bluuebunny/crossref_metadata_2025 huggingface dataset:
3110 A Case of Reflux Esophagitis Mimicking Globus Sensation in a Patient With Cannabis Abuse
Authors: Wankhade Charudatta , Jacob Bobby , Jiyani Rucha , Karim Syed , Rizvon Kaleem
Published: October 2019

INTRODUCTION:

Cannabis is a widely used drug of abuse in the United States (US). It is mostly commonly abused by young individuals and is known for it's psychedelic effects. Cannabis is also utilized by the medical field for a number of medicinal purposes. We present a case of a young male who presented with sudden onset dysphagia and had a significant history of marijuana abuse for several years.

CASE DESCRIPTION/METHODS:

28 year old Caucasian male with a past medical history of ADHD presented with dysphagia. The symptoms started 2 days ago. He felt like the food was stuck in his throat. Every time he attempted to drink water or liquids it regurgitated. He also reported several episodes of nausea and vomiting since the onset of his symptoms. Review of systems was negative for odynophagia, fever, drooling, weight loss, chest pain, diarrhea, constipation or acid reflux. Denied any allergies, surgical history or family history. He denied alcohol or cigarette smoking. He agreed to smoking marijunana 2-3 times per day for over 4 years. Physical examination revealed a healthy non obese male with blood pressure and pulse of 120/80 mmhg and 86 per minute respectively. Rest of his examination was unremarkable. Upper endoscopy was performed on the day of admission which revealed LA Grade D esophagitis with multiple superficial ulcers extending 5 cm from GE junction. Patient was started on proton pump inhibitors twice daily. His symptoms improved and was eventually discharged. Biopsies were suggestive of changes consistent with chronic reflux esophagitis.

DISCUSSION:

Tetrahydrocannabinol (THC) is the active ingredient derived from Cannabis Sativum. THC works by stimulating the G protein-coupled cannabinoid receptors (CBR) receptors. The presence of CBRs in the esophagus, specifically those affecting transient lower esophageal sphincter relaxations (TLESRs), offers a potential therapeutic target for treating GERD. Using Delta (9)-THC, Beaumont et al. demonstrated decreased rate of TLESRs in healthy volunteers who received 10 and 20  mg of Δ9-THC on three occasions a week apart. However, in the high dose of ΔDelta (9)-THC (20  mg) group, central activity led to increased nausea, vomiting and reflux symptoms. With ongoing discussions for the legalization of recreational cannabis use in US, we may encounter an increase in the number of reflux esophagitis cases. With this in mind, additional studies would be beneficial to determine potential risk factors for developing severe reflux esophagitis with extensive marijuana use.
3115 Bronchoscope in the Esophagus?! A Novel Technique for Esophageal Strictures Management
Authors: Patel Shruti , Desai Jiten , Jiyani Rucha , Desai Zalak , Rizvon Kaleem
Published: October 2019

INTRODUCTION:

Benign esophageal strictures can result from long-standing GERD, ablative or radiation therapy, corrosive substance ingestion etc. Management of strictures could be very challenging. We describe a case of esophageal strictures that was managed with an innovative approach.

CASE DESCRIPTION/METHODS:

A 36-year-old Indian female with a history of esophageal strictures secondary to caustic ingestion 9 years ago presented with complaints of dysphagia. Patient underwent multiple EGD with dilatations in the early years of her stricture formation. Subsequently she was taught to perform self dilations in India, every 2 weeks to relieve dysphagia. An esophagram revealed a narrow caliber mid and distal esophagus with 3 prominent stricture points. During endoscopy an 8.8 mm gastroscope could not traverse the most proximal stricture hence a bronchoscope was used to evaluate the number and size of strictures for optimal use of pneumatic balloon catheter for dilation. The bronchoscope evaluation revealed 3 esophageal strictures at 25 cm, 30 cm and 35 cm from incisors. Serial dilations were performed with a balloon dilator and triamcinolone was then injected at the stricture site post dilation. Following this intervention she was able to defer dilatation for 6 weeks. Using a Bronchoscope a second session of dilatation and triamcinolone injection was repeated 6 weeks later. Therapy was required for one of the three strictures with the others having healed well. Patient has not been performing self dilations since her first EGD and continues to be asymptomatic.

DISCUSSION:

Caustic ingestion and its gastrointestinal sequelae such as stricture formation have been an important public health concern for decades. Damage and complications depend on several aspects: substance concentration and pH, length of time of tissue contact and amount ingested. The primary treatment of a caustic esophageal stricture is endoscopic dilatation, however sometimes management could be challenging. Using a bronchoscope (thin caliber scope), the high grade strictures in our patient were traversed and evaluated optimally prior to execution of the treatment modality. In our extensive literature review, a bronchoscope has never been used before for managing high-grade strictures, which makes our case unique. We believe that this new technique of utilizing a bronchoscope for evaluation of high-grade strictures can provide more targeted therapeutic approach and superior management to the patient.
3118 Case of Capecitabine-Induced Diarrhea Leading to Renal Failure Requiring Hemodialysis
Authors: Arroyo Yadis M. , Narasimha Shruthi , Bertran-Rodriguez Carlos E. , Pagan Andrea
Published: October 2019

INTRODUCTION:

Capecitabine is a cytotoxic oral prodrug of 5-fluorouracil used as a chemotherapeutic adjuvant in the treatment of colorectal cancer. The most common adverse effects reported are hand-foot-syndrome and diarrhea. Incidence of diarrhea has been reported in up to 67% of patients. The pathophysiology of capecitabine induced diarrhea is not well understood with most cases being attributed to drug toxicity and overexpression of inflammatory cytokines. Chemotherapy induced diarrhea (CID) can be deleterious and, in some cases, life threatening. The subsequent case presents the development of acute renal failure requiring hemodialysis after treatment with capecitabine.

