bluuebunny/crossref_metadata_2025 huggingface dataset:
2511 Acute Cholestatic Hepatitis E Infection: Immune Dissociation With Intra-Hepatic Replication
Authors: Debes Jose D. , Doukas Michael , de Man Robert , Boonstra Andre
Published: October 2019

INTRODUCTION:

There is a lack of understanding of immune modulation during acute hepatitis E virus (HEV) infection. We evaluate the immune response during a case of autochthonous acute HEV genotype 3 infection in the Netherlands.

CASE DESCRIPTION/METHODS:

A 73 y/o patient initially presented with typical features of acute hepatitis. Extensive work up showed detectable HEV RNA in blood with positive IgM and genotype-3 molecular detection. The liver enzymes improved, there was viral clearance from blood and the patient was discharged home. However, on follow up appointment he was found to have severe cholestasis, was readmitted and passed away shortly. Real time PCR of liver biopsy revealed presence of HEV in liver tissue, suggestive of active intrahepatic infection despite clearance in blood. Peripheral immune evaluation performed via Pro-carta multiplex array showed that during the phase of detectable HEV RNA in serum, there was a surge of T-cell related immune mediators, as well as IFN-a and IP-10 characteristic of viral infections. After clearance of the virus in blood and development of cholestatic hepatitis, several inflammatory markers subsided, followed by an increase in immune factors related to anti-inflammatory activity as well as monocyte/macrophage related markers likely due to the intrahepatic presence of the virus.

DISCUSSION:

Our case describes a dissociation of intra- and extra-hepatic immune responses during acute HEV infection. As the shedding of the virus became solely intrahepatic, we observed an immune profile reflective of the activity of hepatic resident cells reflecting “competing immune interests' during HEV infection. Moreover, it exposes a less-known aspect of HEV: intra-hepatic morbidity despite lack of detection in blood.
2514 The Biggest Loser: A Case of Dramatic Weight Loss Achieved With an Intragastric Balloon
Authors: Chauhan Kirtan , Popov Violeta
Published: October 2019

INTRODUCTION:

The prevalence of obesity and the medical costs associated with it are steadily rising, both among the adult and adolescent populations. New procedures such as the intragastric balloon (IGB), can provide rapid improvement in overall health to help manage and maintain weight loss with few adverse events.

CASE DESCRIPTION/METHODS:

A 61-year-old male patient with class III-IV obesity and multiple comorbidities had been in discussion with his gastroenterologist for over a year to undergo an IGB procedure. Peak weight was 302 lbs, with BMI of 43 kg/m2. He underwent intensive lifestyle and medical therapy, was started on Liraglutide 1.8 mg daily, with 15 lbs weight loss that plateaued. On his pre-procedure visit, hemoglobin A1C was 9.4, with a weight of 275 lbs and BMI 40.7 kg/m2. An intragastric Orbera™ IGB System (Apollo Endosurgery Inc, Austin, TX, United States) was placed and inflated with 600 ml of saline. On 2-month follow-up, the patient had lost 34 pounds. A number of his chronic medications, including those for hypertension and diabetes mellitus, were held due to improvement in lab and exam findings. The IGB was removed after 6 months. The patient continued to lose weight and has maintained daily exercise and dietary guidelines. Most recently, the patient's A1C level has trended down to 6.4%, with a weight of 202 lbs and a BMI of 29.9 kg/m2. Since starting the program, he has lost a total of 101 lbs.

DISCUSSION:

This case highlights the dramatic weight loss after a minimally invasive weight loss procedure in conjunction with proper diet and, exercise. The patient lost 27% of his body weight (275 lbs to 202 lbs) and went from class III obesity (>40 BMI), to an overweight range (25.0–29.9 BMI) with the IGB. Overall, he has lost over 100 lbs with 34.4% total weight loss, making him the “biggest loser' in our program. The effect on the patient's overall well-being has been extraordinary; over time, he has been able to start a regular exercise and dietary regimen, use less medication or experience remission of his chronic conditions. The typical weight loss expected with a gastric balloon is 10-12%. This patient's results have far exceeded the expected trajectory. Given the chronicity of obesity, and improvements in health seen with even 5-10% weight loss, a relatively safe endoscopic procedure such as the gastric balloon can significantly improve the health status of patients with obesity and should be considered before more invasive interventions.
2518 Transitory Hemophagocytic Lymphohistiocytosis (HLH)/Macrophage Activation Syndrome (MAS) in a Child With Very Early Onset (VEO) of Ulcerative Colitis (UC) Complicated With Primary Sclerosing Cholangitis (PSC)
Authors: Galeano Narmer F. , Rivera-Penera Maria T. , Bonilla Mary A. , Menell Jill S. , Kosinski Mark , Gupta Punita , Srinivasan-Mehta Jaya
Published: October 2019

INTRODUCTION:

VEO - Inflammatory bowel disease (IBD), in children younger than 6 years of age, is frequently associated with a more severe course and distinct genetic profile compared with later onset IBD. We report the case of a child with VEO - UC complicated with PSC and HLH/MAS.

