy, a Benign Finding
Authors: Pineda Bonilla Jonh J. , Volosenco Ion , Raza Tahir , Lindsey Justin
Published: October 2019

INTRODUCTION:

Pneumoperitoneum is the presence of free air in the peritoneal cavity. Visceral perforation, obstruction, and infection are the most ominous causes and usually present with signs of acute peritonitis requiring emergent surgery.

CASE DESCRIPTION/METHODS:

A 60-year-old man was found to have extensive colonic wall bullae (pneumatosis coli) in the transverse colon during a colonoscopy (Figure 1). Contrast-enhanced abdominal computed tomography (CT) 6 days later detected free air in the peritoneal cavity, the umbilical subcutaneous fat, and pneumatosis intestinalis in the distal transverse colon (Figure 2). Patient reported mild abdominal distension which quickly improved, otherwise he was asymptomatic. His abdomen was distended, but benign with no signs of peritoneal irritation. His laboratory work was unremarkable with normal white blood cell count and lactic acid. He was managed conservatively with nothing by mouth, intravenous fluids and systemic antibiotic therapy. He completed a 10-day course of antibiotics at home. A CT abdomen 2 months later showed complete resolution of the pneumoperitoneum (Figure 3).

DISCUSSION:

Prompt diagnosis of pneumoperitoneum and its cause is crucial, and it may require timely surgical intervention. However, there are causes of pneumoperitoneum that do not require surgery; these cases must be readily distinguished. One of the etiologies of asymptomatic pneumoperitoneum is rupture of the sub-serosal cysts present in the colonic wall of patients with idiopathic pneumatosis cystoides intestinalis. Primary pneumatosis intestinalis (15% of cases) is a benign idiopathic condition in which thin-walled cysts develop in the submucosa or subserosa of the colon. The secondary form (85% of cases) is associated with obstructive pulmonary disease, as well as with obstructive and necrotic gastrointestinal disease, infection, inflammatory bowel disease, medication-induced (chemotherapy and steroid), autoimmune disease, immunosuppression, and connective tissue disorders. In conclusion, intraperitoneal air is not always related to life-threatening conditions e.g. visceral perforation requiring invasive interventions; sometimes it is related to benign causes, one of them which we mentioned in our case. Therefore, the correlation should be made with the clinical presentation, frequent abdominal exams, imaging findings, and laboratory tests to prevent unnecessary interventions.
1622 A Rare Case of Small Cell Carcinoma of the Rectum
Authors: Jencks Kara J. , Le Thanh-Truc , Shabot Marc
Published: October 2019

INTRODUCTION:

Small cell carcinoma (SCC) of the rectum is very rare, with an incidence rate of 0.2% of all colorectal malignancies. Amongst all primary SCCs of the gastrointestinal tract, the rectum is the least common site of occurrence. We present a rare case of SCC of the rectum of unknown primary.

CASE DESCRIPTION/METHODS:

A 58-year-old male with a past medical history of prostate adenocarcinoma (gleason 4 + 3 = 7, previously treated with chemoradiation and brachytherapy) presented with a one year history of rectal pain and hematochezia. Laboratory results were significant for hemoglobin of 14.2 grams/dL, platelets 185,000/microliter, prostate specific antigen of < 0.06 nanogram/mL. Computerized tomography scan of the chest and abdomen/pelvis revealed mild circumferential rectal thickening, prostatic brachytherapy seeds, increased size of pelvic lymph nodes, and a lytic lesion in the 7 th rib. A colonoscopy was performed with findings of a 4 centimeter ulcerated, non-circumferential, non-obstructing rectal mass just above the dentate line. Pathology from rectal biopsies was consistent with small cell carcinoma; immunohistochemistry was positive for AE1/AE3, CD56, Synaptophysin, and Thyroid Transcription Factor-1. Bone biopsy of the rib lesion was also consistent with small cell carcinoma. A magnetic resonance imaging of the prostate was obtained which demonstrated an enhancing focal lesion in the right apical peripheral zone, suggestive of recurrence of prostate malignancy. A prostate biopsy was not obtained as it would not affect the overall treatment plan. The patient was started on etoposide and cisplatin with plans to be closely monitored for disease response.

DISCUSSION:

Small cell carcinoma of the rectum remains a very rare diagnosis and there is only a paucity of information limited to brief case reports. Our patient’s case is unique in that he has a previous history of prostate adenocarcinoma and there have been hypotheses that certain prostate stem cells can differentiate into SCC; a prostate biopsy would have provided a more definitive answer as to the source of this patient’s primary malignancy. Regardless, the proposed treatment of SCC remains the same (whether this is of primary rectal origin or metastatic prostate SCC to the rectum) and involves chemotherapy along with consideration of surgery/radiotherapy based on the extent of disease.
1624 Metal Stent Insertion for Malignant Obstruction of a Colostomy
Authors: Wehbeh Antonios , Rahal Mahmoud A. , Fatima Hala
Published: October 2019

INTRODUCTION:

Malignant obstruction of a colostomy is a rare occurrence that is traditionally treated with surgical intervention; however, there are no clear recommendations for management when surgery is not feasible. Here we report a case of successful placement of a colonic stent for malignant stomal obstruction due to metastatic cervical cancer.

CASE DESCRIPTION/METHODS:

A 47-year-old female with a history of metastatic cervical cancer presented with abdominal distention and minimal stool output from her colostomy for 2 weeks duration. She was diagnosed with cervical cancer three years prior. Her disease progressed rapidly despite treatment and was complicated by rectovaginal fistula for which she underwent laparoscopic diverting colostomy. The patient noticed an enlarging mass near the ostomy site which was biopsied and showed metastatic adenocarcinoma of endocervical origin. Examination revealed a benign abdomen with palpable peristomal subcutaneous masses. A CT scan showed a large heterogenous abdominal mass causing compression and obstruction at the level of the colostomy with significant proximal colonic dilation, measuring up to 8 cm. As a temporizing measure a rubber catheter was passed through the stoma for decompression. Given the extensive metastatic disease she was not a candidate for any operative intervention, and subsequently endoscopic stent placement was pursued. Colonoscopy was performed showing a severe stenosis 4 cm in length at the surgical stoma. A 25 mm × 6 cm self-expandable covered metal stent (SEMS) was successfully placed with the distal edge visible externally but not protruding beyond skin level. Her obstructive symptoms resolved shortly after the procedure. Two months later, a CT scan showed a patent stent still in place without recurrent colonic obstruction.

DISCUSSION:

Stenosis and malignant colostomy obstruction are among the complications of stoma construction. Surgery is usually the traditional treatment of these complications, but data is limited concerning the management of patients that are not good surgical candidates. There are very few case reports describing the use of either covered or uncovered SEMS for colostomy obstruction, all of which remained patent until the patients’ death 1.5 – 6 months later. In conclusion, metal stent insertion for malignant obstruction of colostomy could be a viable palliative treatment option in patients who are not operative candidates.