CASE DESCRIPTION/METHODS:

Case of a 50-year-old man with stage 3B T2N2M0 moderately differentiated adenocarcinoma of the rectum who presented with non-bloody diarrhea after recently starting his first chemotherapy treatment with CAPOX-Oxaliplatin and Capecitabine. Laboratory studies were significant for acute kidney failure with creatinine of 2.9 mg/dL and non-anion gap metabolic acidosis with bicarbonate of 18 mmol/L. Physical examination was unremarkable. Infectious workup for diarrhea was negative. Patient's renal function progressively worsened and ultimately required hemodialysis. After a negative colonoscopy and multiple bowel regimens, including lomotil, questran, octreotide and budesonide, his diarrhea was deemed to be secondary to Capecitabine therapy and only started to resolve after initiation of budesonide. Upon interval follow up with gastroenterology his diarrhea had completely resolved, and creatinine was at baseline.

DISCUSSION:

Grade 3–4 diarrhea occurs in 11.4% of patients treated with capecitabine monotherapy. However, when used in combination with other chemotherapeutic drugs also known to cause diarrhea such as oxaliplatin, the incidence increases to 18.2%. In general, treatment is conservative and limited to IV hydration, electrolyte replacement, and medications such as, loperamide and octreotide. However, in cases with standard treatment failure, it has been proven that budesonide effectively reduces the effects of 5-FU on the intestinal mucosa. In the literature, no other cases have been reported of acute renal failure requiring hemodialysis after treatment with capecitabine. Given the unpredictability of the effects of chemotherapy induced diarrhea and its potential to increase morbidity and mortality, it is essential to maintain close monitoring of such patients and provide adequate supportive treatment.
3121 Spontaneous Breakage and Antegrade Enteral Migration of Jejunal Extension Tubing
Authors: Goens Donald , Berger Matthew , McDonald Edwin K.
Published: October 2019

INTRODUCTION:

Gastroenteric tube feeding can provide essential nutrition for patients with neurologic or mechanical dysphagia. Many patients undergo pre-pyloric feeding; however, some patients require post-pyloric feeding through jejunal access. These present additional challenges in placement with potential for complications. Here we discuss a rare complication of a jejunal extension portion of a gastrojejunostomy (G-J) tube separating and becoming a foreign body.

CASE DESCRIPTION/METHODS:

A 77-year old woman with a past medical history of rheumatic heart disease with mitral stenosis and pulmonary hypertension (pHTN) was admitted for acute decompensated pHTN. Three months prior the patient had underwent radiologic percutaneous placement of a pull-type gastric-tube (G-tube) for dysphagia due to severe deconditioning. One week later she developed gastroparesis and the tube was exchanged under fluoroscopy with a 9-french G-J tube extension. Upon admission patient was tolerating tube feeds without complication and underwent intravenous diuresis for her pHTN exacerbation. On hospital day seven she reported onset of abdominal pain and bloating. Physical exam noted new right-upper quadrant tenderness and mild distention, G-J tube insertion site appeared normal without leakage or skin breakdown. Abdominal x-ray showed the jejunal extension tubing had separated from the G-tube balloon insertion and was visualized projecting coiled over right lower quadrant (Figure 1). Tube feeds were held and the gastroenterology service was consulted. At time of re-examination abdominal symptoms had resolved. Given the positioning of the tubing, serial abdominal imaging and supportive measures of daily suppositories to facilitate spontaneous passage by rectum were recommended. The patient was restarted on tube feeds through the remaining G-tube without complication. Ultimately the jejunal extender proceeded through the colon (Figure 2) and passed by rectum 5 days later without complication (Figure 3).

DISCUSSION:

The placement of jejunal extensions through existing gastrostomy tubes is typically a well-tolerated procedure and antegrade migration of jejunal tubing is rare. In this case the jejunal tubing somehow separated from its gastrostomy tube anchor. In the event of this rare complication it is reasonable to monitor for spontaneous passage with serial imaging as demonstrated in this case, with consideration for surgical exploration or endoscopic retrieval if there is non-progression of the tube or an associated complication.
3122 The Adventures of a Missing Denture
Authors: Rojas Patricia Guzman , Gonzaga Ernesto Robalino , Henriquez Richard , Vergeli-Rojas Jeannette
Published: October 2019

INTRODUCTION:

Foreign body ingestion is a common clinical situation, and most of the ingested foreign bodies (80%) pass spontaneously through the gastrointestinal tract. Though, if an impaction is present, it usually occurs in the anatomic constrictions or angulations of the GI tract.