CASE DESCRIPTION/METHODS:

A 10-year-old male, presented with bloody diarrhea, hepatomegaly and elevated transaminases when he was 30 months old. He had moderate pancolitis associated with C difficile (Cdiff) infection. He improved after metronidazole and sulfasalazine (SFZ) treatment. Two months later, he had hematochezia and endoscopic worsening of his colitis, which improved after discontinuing SFZ and receiving steroids and 6-MP. MRCP was consistent with PSC (Figure 1) and he was started on ursodiol. At ∼ 7 years of age, while receiving treatment with 6MP and Infliximab, he was hospitalized due to fever, hepatomegaly, diarrhea and pancytopenia. Blood and stool cultures, and tests for Cdiff, EBV, CMV, rota and parvovirus were negative. Triglyceride and ferritin levels were normal. He improved clinically and his pancytopenia resolved after 5 days of empirical antibiotic treatment (AbTx). Bone marrow biopsy (BMBx) was deferred. Metabolites of 6MP were normal but 6MP was held temporarily. Six months later, he had fever and diarrhea associated with pancytopenia and high levels of ESR, CRP, ferritin, triglyceride and interleukin 2 receptor. Number and function of NK cells were decreased. Stools and blood cultures, and tests for EBV, HSV and CMV were negative. Cdiff stool antigen was positive but PCR was negative. BMBx showed histiocytosis and erythophagocytosis (Figure 2). Lymphocyte flow cytometry was negative for lymphoproliferative disorder. After AbTx he improved and pancytopenia and ferritin level corrected within one week. Routine immunodeficiency tests were normal. Gene mutations associated with familial HLH: PRF1, Rab27A, SH2D1A, STX11, STXBP2, UNC 13D and XIAP were negative. 6MP was held. Infliximab initially, and subsequently Adalimubab, were discontinued because of high antibodies and allergic reactions. Five months later 6MP was restarted. He has been in remission of UC for 16 months.

DISCUSSION:

HLH/MAS is a very rare, potentially fatal complication in IBD patients. Our patient has a history of VEO - UC, PSC and two episodes of pancytopenia not associated with EBV or CMV - one of which fulfilled criteria for HLH/MAS. Remarkably, he recovered within one week after empirical AbTx without steroids or other treatment for HLH/MAS.
2519  A Rare Case of Mucosa-Associated Lymphoid Tissue (MALT) Lymphoma Involving Duodenum
Authors: Sonti Sravanthi , Nagireddy Sumana , Parsa Laxmi , Birsan Christina
Published: October 2019

INTRODUCTION:

Primary small bowel lymphomas account for only 8-9% primary gastrointestinal malignancies and mostly represent extra nodal B- or T-cell origin. Immunoproliferative small bowel disease (IPSID) is a common small bowel extra nodal primary lymphoma. Associated Lymphoid Tissue B cell lymphoma (MALT lymphoma) is a common primary gastric lymphoma. However, it is very rare to find MALT lymphoma in small bowel especially in duodenum. We report a unique case of MALT lymphoma involving duodenal bulb.

CASE DESCRIPTION/METHODS:

A 58-Yr-Old African American female, with history of type II diabetes, Hypertension, Osteoarthritis, and chronic GERD with symptom control on once a day low dose omeprazole was referred for evaluation of epigastric discomfort, bloating, and nausea for 2 months. Abdominal examination normal. Labs showed normal CBC with differential, and CMP. An upper endoscopy showed mild patchy erythema in stomach and a localized, raised, and nodular area about 4-5 cm in the duodenal bulb. Biopsies from stomach showed Helicobacter pylori chronic active gastritis. Biopsies from duodenum showed homogenous population of lymphoid cells with moderate amounts of clear cytoplasm expanding the lamina propria. Molecular studies showed positive B-cell Gene Rearrangement with positive Framework 1, 2, and 3. Immunohistochemical staining was positive for CD20, bcl2, and kappa; and negative for CD3, CD5, CD10, bcl6, CD43, Cyclin D1 and lamda. The pathology findings confirmed Margina zone lymphoma of Mucosa Associated Lymphoid Tissue (MALT lymphoma). Colonoscopy was normal except few diverticula. A CT scan of abdomen, pelvis, and chest did not show any other masses except prominent lymph nodes at the gastrohepatic ligament and duodenum. She is treated with antibiotic therapy for H pylori gastritis, and referred to oncology for further management.

DISCUSSION:

MALT lymphomas of stomach usually occur in females and can be associated with Helicobacter pylori infection. They are usually low grade lymphomas and localized to gastrointestinal epithelium. Clinical features, imaging, or endoscopy findings are not specific. Immunohistochemical staining shows positive for B cell phenotype markers like CD20, Bcl-2, and negative for CD 23, CD 10, and CD 5. Usually, they present with non-specific symptoms like epigastric pain, nausea, vomiting, early satiety, though can present with obstruction when the tumor is too large. Treatment of associated H pylori infection may help though chemoradiotherapy may be needed rarely.
2521 Jejunal Carcinoid in a Patient With Primary Biliary Cholangitis Presenting as Small Bowel Obstruction
Authors: Singh Khushboo , Subramanian Sruthi K. , Abraham Fiyinfoluwa , Zhao Bihong , Machicao Victor
Published: October 2019

INTRODUCTION:

Gastrointestinal carcinoid tumors arise from specialized neuroendocrine cells all along the gastro-entero-pancreatic system, which secrete bioactive amines and peptides. These are often asymptomatic and rarely cause obstructive symptoms. We describe a rare case of jejunal carcinoid presenting as small bowel obstruction.

CASE DESCRIPTION/METHODS:

A 60-year-old female with primary biliary cholangitis and scleroderma presented with three-months of abdominal pain, vomiting, and constipation with worsening three days prior to presentation. Patient was hemodynamically stable with unremarkable physical examination findings. Computed Tomography (CT) of abdomen and pelvis and follow up magnetic resonance enterography (MRE) showed a focal small bowel ileus with enlarged mesenteric lymph nodes (Figure 1). Chromogranin-A level was elevated to 11 nmol/L. The patient underwent exploratory laparotomy for small bowel obstruction; mesenteric mass and jejunal resection with jejunojejunal anastomosis was performed. The final histopathology report of both the lymph node and mesenteric mass revealed well-differentiated neuroendocrine tumor (NET), also termed carcinoid tumor (Figure 2). A follow-up Gallium PET/CT three weeks later showed residual disease in the small bowel mesentery near the site of resection for which the patient was started on Lanreotide.