CASE DESCRIPTION/METHODS:

We present a 56 y.o. man with PMH of reflux and diverticulosis. The patient presented to the ED complaining of swallowing his dental implants 5 hours prior to admission. He denied having abdominal pain, nausea, vomiting after the accidental ingestion. Physical exam showed a soft, non-tender abdomen and oral examination revealed a 4 cm × 1 cm denture missing that corresponded to the teeth implant. CT abdomen was done showing an ingested denture located at the gastric area (Figure 1: left panel). GI was consulted and an EGD was performed the morning after admission. The EGD was unremarkable and no dentures were found, for this reason a repeated abdominal serial xrays were ordered to monitor the foreign body. The X-Ray (Figure 1: middle panel) displayed the denture at the region of the distal ileum. In light of failure to pass spontaneously, a colonoscopy was performed the next day. At the colonoscopy, the dentures were found in the cecum (Figure 2) and these were retrieved without immediate complications.

DISCUSSION:

Although dental ingestion is not uncommon, there are several risks factors that were absent in our patient, like edentulism, psychoneurological deficit, and abnormal level of consciousness. Furthermore, this patient was a middle-aged healthy adult, completely alert and able to report any sudden GI symptom. Regarding the management of ingested foreign bodies, timing of the intervention depends on the size, shape, content and anatomic location of these, being the esophagus the most common site for impaction, and if occurs, this warrants an emergent endoscopy. Objects longer than 6 cm are unlikely to pass the duodenum and they need urgent removal. In our case, the foreign body had a maximum diameter of 4 cm; reason why an EGD was not emergent. A colonoscopy was performed in view of the possibility that the dentures were located at the IC valve, which is the most frequent place of perforation. We present this patient in order to elucidate a non-complicated foreign body ingestion, that needed endoscopic removal by means of a colonoscope. Furthermore, we would like to emphasize the safety of monitoring foreign objects with blunt edges and less than 6 cm in diameter.
3123 Massive Pneumoperitoneum Following G-Tube: Is Severe Constipation a Risk Factor?
Authors: Senatore Frank , Dellatore Peter , Seril Darren
Published: October 2019

INTRODUCTION:

Pneumoperitoneum has been shown to occur in approximately 5% of patients undergoing gastrostomy tube (G-tube) placement via esophagogastroduodenoscopy (EGD). Of those, only half have clinically significant symptoms normally in the setting of moderate to large pneumoperitoneum. We report a case of massive pneumoperitoneum presenting as an acute abdomen without overt perforation.

CASE DESCRIPTION/METHODS:

An 80-year-old male with recently diagnosed piriform sinus squamous cell carcinoma was directly referred to our endoscopy unit by his oncologist for G-tube placement given plans for chemoradiation. He was asymptomatic. We performed an EGD which revealed normal gastric and duodenal mucosa. A site was located in the gastric body and the stomach was insufflated revealing excellent transillumination and one-to-one manual external pressure. A 20Fr G-tube was successfully placed via the pull-guidewire technique. Post procedure, he was asymptomatic and tolerated an oral diet. Next day he presented to the emergency room with severe abdominal pain and distention. He was afebrile, tachycardic and had a rigidly distended abdomen. White blood cell count was 11.8 and lactic acid was 2.3. Computed tomography (CT) scan showed large free intraperitoneal air concerning for perforation. He was given antibiotics, kept NPO and seen by general surgery. Review of the CT scan showed the G-tube bumper in the stomach with oral contrast filling it without extravasation and dense stool burden filling the entire colon (Figure 1). Delayed images showed contrast in the small and large intestine without any extravasation. Polyethylene glycol solution was initiated via the G-tube resulting in numerous bowel movements and significant symptom improvement. Imaging performed 48 hours after revealed resolution of pneumoperitoneum and stool burden (Figure 2). He was discharged on a bowel regimen and continued to be asymptomatic at follow-up.

DISCUSSION:

This case illustrates the importance of clinical acumen when evaluating patients' post-procedure, as this patient's initial imaging and exam findings could have resulted in an unnecessary surgery. Further, we hypothesize insufflation during EGD in a patient with severe constipation can result in a high-pressure gradient driving air into the peritoneum via the iatrogenic perforation site. This case emphasizes caution in performing G-tube placement in patients with severe constipation and also highlights the potential pitfalls of a direct referral endoscopy system.
3129 Management of a Massive Peptic Ulcer Bleed With Over-the-Scope Clip
Authors: Namn Yunseok , D'Souza Lionel , Guillaume Alexandra
Published: October 2019

INTRODUCTION:

Actively bleeding ulcers located in the posterior duodenal bulb are often difficult to manage with conventional endoscopic treatment. We present a case of a successful use of over-the-scope-clip (OTSC) of a spurting artery after failing multiple standard endoscopic therapies.

CASE DESCRIPTION/METHODS:

A 60 year-old man with a history of myocardial infarction in 2014 on aspirin and plavix presented with pre-syncopal symptoms and five episodes of melena that started one day prior to admission. The patient denied prior use of anticoagulants and history of gastrointestinal bleeding. Upon presentation, his vitals were stable and initial lab values were as follows: hemoglobin 9.8 g/dL (baseline 15 g/dL), platelet count 342 K/uL, INR 1.2, and BUN 29 mg/dL. He was started on an intravenous proton pump inhibitor. An esophagogastroduodenoscopy showed multiple large cratered ulcers measuring 1-2.5 cm involving most of the duodenal bulb. There was evidence of active bleedingfrom a spurting pulsatile vessel along the posteroinferior wall at the apex of the duodenal bulbnear the sweep (Figure 1). Initial attemptsat hemostasis wereunsuccessful despite injection of 1:10,000 solution of epinephrine andthe use of thehemostatic spray. The use of a coagulation forceps was unsuccessful as well. Given the location of the vessel and mucosal friability, the lesion was not amenable to through the scope clipping. Hemostasis was finally achieved after successful placement of a 12 mm OTSC (Figure 2). In addition, the area was retreated with the remainder of the hemostatic spray (Figure 3). The patient was transferred to the medical intensive care unit where overnight, the hemoglobin decreased from 8.2 g/dL to 7.2 g/dL without overt evidence of bleeding. The patient underwent angiography which did not reveal any active extravasation and empiric coil embolization of the gastroduodenal artery was performed.

DISCUSSION:

We present a case of a massive peptic ulcer bleed that was difficult to manage with standard treatment based on the large size and posterior bulb location. OTSC is commonly used for severe recurrent bleeding but its role during the index endoscopy is still unclear. OTSC should be considered as a potential first line therapy in bleeding lesions at high risk of standard endoscopic treatment failure.
3132 Duodenal Spindle Cell Lipoma as a Rare Cause of Upper GI Bleeding
Authors: Hafiz Nazar , Pandit Sudha , Rashid Shazia , Maruvada Smita , Alexander Jonathan , Jordan Paul , Manas Kenneth J. , Morris James D.
Published: October 2019

INTRODUCTION:

Spindle cell lipomas are benign tumors commonly seen arising from subcutaneous tissue. Incidence of duodenal lipoma as a cause of GI bleed is very rare, however spindle cell variant of duodenal lipoma has never been reported per our review. To our knowledge this is the first case of duodenal spindle cell lipoma in an atypical location presenting as upper GI bleed.

CASE DESCRIPTION/METHODS:

A 68 year old lady with medical history significant for coronary artery disease with stents and GERD came in with complaints of shortness of breath. She also complained of melena and weight loss without any hematemesis or abdominal pain. Vitals were stable. Labs remarkable for Hb 9.9, iron panel suggestive of significant iron deficiency with serum iron of 16, ferritin 17. Endoscopy showed a 5 cm non bleeding submucosal lesion with ulceration which was concerning for GIST and a possible source of chronic bleeding. Mass was not biopsied, however patient later underwent duodenal bulb lesion resection with end to end gastroduodenostomy. Pathology of intestinal resection showed duodenal mucosa with an associated spindle cell lipoma. Immunohistochemical stain of duodenal lesion was positive for S100 and CD34, and immuno-negative for remaining stains (CD117, beta-catenin, and EMA), thus consistent with spindle cell lipoma. On follow up, Hb increased and pt reported clinical improvement.

DISCUSSION:

Primary GI lymphoma is common in stomach. Small intestine and colonic lymphoma account for 9% and 1% respectively. There have been multiple reports published citing association of lymphoma in IBD patients treated with immunomodulators. Our patient had two stomas (ileostomy and colostomy). Both peristomal biopsies were positive for B cell lymphoma. Peristomal lymphoma has been rarely reported. Parnesh et al. (Case 1) reported a similar case of stomal lymphoma in a patient with history of Ulcerative Colitis. Levecq et al. (Case 2) reported a stromal lymphoma in a patient with transfusion related AIDS who underwent total colectomy and ileostomy for indeterminate colitis. The lymphoma was diagnosed at 20 years (case 1) and 2 years (Case 2) post-stoma formation. Lymphoma should be in the differential of stoma being complicated by peristomal tissue proliferation, fistula and infection.
3134 Rare Complication of Delayed Bleeding After Polypectomy
Authors: Truscello David , Torres Justin , Shah Maulik , Weston Joshua , Blair Brian
Published: October 2019

INTRODUCTION:

Colonoscopic polypectomies have been the mainstay in polyp removal since the 1970s and are associated with a much better morbidity and mortality than surgery. However, clinically evident bleeding can occur in 0.2-1.0% of cases. Herein lies a case report of postpolypectomy bleeding following a routine esophagogastroduodenoscopy and colonoscopy. We also discuss the risk factors and management of these patients.

CASE DESCRIPTION/METHODS:

Patient is a 77 year old male who present to the Emergency Department from home after an elective EGD and colonoscopy earlier that day. The patient was found to have a deep antral polyp and required cautery. A sigmoid polyp was also found, and was removed. After the elective procedure earlier in the day, the patient denied any signs overt bleeding. However, upon returning home he felt very weak. The patient had a bloody bowel movement at home and became pale and diaphoretic. Patient was taken to Emergency Department and found to be hypotensive at 60/40 mmHg and had a witnessed episode of hematemesis. Hemoglobin on admission was 8.0 g/dL. Protonix drip was started yet despite a 1L bolus of saline and 2 units of RBCs in ED, patient remained unstable. His AIMS65 score was 3 which was indicative of a 10.3% mortality. Patient was on coumadin for afib but it was held 5 days prior to procedures. Overnight patient had a 3 more bloody bowel movements and 5 more units of RBCs given, however he remained hypotensie and required ICU monitoring and norepinephrine. Emergent EGD revealed no active bleeding but a large 2 cm clean based ulcer where antral polypectomy occurred earlier. No intervention was done due to lack of active bleeding and size of ulcer. By day 9 patient had hemodynamically stabilized and biopsy from initial endoscopy resulted as hyperplastic histology concerning for mild dysplasia.