DISCUSSION:

Carcinoid tumors are most common in the small bowel (30.8%) typically within 60 cm of ileocecal valve and are mostly asymptomatic. While midgut carcinoid may present with abdominal pain due to intermittent obstruction, mesenteric ischemia, or intraluminal tumor, it is rare. Although the initial modality of choice for small bowel obstruction is CT abdomen, it has low sensitivity in detecting small primary intestinal masses. MRE is more sensitive in detecting the dominant finding of a mesenteric mass. Octreotide scan and gallium-68 PET/CT can detect extent of disease or preoperatively diagnose patients with suspected NET that could not be detected using other modalities. Surgical resection with lymphadenectomy remains the standard treatment with a favorable prognosis of 83% five-year survival rate. Somatostatin analogs are the first line of treatment for any residual disease. With a favorable prognosis in mind, our case highlights the need for high clinical suspicion for carcinoid as part of the differential, especially in a patient presenting with small bowel obstruction and mesenteric mass in the setting of autoimmune disease.
2524 Rare Case of Numerous Duodenal Neuroendocrine Tumors Encompassing Entire Proximal Duodenum
Authors: Kendrick Katherine , Adsay Volkan , Sarmiento Juan , Sedghi Shahriar
Published: October 2019

INTRODUCTION:

Gastrointestinal neuroendocrine tumors (GI-NETs) are rare neoplasms, but incidence is on the rise, in part due to increased detection. GI NETs can be found from the esophagus to the rectum. The appendix is the most common location.1,2 Primary duodenal NETs (D-Nets) are rare and account for less than 2% of tumors1. We report a case of a rare multiple duodenal NET.

CASE DESCRIPTION/METHODS:

44-year-old female who presented for anemia complaining of belching, flatus, and loose stools. EGD found the post-bulbar area studded with numerous 1 cm nodules, covering the entire proximal colon. Endoscopic biopsy revealed a spectrum of proliferations, which followed the distribution of Brunner glands. Many of the proliferations turned in the full-blown D-NETs positive for synaptophysin and chromogranin, the Ki-67 index was less than 3%, consent with neuroendocrine neoplasm grade 1 (NET tumor), in the 1st through the 3rd portion of the duodenum. Octrotide scan was negative. The patient was sent for a Whipple procedure. MEN type 1, NF, TSH, and 24 hr urine 5-HIAA were normal.

DISCUSSION:

GI NETs are often diagnosed in the 5th–6th decade of life and are common in African Americans and females.3 Primary tumors in the duodenum are rare and their frequency decreases toward the distal duodenum.4 Symptoms are non-specific, presenting with dyspepsia and epigastric pain. EGD is the best method for preoperative diagnosis, neuroendocrine markers such as serum chromogranin A and urine 5-HIAA, are supportive.4 In duodenal carcinoid tumors, ∼4% are associated with carcinoid syndrome.5 Duodenal carcinoids can be associated with clinical syndromes, such as Zollinger-Ellison syndrome or Multiple endocrine neoplasia-1 3. Carcinoid tumors, with metastasis express, have a high affinity for octreotide, and can be visualized with an OctreoScan.2,3 Duodenal tumors can be removed endoscopically or with resection. Our patient underwent Whipple's pancreaticoduodenectomy due to the peri-ampullary location of the tumors (Figure 1). The current study describes a rare case of multiple D-NETs carpeting the proximal duodenum, in a patient without elevated neuroendocrine markers, ZES, or MEN. Proliferation in the distribution of the Brunner glands indicates an underlying genetic alteration in the neuroendocrine cells associated with THE Brunner glands. From our literature search, we were only able to find two other case reporting multiple D-NETs and no cases reporting D-NETs proliferations from Brunner glands, thus a rare presentation.
2526 A Rare Cause of Intestinal Pseudo-Obstruction: Gastrointestinal Amyloid
Authors: Kochar Tanureet , Dhingra Parminder , Shah Hamza
Published: October 2019

INTRODUCTION:

Amyloidosis is characterized by extracellular deposition of amyloid protein. It affects most commonly heart, kidney and GI tract. It can occur sporadically or in association with other conditions like multiple myeloma, chronic inflammatory diseases, infections etc. It has variable manifestations in GI tract from involving the stomach to the large bowel including liver.

CASE DESCRIPTION/METHODS:

This is 55 year old Caucasian male with past medical history of recent diagnosis of multiple myeloma, chronic kidney disease, hypertension, atrial flutter who presented to the hospital with chief complaints of multiple episodes of nausea and vomiting, diffuse abdominal pain, subjective fevers and chills from past 2 days. On presentation, vitals were stable. CBC- wnl, CMP – wnl, CT abdomen/pelvis without contrast revealed partial small bowel obstruction. Patient had similar symptoms in prior admissions. During the initial hospitalization 1 month ago, he underwent exploratory laparotomy with no findings to suggest mechanical small bowel obstruction. Subsequently, he had an EGD with push enteroscopy which identified enteritis and a Mallory-Weiss tear. Small bowel biopsies were performed with pathology noting: focal acute cryptitis and a background of moderate chronic nonspecific inflammation. Repeat EGD with push enteroscopy revealed non erosive esophagitis, mild gastritis and severe duodenitis, biopsies were obtained. Congo red staining of the biopsy revealed amyloidosis of the small bowel but the gastric biopsy was negative. The patient was then referred to higher center for consideration of bone marrow transplant. The fat pad biopsy was never obtained for systemic amyloidosis.