DISCUSSION:

Bleeding can occur immediately following a polypectomy or can be delayed from hours to weeks. Delayed PPB can occur due to sloughing of eschar or scab that covered a blood vessel, or an increasing zone of necrosis induced by the thermal energy used to resect the polyp and cauterize the site. Rates of delayed PPB range from 0.02-2.0% with a variety of risk factors. The larger the polyp, the higher the risk of PPB with some reports indicating an increase incidence of 9-13% for every 1 mm in polyp diameter. Patients should have any antiplatelet therapy held, with the exclusion of aspirin, prior to these procedures. NSAIDs should be avoided up to two weeks after polypectomies.
3142 Atypical Presentation of an Upper Gastrointestinal (GI) Bleed Manifesting as Extranodal Involvement of Diffuse Large B-Cell Lymphoma (DLBCL) Diagnosed in a Community Setting
Authors: Giang Jimmy , Ruzkowski Charles , Woslegel Colin E.
Published: October 2019

INTRODUCTION:

Diffuse large B-cell lymphoma (DLBCL) is the most common type of Non-Hodgkin's Lymphoma (NHL), with 5.4 new cases diagnosed per 100,000 persons as of 2016. There is a male predominance, with an average age of 64.2. One extranodal site involves the GI tract, predominantly the stomach. Commonly seen are mucosa associated lymphoid tissue lymphomas and DLBCL. The majority of cases present at stage III/IV, with 40% presenting as local involvement. Here we present an unusual case of extranodal DLBCL in a patient presenting with dysphagia and an upper GI bleed.

CASE DESCRIPTION/METHODS:

An 85 year-old female presented for evaluation of dysphonia, ongoing for several months. The patient complained of bilateral submandibular adenopathy, dysphagia, trouble breathing, and a 15 pound weight loss over two weeks. Computed tomography of the neck revealed a nasopharyngeal mass in the left (L) nasopharynx extending into the nasal cavity, right (R) nasopharynx, and eroding into the skull. Additionally, bilateral necrotic cervical lymph nodes and L supraclavicular adenopathy were also seen. Histologic sample was consistent with DLBCL, non-germinal center type. Fluorescence in-situ hybridization was negative for MYC rearrangement, t(8:14), t(4:18), and Epstein Barr Virus, but indeterminate for BCL6 rearrangement. She was staged IIA and underwent radiation therapy without chemotherapy. During treatment, the patient was admitted for evaluation of an upper GI bleed associated with dysphagia, fatigue, and progressive weakness. She underwent an esophagogastroduodenoscopy with findings showing Los Angeles class A esophagitis, large, inflammatory nodular tissue within the lesser curvature of the stomach with associated linear ulcerations, multiple punctate ulcers throughout the gastric body and antrum, duodenitis, and a small, clean-based ulcer in the duodenal sweep. Histology of the gastric mass revealed an atypical clonal lymphoid infiltrate involving the gastric mucosa, suggestive of DLBCL, with clonal immunoglobulin heavy chain gene rearrangement.

DISCUSSION:

This case represents an atypical presentation of an upper GI bleed that is the result of extranodal involvement of DLBCL. An atypical presentation like this should have lymphoma in the differential for those with a history. Treatment is dependent upon the extent of disease, usually starting with the regimen of rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone therapy. If left untreated, this disease can progress rapidly and prove fatal.
3143 Gastric Volvulus: Coffee Ground Emesis and NGT Resistance in an Otherwise Asymptomatic Elderly Man
Authors: Chaudhury Samiran Roy , Oak Rachana , Akhavan Shahrzad Anita , Lapin Seth , Mun Michael
Published: October 2019

INTRODUCTION:

Adult gastric volvulus is generally diagnosed by the symptoms of abdominal or chest pain. Acute presentation include symptoms of pain, vomiting, and failure of placement of naso-gastric tube (NGT) also known as Borchardt Triad. Severity of sequelae is dependent on significance of the rotation with rotations of >180° causing possibly outlet obstruction, strangulation, necrosis leading to perforation and severe sepsis leading to death.

CASE DESCRIPTION/METHODS:

A 92 year old gentleman is admitted for UTI related sepsis and started on antibiotics. On day 8 of his admission, patient complained of abdominal epigastric pain and had two episodes of dark red colored particulate emesis. Hemoglobin was stable and physical exam showed mild distention and slight tenderness on palpation but was otherwise nonsignificant. Multiple attempts at nasogastric tube placement were difficult due to resistance during insertion at below oro-pharyngeal levels. Abdominal CT scan (Figures 2 and 3) was completed showing left diaphragmatic hernia with herniation of the stomach with upside down stomach is noted with partial gastric outlet obstruction with the distended stomach, indicating organo-axial volvulus. This was not obviously noted in the admission chest X-ray (Figure 1). Given requirement for gastrostomy, patient was transferred to hospital of their choice where he subsequently received surgery and was discharged 4 months later.