DISCUSSION:

The AL amyloidosis which is most commonly associated with monoclonal free light chains deposition, which was also previously called primary amyloidosis is most common. The AA amyloidosis (also called as secondary amyloidosis) is secondary to chronic inflammation in the body due to infection, rheumatoid arthritis etc. Diagnosis of amyloid, irrespective of the type, depends upon clinical, laboratory and histological findings. Serum and urine immunoelectrophoresis are the initial laboratory tests, but confirmation requires histological evaluation. Overall median survival in untreated patients or nonresponders with systemic amyloidosis is <2 years. Treatment should be directed at the underlying cause. GI complications are managed with symptomatic control.
2528 Extensive Small Bowel Ischemia With Heavy Alcohol Consumption
Authors: Leung David , Gaddipati Kishore
Published: October 2019

INTRODUCTION:

Acute mesenteric ischemia (AMI) is a disorder associated with atherosclerosis and cardiovascular disorders. It includes a range of disease etiologies including nonocclusive mesenteric ischemia (NOMI). NOMI is the most lethal form of AMI with mortality rates up to 70%. Alcohol is well recognized as a systemic toxin that causes serious health problems. Intestinal complications caused by alcohol consumption, however, are not well documented. We present a rare case of a patient who developed NOMI following excessive alcohol consumption.

CASE DESCRIPTION/METHODS:

A 52-year old male presented with a chief complaint of abdominal pain. The abdominal pain began after uncharacteristically drinking 11 shots of hard liquor. The patient developed abdominal pain along with several bouts of emesis. Initial imaging with a CT abdomen demonstrated non-specific enteritis. Later that evening, the patient developed peritoneal signs. A repeat CT abdomen showed progressive proximal small bowel distension, free fluid in the abdomen and pelvis along with pneumatosis in the proximal ileum (Figure 1). Surgery revealed frank necrosis, gangrene and extreme distension of small bowel, 20 cm proximal to the ileocecal valve. The ischemic small bowel was resected as a result. The proximal and distal ends of the small bowel were stapled and left in discontinuity. Pathology collected from the small bowel resection revealed acute inflammation and both mucosal necrosis along with transmural gangrenous necrosis of the small bowel (Figure 2). It additionally showed patent mesenteric vessels without evidence of fibrin thrombi (Figure 3). The patient subsequently underwent a small bowel anastomosis and was discharged.

DISCUSSION:

NOMI secondary to excessive alcohol binging has only been reported in the literature only once before. Similar to the case reported in the Journal of the Korean Society of Coloproctology, there was no history of CVD or atrial fibrillation to suggest thrombotic or embolic mesenteric ischemia. Additionally, there were no findings suggestive of correlating mesenteric involvement on pathology. Of note, our case differed in that our patient did not have a significant alcohol abuse history which the previously reported case had noted. Studies in the literature suggest that ethanol can produce prolonged vasoconstriction in cerebral blood vessels which become involved in hypoxic, ischemic and hemorrhagic actions on the brain. However, mechanisms of alcohol-induced vasoconstriction of splanchnic vessels are still unclear.
2529 A Case of Cytomegalovirus Causing Duodeno-Colonic Fistula in Immune Competent Patient
Authors: Myadam Rahul , Zafar Yousaf , Jamil Laith H.
Published: October 2019

INTRODUCTION:

Cytomegalovirus (CMV) is a common opportunistic infection in immune compromised patients. Within the gastro-intestinal tract, it is a known cause of esophagitis and colitis. A rare presentation of CMV infection is an enteric fistula with only a few cases reported. We present a case of duodena-colonic fistula secondary to CMV in an immune competent host.

CASE DESCRIPTION/METHODS:

86-year gentleman with past medical history of dementia who presented with complaints of feeling tired, jaundice and colorless diarrhea, significant weight loss for two months. He denied alcohol use and was not taking any prescription medications. He denied family history of cancer or liver disease. His initial labs showed non-specific elevation in the liver enzymes along with mild anemia. He underwent an MRI abdomen that showed duodenal swelling but no obstructive mass or bile duct dilation. Endoscopic ultrasound showed a large duodenal ulcer with duodena-colonic fistula that was large enough for the scope to pass through. Biopsies were taken from the fistula and liver which showed cytoplasmic inclusion bodies characteristic of CMV. HIV antibodies were negative and CMV blood titres were elevated. His acute liver injury was attributed to CMV hepatitis. He completed 6 weeks of anti-viral treatment with ganciclovir. A repeat endoscopy 2 months later showed healing duodenal ulcer with no fistula present. Blood CMV level was negative at the time of completion of anti-viral treatment. He was seen later in the immunology clinic to evaluate why he had such a severe infection from CMV. His labs were significant for only mildly reduced B lymphocyte count – 47 (normal 100-700) with slightly lower immunoglobulin G level 748 (normal 762-1488) and immunoglobulin M level 25 (normal 38-328). Rest of the labs were unremarkable including a complete blood picture, lymphocyte subsets and lymphocyte proliferation studies. It was felt that his CMV infection was isolated and because he had no recurrent infections it was decided by the patient and the immunologist to forego any further investigations of immune deficiency.

DISCUSSION:

In clinical practice, it is important to exclude CMV infection as a cause of intestinal ulcers even in immune competent patients. Especially if they are accompanied by an enteric fistula. Treatment of the CMV enteric fistula involves both anti-viral therapy and surgical closure of the fistula. Rarely such as in our patient, healing of the fistula can take place without any invasive procedures.
2530 An Unusual Cause of Abdominal Pain From Salmonella enteritidis (SE): Guess Where the Bug Was?
Authors: Melki Gabriel , Laham Linda , Karim Gres , Komal Fnu , Barham Shaker , Yuridullah Ruhin , Vora Aarohi , Sultana Yasmeen , Baddoura Walid
Published: October 2019

INTRODUCTION:

Aortitis, an inflammatory entity with high mortality that is usually due to a rheumatologic etiology; however, an infectious etiology is sometimes the cause. We present a rare case of aortitis secondary to Salmonella septicemia treated with 6 weeks of antibiotics. Endovascular surgical repair (EVAR) with antibiotics (abx) is the preferred treatment.

CASE DESCRIPTION/METHODS:

A 76 year-old male with HTN, DM and CAD s/p CABG 3 months prior, presented to the ED c/o 7-day hx of suprapubic abdominal pain radiating to the lower quadrants and lower back, associated with fever, chills, night sweats, and chest pain. There was no recent history of a diarrheal illness. VS: T 101 F, BP 100/60, RR 18 and pulse of 100. PE revealed costochondral erythema and tenderness, as well as manubrial and suprapubic tenderness. Labs showed WBC 31000, ESR 100, CRP 150, CT abdomen revealed perineural fibrosis of the aorta just above the ostium of the IMA; the presence of air pockets was concerning for infectious aortitis. Patient refused surgery. Blood C&S were sent and patient was started on IV Cefipime, Linezolid and metronidazole. Sternal osteomyelitis was suspected. Bone scan revealed increased uptake in the region of the manubrium and upper body of the sternum. CTA confirmed aortitis. Blood C&S and sternal biopsy grew SE and abx were switched to IV ceftriaxone for 6 weeks. There was clinical and radiographic improvement without complications.

DISCUSSION:

Salmonella aortitis carries a high mortality even with best treatment options, making prompt diagnosis crucial for survival. Risk factors for Salmonella aortitis include vascular pathologies, CAD, HTN, DM, immunosuppression, seronegative C2 Infections, rheumatological diseases and hematological malignancies. The best treatment for infectious aortitis is EVAR with long-term abx. Treatment with abx alone is controversial; however, their use is the mainstay of therapy. Review of literature revealed that patients treated solely with abx without surgery did not survive. Duration of abx is also controversial with some experts suggesting lifelong treatment. In this case, the patient refused surgery and received abx for 6 weeks only, with resultant clinical and radiological remission.
2536 Celiac Disease Presenting With Duodenal Ulcerations and Small Bowel Intussusception
Authors: Samuel Ronald , Bhatt Asmeen , Bilal Mohammad , Luthra Gurinder
Published: October 2019

INTRODUCTION:

Celiac disease is an autoimmune disorder that is triggered by gluten causing villous atrophy in the small intestine. Patients with celiac disease can present with a wide range of symptoms. We present a unique case of celiac disease presenting with duodenal ulcerations and small bowel intussusceptions.

CASE DESCRIPTION/METHODS:

A 60-year-old male with past history of stage I colon cancer status post partial colectomy 8 years ago presented with diarrhea and weight loss. The patient reported profuse diarrhea accompanied by a 20 lbs. weight loss that started six months ago. He denied other symptoms. His prior colonoscopies 1 year and 4 years after the partial colectomy were unremarkable. Physical examination was unremarkable. Laboratory data including hemoglobin was normal. Stool studies including infectious work up (clostridium difficile, stool cultures, ova and parasites) and fecal calprotectin were normal. A computed tomography (CT) scan of the abdomen and pelvis showed small bowel intussusception, mesenteric lymphadenopathy, and absence of any metastatic disease in the abdomen or pelvis (Figures a and b). A push enteroscopy was performed and revealed multiple scattered superficial ulcerations throughout the duodenum from the bulb to the third portion (Figures c and d). Repeat colonoscopy was unremarkable. Duodenal biopsies showed marked villous blunting, crypt hyperplasia and increased intraepithelial lymphocytes (Figures e and f) consistent with Celiac disease (Marsh 3b criteria). Blood was checked for celiac disease serologies and showed an elevated Anti-Tissue Transglutaminase IgA Antibody and a Deaminated Gliadin Peptide IgA Antibody. The patient was advised to start a gluten free diet. Four months after diagnosis, and being on a gluten-free diet, the patient had complete resolution of diarrhea and regained 20 lbs. of weight.

DISCUSSION:

Celiac disease can present with a variety of symptoms including diarrhea, nutritional deficiencies, weight loss, and gastric distension. Duodenal ulcerations and small bowel intussusception are exceedingly rare presentations of celiac disease. Even though these presentations have been previously been described separately, but they have not been reported together in an adult patient. Our case highlights that gastroenterologists should bear in mind the differential diagnosis of celiac disease in patients with small bowel intussusception, even in adults.
2538 Severe Protein-Losing Enteropathy and CMV Duodenitis in an Immunocompetent Male
Authors: Nhu Quan M. , Hai Faizi , Konijeti Gauree G.
Published: October 2019

INTRODUCTION:

Cytomegalovirus (CMV) infection, typically associated with immunodeficiency, has been reported to also occur in immunocompetent patients. CMV infection of the gastrointestinal (GI) tract is uncommon in immunocompetent hosts and typically involves the lower GI tract. We encountered a case of CMV duodenitis associated with severe protein-losing enteropathy in an otherwise healthy male.