DISCUSSION:

The diagnosis of gastric volvulus in this patient was not initially apparent as his abdominal pain complaints were very mild, his labs were normal and stable, and his initial admission was for sepsis. It was primarily the resistance in the placement of the NGT and the coffee-ground emesis that raised suspicion and prompted the CT imaging scan, which revealed the diagnosis. Therefore, it is important to have medical professionals remain cognizant of the possibility of the diagnosis of gastric volvulus, no matter how rare, in an elderly patient with resistance to NGT placement. And although the Borchardt triad is apparent in 75% of acute gastric volvulus cases, it is important to remember that up to 25% of patients do not present classically, and therefore gastric volvulus should not be excluded as a possible diagnosis.
3145 Dieulafoy's Lesion: An Underdiagnosed and Underrecognized Cause of Gastrointestinal Bleed
Authors: Riaz Sana , Kudaravalli Pujitha , Saleem Sheikh A. , Gupta Anand
Published: October 2019

INTRODUCTION:

Acute gastrointestinal bleed accounts for nearly 50-150 cases per 100,000 each year. The etiology in the majority of cases is peptic ulcer disease (PUD). Dieulafoy's lesion is a rare (accounts for 1-2%), but potentially life-threatening cause of gastrointestinal (GI) bleed. We present a case of recurrent hemodynamically significant upper GI bleeding requiring multiple hospitalizations and endoscopies to identify a duodenal Dieulafoy's lesion as the primary source for bleed.

CASE DESCRIPTION/METHODS:

A 52-year-old male with a history of chronic alcohol use was admitted to the intensive care unit for the third time within a one-year duration for recurrent episodes of melena. During the first two episodes, upper GI endoscopy was positive for mild gastropathy, and a small 4-5 mm partially healed duodenal ulcer respectively. The exam was negative for any esophageal varices or other upper GI pathologies. The patient responded well both times to medical therapy and subsequently discharged home. In the third admission for similar presentation with melena and hemodynamically significant GI bleed, endoscopy was positive for an actively bleeding duodenal Dieulafoy's lesion. Bleeding was controlled with hemostatic clips and epinephrine injections. He was discharged home 48 hours after stabilization. Post-discharge, he was followed for a year, and he remained asymptomatic. It was therefore concluded that Dieulafoy's lesion was the likely cause of GI bleed that had evaded diagnosis during the first two endoscopies.

DISCUSSION:

Dieulafoy's lesion is a dilated submucosal vessel that erodes the epithelium and most commonly found in the stomach. Approximately one-third of the lesions are extragastric and located in the duodenum and colon. They are typically seen in men, around the fifth decade, in the presence of comorbidities such as hypertension, diabetes, chronic kidney disease, or alcohol abuse. Dieulafoy's lesions are under-diagnosed as they are silent until presentation. Approximately 33% of the lesions may require more than one EGD to identify the active source of bleeding, especially in the presence of other causes of GI bleed such as PUD. In our patient, the culprit for his recurrent GI bleeding was identified as Dieulafoy's lesion on the third endoscopy. We want to highlight the importance of the diagnosis and management of Dieulafoy's lesion as it can significantly decrease the mortality from 80% to 8.6%.
3149 Ulcerative Colitis in an Octogenarian: A Diagnostic and Therapeutic Challenge
Authors: Debnath Dipanjan , Singh Pratiksha , Shrimanker Isha , Goel Siddharth , Cheriyath Pramil
Published: October 2019

INTRODUCTION:

Individuals aged >60 years contribute to 10%-15% of inflammatory bowel disease diagnoses with merely 10% of them being over 80 years of age. Older-onset ulcerative colitis (UC) is more common than Crohn's disease, with a male preponderance. Compared to younger patients, UC in the elderly manifests more as proctitis, has a subtler presentation with lesser bleeding, diarrhea, and abdominal pain, and a lower risk of relapse, but with increased severity. Till date, literature regarding UC in the octogenarian age group is limited to a handful of case reports.

CASE DESCRIPTION/METHODS:

An 81-year-old-male, non-smoker, with a history of coronary artery disease and family history significant for systemic lupus erythematosus, presented with moderate to severe, dull, periumbilical abdominal pain of one-month duration, associated with mucoid diarrhea, intermittent high-grade fever, anorexia, and unintentional weight loss. He denied any nausea, vomiting, blood in vomit or stools, icterus or pruritus. He did not report any history of high-risk behavior or recent travel. His examination was unremarkable except periumbilical and diffuse lower abdominal tenderness. Laboratory evaluation was notable for leucocytosis (13.5 K/ul), hyponatremia (128 mEq/L) and hypokalemia (3.1 mEq/L). U/S abdomen showed intestinal distension and a trial of opioid receptor agonists and probiotics was initiated for a probable diagnosis of irritable bowel syndrome, which failed to show clinical improvement. Treatment with broad-spectrum antibiotics, based on CT findings suggestive of colitis, led to partial symptomatic relief. Colonoscopy was performed following a recurrence of symptoms that revealed multiple areas of ulcerations and a biopsy confirmed the diagnosis of UC. The patient received guideline-directed medical therapy with 5-aminosalicylates and corticosteroids, which led to clinical improvement, and since then, the patient has been in remission.