CASE DESCRIPTION/METHODS:

A 27-year-old man with a 2-year history of mild, intermittent non-bloody diarrhea presented with 2 weeks of worsening diarrhea, epigastric pain, nausea, vomiting and poor oral tolerance. His only medication was emtricitabine/tenofovir for HIV pre-exposure prophylaxis, initiated 4 months prior to presentation. Physical examination revealed a tender epigastrium and anasarca. Laboratory evaluation showed WBC 13.2 K/mcL (12.2% monocytes), albumin 1.9 g/dL, AST 64 U/L, ALT 77 U/L, total bilirubin 1.0 mg/dL, INR 1.0, and lipase 346 U/L. Serum HIV antigen/antibody was negative, and CD4 cell count was 873 cells/mcL. Urinalysis was unremarkable and was without proteinuria. Stool studies were negative for common enteric bacterial pathogens, Clostridium difficile, Giardia, and ova/parasites. Fecal calprotectin was elevated at 390 µg/g. MRI/MRCP imaging of the abdomen and pelvis showed a thickened duodenum, and peripancreatic fat stranding and fluid (suggestive of acute pancreatitis), without biliary or pancreatic duct dilation. EGD showed severe duodenitis with diffuse erythema, mucosal denudation, patchy erosions, and nonbleeding ulcerations. Biopsy with immunostain revealed CMV duodenitis. Serum CMV DNA was mildly elevated at 142 IU/mL. Following multidisciplinary discussion, supportive care was provided without antiviral therapy. Over the next month, the patient improved clinically, with normalization of serum albumin, transaminases, and CMV titer.

DISCUSSION:

Several reports have described tissue invasive CMV infection in immunocompetent patients, primarily involving the colon. CMV duodenitis and pancreatitis are rare, even in immunocompromised patients. Our case describes a healthy man with severe CMV duodenitis resulting in protein-losing enteropathy. CMV likely caused mild acute pancreatitis in our patient as well. A recent systematic review did not support antiviral therapy for immunocompetent patients with CMV. Supportive care with close monitoring may be sufficient; however, further investigation is needed to routinely support this practice.
2540 An Exceptionally Rare Cause of Abdominal Pain: Protein C Deficiency-Induced Mesenteric Panniculitis
Authors: Alomari Mohammad , Hader Ismail , Al Momani Laith , El Kurdi Bara , Young Mark
Published: October 2019

INTRODUCTION:

Mesenteric panniculitis (MP) is a rare benign disorder that affects the intestinal mesentery causing unexplained gastrointestinal complaints. Herein, we present a case of MP-induced by microinfarction due to Protein C deficiency.

CASE DESCRIPTION/METHODS:

A 46-year-old female patient with a significant medical history of protein C deficiency and recurrent deep vein thrombosis on long term anticoagulation with warfarin presented to the emergency department after a syncopal episode. She suffered from persistent nausea, vomiting, inability to tolerate oral intake, and mild abdominal pain for the last two weeks prior to presentation. Physical examination was mostly unremarkable except for mild periumbilical tenderness and orthostatic hypotension. Laboratory testing revealed a white blood count of 8 K/uL, hemoglobin of 14.9 g/dL, serum sodium of 135 mmol/L, serum potassium of 4.1 mmol/L, blood urea nitrogen of 20 mg/dL, creatinine of 1.0 mg/dL, international normalized ratio (INR) of 1.23, D-Dimer of 1221 ng/mL, C-reactive protein of 20 mg/L, and erythrocyte sedimentation rate of 29 mm/hr. Contrast-enhanced computed tomography (CT) of the chest and abdomen was negative for thromboembolism, however, it showed a hazy, misty appearance of the mesentery with multiple prominent lymph nodes. The patient was treated conservatively; warfarin was resumed with heparin bridging. With clinical improvement, the patient was discharged home.

DISCUSSION:

MP is a benign fibroinflammatory disorder primarily affecting the adipose tissue of the mesentery with a prevalence range between 0.16-0.6%. It typically occurs in the 6th decade of life with a male to female ratio of 2:1. The underlying etiology of MP remains unclear, history of abdominal surgery and trauma were considered predisposing factors in the majority of the cases, in addition to autoimmune disorders and vasculitis. Clinical presentation varies with most of the cases being typically asymptomatic. Symptomatic patients report nonspecific complaints such as abdominal pain, fever, nausea, and fatigue. Physical examination and laboratory workup are usually nonrevealing but palpable masses have been reported. These factors make the diagnosis even more challenging and usually requires a contrast-enhanced CT scan. Hence, high clinical suspicion is required to diagnose MP while investigating otherwise unexplained abdominal pain.
2541 Cryptosporidial Colonization of a Peptic Ulcer in a Healthy Patient—Random Occurrence or a Risk Factor?
Authors: Amarnath Shivantha , El Imad Cheikh Talal , Kingsley Ebare , Wu Hueizhi , Mulrooney Stephen
Published: October 2019

INTRODUCTION:

The incidence of Cryptosporidial enteritis (CE) has recently risen in the USA due to water and foodborne outbreaks. It has a self-limited course in healthy hosts. We describe a case of a healthy female with history of gastric bypass surgery who presented with a one-month history of voluminous watery diarrhea and vomiting. This was a rare case of CE diagnosed by endoscopic biopsies of two anastomotic peptic ulcers that were colonized by Cryptosporidium spp.