DISCUSSION:

The unique pathophysiology, clinical manifestations and disease course of UC in the elderly add to its diagnostic challenge. Additionally, the scarcity of literature regarding treatment guidelines and lack of clarity of appropriate clinical endpoints (objective vs.symptom control) limits evidence-based decision in this population with a higher hospitalization and mortality rate. Consequently, a high degree of suspicion needs to be maintained in the aging population presenting with clinical features of colitis to ensure prompt treatment and limit complications.
3155 Macroscopic to Microscopic: A Case of Crohn's Disease Progressing to Collagenous Colitis
Authors: Dwivedi Sankalp , Balagoni Harika , Piper Marc , Piper Michael
Published: October 2019

INTRODUCTION:

Microscopic colitis (MC), sub-typed into lymphocytic and collagenous colitis is characterized by normal endoscopic/macroscopic/radiologic colonic mucosa but abnormal histological findings and presents as chronic, non-bloody diarrhea mostly in elderly females. Association of MC with inflammatory bowel disorders (IBD), Crohn's or Ulcerative colitis is unclear and has been rarely reported. Herein, we present a patient with Crohn's disease with eventual progression to MC.

CASE DESCRIPTION/METHODS:

56-year-old female presented with 12-day non-bloody diarrhea with nocturnal symptoms, weight loss, and diffuse cramping abdominal pain. No fever, sick contacts, travel, food contamination, recent antibiotics or new medications. CT Abdomen/Pelvis was normal. Labs showed leukocytosis, elevated CRP and fecal-calprotectin. Colonoscopy showed inflammation characterized by congestion, granularity, cobblestoning of mucosa from the rectum to the transverse colon. The IC valve was stenotic and difficult to intubate. Biopsy showed mild-chronic active colitis without granulomas or dysplasia. CT Enterography showed narrowing of TI and two other small bowel segments. The patient was started on steroids for possible Crohn's disease and bridged to Adalimumab. Despite being compliant, the patient was re-admitted with 10-day non-bloody diarrhea after 2-3 months. Colonoscopy showed improved endoscopic inflammation but biopsies revealed collagenous microscopic colitis. Trials of budesonide, cholestyramine, bismuth and loperamide along with Adalimumab were unsuccessful. The patient was on SSRI, which was discontinued. The patient continued to be symptomatic. Repeat colonoscopy showed endoscopically benign mucosa and continued presence of collagenous colitis on biopsy. Given the refractoriness of the patient's symptoms, she was referred to IBD specialist at a tertiary center.

DISCUSSION:

Concomitant presence of MC with IBD or progression of one condition to other is rare and the pathogenesis is unclear. It is hypothesized that IBD and MC may share common pathophysiologic pathway, but there is no clear data. A study proposed increased Th1/Tc1, TNFα-producing cells, and a subset of Th2/Tc2 cells, to be involved in MC-to-IBD transformation. The clinical relevance of our case is to emphasize the consideration of MC in a patient with UC or CD, who develops chronic, non-bloody diarrhea. Mucosal biopsies should be obtained to rule out MC. Once confirmed, the management should be adjusted accordingly.
3156 A Case of Rapidly Progressing Ulcerative Colitis
Authors: Laharwal Mehak M. , Vikraman Praveen K. , Sapru Sunil , Ramasamy Dhanasekaran
Published: October 2019

INTRODUCTION:

Ulcerative colitis is often characterized by a relapsing and remitting course. Acute flare ups may present as a serious illness. Most patients show a good response to intravenous corticosteroids which is the cornerstone of management of flare ups. However, a number of patients may develop a rapidly progressive illness and will need a colectomy. We present one such case where a colectomy was needed within four weeks of presentation.

CASE DESCRIPTION/METHODS:

Case report: A 30-year-old female presented to the emergency department for evaluation of high grade fever and abdominal pain associated with vomiting and foul-smelling, non-bloody, diarrhea 5-6 times a day. She had a history of developmental delay with refractory epilepsy but no previous reports of bowel symptoms. Abdominal X-ray showed small bowel obstruction. Further, a dilated colon with intramural edema was seen on CT scan along with an obstruction of distal small bowel. Stool was positive for leukocytes and calprotectin. CRP was elevated. Blood and stool cultures were negative. Three days later, she started having bloody diarrhea. Flexible sigmoidoscopy showed features of chronic severe colitis with ulceration. The tissue was negative for cytomegalovirus. She was diagnosed with inflammatory bowel disease after positive serology and treated with mesalamine and intravenous steroids followed by infliximab infusions with minimal improvement. She developed recurrent bowel obstructions and toxic megacolon for which she underwent a total colectomy with end ileostomy which was life saving for her.