CASE DESCRIPTION/METHODS:

57-year-old female with a history of GERD, iron deficiency anemia, and Roux-en-y gastric bypass complicated by jejunal strictures with revision of the gastro-jejunal anastomosis, presented with a 7-day history of vomiting and crampy epigastric abdominal pain. She recently returned from a two-week vacation to Latin America. Upon arrival, she experienced progressively worsening voluminous watery diarrhea associated with intermittent melanotic stools followed by frequent episodes of non-bilious, non-bloody vomiting along with reduced oral intake. Abdominal exam revealed hyperactive bowel sounds with tenderness to deep palpation of the epigastrium. Her hemoglobin dropped from a baseline of 11.2 g/dL to 9.1 g/dL. CT scan of the abdomen with contrast showed inflammation around the gastro-jejunostomy site. Blood and stool cultures were negative. Upper endoscopy revealed a 1 cm and 2 cm clean-based ulcers with a deep crater at the anastomotic site. Biopsy demonstrated spherical bluish-purple organisms, 2-5 µm in diameter on hematoxylin and eosin, Gomori Methanamine Silver Nitrate and Masson's trichrome stains. They were suggestive of Cryptosporidium, and the patient was diagnosed with CE. Patient's immunodeficiency workup was unremarkable. Patient's symptoms resolved with a three-day course of Nitazoxanide 500 mg twice per day.

DISCUSSION:

CE is a significant cause of chronic diarrhea in both healthy and immune-compromised individuals, thus stands as a key differential in those presenting with persistent voluminous diarrhea. The modified acid-fast stain carries only 50% sensitivity to this protozoan, and diagnosis is often missed on routine stool ova and parasite tests. Novel diagnostic modalities have proven useful in identifying this protozoan in stool samples. We report the first case documenting Cryptosporidium colonization of anastomotic site peptic ulcers with complete resolution of symptoms following a short course of Nitazoxanide.
2545 If Any Doubt, Rule It Out: Having a High Clinical Suspicion for Paraduodenal Hernia
Authors: John Jason J. , John Elizabeth S. , Tarnasky Paul
Published: October 2019

INTRODUCTION:

Paraduodenal hernia (PDH) is a type of internal abdominal hernia (IH), a rare entity with a reported incidence of 0.2-0.9% on autopsy. Though typically asymptomatic, it is an important diagnosis to consider when suspicious for bowel obstruction as mortality can reach up to 20%. We report a case of a 46 year old female with vague abdominal complaints who had a PDH.

CASE DESCRIPTION/METHODS:

A 46 year old female with a history of questionable bowel obstruction and hysterectomy, presented with 3 days of abdominal pain, nausea, and vomiting. She had decreased stool caliber over the previous week with no bowel movements, and inability to pass gas for 2 days. The patient reported having a similar episode 2 years prior that resolved with nasogastric tube decompression. Imaging was unrevealing and an etiology for her symptoms was not identified. On admission, her vitals were stable and her physical exam was positive for abdominal distention, high-pitched bowel sounds, and tenderness to palpation in the right upper quadrant. Labs were remarkable for leukocytosis with a WBC of 13.6. CT abdomen/pelvis with contrast revealed an internal hernia with small bowel and mesentery extending lateral to the right colon through a defect in the ascending mesocolon (Figure 1). The patient's symptoms persisted so she was taken to the operating room for a diagnostic laparoscopy. A PDH was repaired, and her symptoms subsequently improved.

DISCUSSION:

PDH is rare and difficult to diagnose, but is an important entity to consider in bowel obstruction. Though responsible for bowel obstruction in 5.8% of patients, early diagnosis is crucial as there is an overall 20% mortality rate, 50% mortality if the bowel is strangulated, or nearly 100% if ischemic. The etiology of PDH is widely debated, but the most accepted theory is an error in intestinal rotation and fixation causing entrapment of the small bowel between the mesocolon and posterior abdominal walls. In adolescents, it is thought to arise from congenital defects. In adults, the major risk factor is prior surgical intervention, including Roux en Y bypass, peripheral adhesive bands, laparoscopic surgeries, or gynecologic surgeries. Clinical diagnosis of PDH is extremely challenging as abdominal exams and radiologic studies are subtle or negative until patient becomes acutely ill. Compared to other IHs, symptoms and radiologic findings in PDHs may be particularly subtle. Having a high clinical suspicion is crucial given high mortality rate of complications.
2546 Rare Case of Duodenal Melanosis in a 72-Year-Old Male
Authors: Rana Navpreet , Minhas Umair , Mahl Thomas
Published: October 2019

INTRODUCTION:

Pseudomelanosis (PM) is a rare condition of unknown etiology. Prevalence of this condition is not well documented however, there have been several case reports. It is described as speckled black pigmentation of intestinal mucosa. Underlying pathogenesis and significance of PM is not well understood. Reports have associated it with medications, including anti-hypertensives and iron supplements and systemic diseases such as chronic renal disease, iron deficiency and diabetes mellitus. It is most commonly discovered as an incidental finding during endoscopy and frequently seen in the duodenum, however, few cases have also reported it in the stomach and jejunum.

CASE DESCRIPTION/METHODS:

A 72-year-old male with multiple co-morbidities including diabetes, hypertension, peripheral arterial disease and chronic kidney disease presented with epigastric pain, nausea and hematemesis. There was no melena or hematochezia. Last colonoscopy 10-years ago was significant for diverticulosis and hemorrhoids. His home medications included aspirin, clopidogrel, amlodipine, hydralazine, hydrochlorothiazide, atorvastatin, levothyroxine, furosemide and baclofen. On evaluation, digital rectal exam was significant for dark stools and hemoglobin decrease from 11.4 to 9.2 over 8 months. Upper endoscopy showed normal appearing esophagus and gastric mucosa. Dark pigmentation of the duodenal mucosa was noted and biopsied. Pathology findings were consistent with intestinal pseudomelanosis. Patient's symptoms resolved without any additional intervention. He was discharged on pantoprazole and continued on aspirin, but his clopidogrel was discontinued.

DISCUSSION:

Prognosis of PM is not well understood, but it is considered a benign condition. Unlike melanosis coli, which is a similar finding of black/brown speckles in the colon that has been associated with colon cancer. Histochemical studies have shown the pigments found in PM are likely secondary to accumulation of iron sulfide, ferrous sulfate or lipomenin within the lysosomes of macrophages in lamina propria of small intestine. Current theories suggest PM develops secondary to impaired iron transport coupled with sulfur from anti-hypertensive medications. In our patient, his medical conditions and anti-hypertensive medications likely contributed to this benign finding. Although, considered a benign condition, it is imperative to identify this condition during endoscopy to exclude other serious conditions.
2548 Jejunal Perforation: A Very Rare Presentation of Jejunal Adenocarcinoma
Authors: Gill Jasmeet , Sannapaneni Shilpa , Feldman Mark
Published: October 2019

INTRODUCTION:

Small bowel malignancies constitute less than 5% of all gastrointestinal malignancies. The most common histological types of small bowel cancer are adenocarcinoma, neuroendocrine cancer, lymphoma and sarcoma. Adenocarcinoma represents 25-40% of primary small bowel malignancies, with the highest incidence in the duodenum and the incidence progressively decreasing down the small intestine.

CASE DESCRIPTION/METHODS:

A 69 year old previously healthy women presented with periumbilical pain for four weeks. She also reported early satiety but no weight loss. The night prior to presentation abdominal pain became severe with one episode of vomiting. There was no history of chronic NSAIDs use. She had a 40 pack-years smoking history. She had two cesarean sections and a total abdominal hysterectomy with bilateral salpingo-opherectomy. She did not have routine colorectal cancer screening. On abdominal examination she had a distended abdomen and mild periumbilical tenderness. Laboratory testing revealed leukocytosis of 15000/µL and a hemoglobin level of 10.2 g/dl with a low MCV 78.6 fl. Noncontrast CT of the abdomen showed wall thickening and focal perforation in a loop of jejunum. There was no bowel obstruction and no free intraperitoneal air seen. Exploratory laparotomy revealed a large inflammatory mass in the proximal jejunum densely adherent to the mid-transverse colon. There was a large perforation (3.5 cm of greatest dimension) of a jejunal mass. The mucosa surrounding the defect was hyperemic and thickened. Microscopic examination showed a well-differentiated adenocarcinoma invading into muscularis propria. There was no lymphovascular invasion and no metastasis were identified in 13 excised regional lymph nodes. Immunostains were negative for cytokeratin 7 (expressed in lung and pancreatic adenocarcinomas), focally positive for cytokeratin 20 (colorectal adenocarcinoma) and were positive for CDX2. CDX2 is a highly sensitive and specific marker of adenocarcinoma of intestinal origin.

DISCUSSION:

Jejunal adenocarcinoma is an extremely rare GI malignancy. The clinical presentation is often with abdominal pain and distension; only 10% present as a bowel perforation. Surgical resection is considered curative treatment for localized adenocarcinoma. Oxaliplatin-based adjuvant chemotherapy is suggested for patients with lymphovascular invasion. In our patient perforation per se was considered a high-risk feature and the patient was advised to have post-operative adjuvant chemotherapy.
2549 Unique Thoracic Cause of Atypical Adult Small Bowel Intussusception
Authors: Patel Neej J. , Kahn Allon , Lidner Thomas , Samadder Jewel
Published: October 2019

INTRODUCTION:

Rare in adults, intussusception can occur anywhere in the gastrointestinal (GI) tract causing an array of symptoms from abdominal pain, distension, and emesis to obstruction and bleeding. Most adult cases are caused by benign or malignant neoplasms while less are due to infection, surgical sequelae or congenital conditions. This unique case outlines the high suspicion warranted for rare causes and manifestations of small bowel intussusception (SBI).

CASE DESCRIPTION/METHODS:

A 70-year-old woman with a recent left parietal lobe hematoma with mass effect was admitted with 2 days of melena and symptomatic anemia. She quit smoking 1 month ago, takes aspirin, no NSAIDs and had no other significant histories. She had normal vitals and a benign abdominal exam. Rectal exam revealed nonbleeding external hemorrhoids, no melena or hematochezia. Initial Hgb was 5.9 g/d. After resuscitation, EGD and colonoscopy were performed. EGD revealed a normal upper GI tract with no source of bleeding. Colonoscopy revealed clotted blood throughout the colon but no source of bleeding. A video capsule endoscopy (VCE) was deployed the next day to evaluate suspected SB bleeding. While the VCE was recording, she bled briskly overnight with painless hematochezia. Urgent imaging revealed mid-jejunal SBI with active bleeding. She was stable, but given the concern for an underlying malignancy (large right upper lobe lung mass), she underwent an exploratory laparotomy with evidence of palpable, firm, immobile luminal masses in the jejunum corresponding well with her VCE findings, which is quite rare. This portion of SB was resected with end-end anastomosis. Pathology yielded 3 metastases from primary lung adenocarcinoma. She received 1 cycle of chemotherapy before pursuing hospice after suffering another intracerebral hemorrhage with severe mass effect.

DISCUSSION:

Intraluminal lead points in SBI are benign, metastatic or inflammatory. Despite most benign lesions being adhesions, Meckel diverticula, adenomas, lipomas or hemangiomas; malignancies can account for 15%-30% of cases. Malignancies are more common in colonic intussusception (65%-80%). Primary SB cancers are often leiomyosarcoma, lymphoma, adenocarcinoma, GIST, carcinoid and NETs. Metastatic melanoma commonly spreads to SB, while lung cancer rarely involves SB. Thus, our patient and her timely diagnostics/therapeutics highlight the clinical acuity garnered for this rare thoracic metastatic cause of an atypical adult SBI.