DISCUSSION:

Acute severe colitis is a medical emergency and despite improvements in medical care, a substantial number of patients fail to achieve remission. Based on the criteria developed by Truelove and Witt, acute severe ulcerative colitis is characterized by the presence of more than 6 bloody stools per day along with any one of the following: tachycardia >90 bpm, fever >37.8 °C, Hb <10.5 gm/dL, and/or ESR >30 mm/h. Nearly 20% of patients end up needing a colectomy during first admission. Intravenous corticosteroids are the mainstay of initial therapy. Response to steroids should be assessed after 3 days. This is indicated by an improvement in symptoms as well as laboratory parameters like CRP, hemoglobin and serum albumin. Partial or non-responders should be considered for alternative therapies. Colectomy is regarded as a lifesaving procedure in those not responding to medical treatment and must be considered as the next therapeutic step.
3163 Laparoscopic Transgastric ERCP for Choledocholithiasis After Roux-en-Y Gastric Bypass: A Different Approach to ERCP
Authors: Wojtkowski Antoni , Pandit Sarbagya , Atia George , Chalise Shyam
Published: October 2019

INTRODUCTION:

With bariatric procedures becoming more prevalent, performing an ERCP becomes a challenge with patients who have had bariatric surgeries.

CASE DESCRIPTION/METHODS:

A 60 year old male with a past medical history of hypertension, diabetes mellitus type 2, and Roux-en-Y gastric bypass surgery developed abdominal pain 3 days prior to admission and was admitted for a laparoscopic cholecystectomy. Pre-operative MRCP did not show any significant common bile duct obstruction (a small non-obstructing stone was noted). Intraoperatively, the stone was found to be obstructing the common bile duct after a cholangiogram was performed. A laparoscopic trans-gastric ERCP was scheduled. The ERCP was scheduled for the next day. After a laparoscopic gastrostomy, the ERCP scope was advanced through the gastrostomy and the stone was removed with standard biliary sphincterotomy and balloon extraction without complications. The gastrostomy site was closed, and the procedure finished without complications. The patient was discharged in good condition 2 days after the procedure.

DISCUSSION:

An ERCP in a Roux-en-Y gastric bypass patient requires careful planning with surgery. Nonetheless, the time of the procedure is shortened considerably compared to the older double-balloon approach and shorter anesthesia overall is associated with better outcomes for the patient. One surgical approach to these patients is a transgastric approach through gastrostomy (either laparoscopic or open surgical approach). The open approach is achieved by creating an opening in the abdominal wall, and attaching the gastric wall to the opening, then opening it for the ERCP scope to be advanced through. In this particular case, a laparoscopic gastrostomy was performed in the distal area of the stomach, and cannulated with a 15 mm cannula through an umbilical port. An 11 mm ERCP scope was then inserted through the trocar directly into the stomach, and advanced to the pylorus where the gastroenterologist was able to cannulate the common bile duct. A stent was not placed in this particular case, as it would require repeat surgery to remove it. The gastrostomy was then closed by a mini laparotomy. Alternative approaches to GI procedures will become more common with the growing prevalence of bariatric procedures.
3164 The Unhelpful Biopsy: Autoimmune Hepatitis in a Young Woman With Kikuchi Fujimoto Disease
Authors: Magee Jared S. , Lindholm Phillip C.
Published: October 2019

INTRODUCTION:

Kikuchi Fujimoto disease (KFD), also known as histiocytic necrotizing lymphadenitis, is a rare, immune-mediated condition usually seen in young Asian females. There are only two reported cases of autoimmune hepatitis (AIH) in a patient with KFD. Systemic lupus erythematosus (SLE) has a strong association with KFD and introduces diagnostic uncertainty in differentiating AIH and SLE-hepatitis. We present a challenging case of acute hepatitis in a woman with KFD, positive rheumatologic signal and bland liver biopsy.

CASE DESCRIPTION/METHODS:

A 33-year-old female presented with non-bloody emesis. Her history was significant for KFD and exam was notable for jaundice and a diffuse maculopapular rash involving palms and soles. She had normal vitals and was previously known to have a positive ANA (1:640) and anti-dsDNA. Labs were notable for ALT 843, AST 646, alkaline phosphatase 173, total bilirubin 10.6 with direct bilirubin 8.6. Given her elevation in transaminases, additional serologies and imaging were performed demonstrating a mildly elevated transferrin, no sign of viral hepatitis and a right upper quadrant ultrasound and MRCP with nonspecific hepatitis. She was admitted for expedited workup and further laboratory evaluation was notable for a mildly elevated IgG and negative for abnormalities in ASMA as well as p-ANCA, Anti-LKM1, and ALC-1. Serologies were overall consistent with a probable diagnosis of AIH and a liver biopsy was planned to secure a definitive diagnosis. However this demonstrated non-specific necrosis and cholestasis, inconsistent with AIH. After a prompt response to steroids and a negative antiribosomal P antibody, probable AIH was suggested and she recovered uneventfully.

DISCUSSION:

Diagnosis of AIH can be made with clinical presentation, laboratory evaluation and biopsy. Our patient presented with a probable diagnosis of AIH (score of 14 by AASLD guidelines), yet a negative ASMA, bland biopsy and a positive SLE signal (though not meeting formal diagnostic criteria) were significant confounders. Treatment response to steroids suggested AIH by AASLD scoring, yet SLE hepatitis is also steroid responsive. Negative anti-ribosomal P antibody may suggest decreased likelihood of SLE hepatitis, and this distinction is critical given the more benign course of SLE-hepatitis. This is a rare case of KFD associated, probable AIH, yet there remains much overlap with SLE-hepatitis. We recommend additional research to determine clinical or laboratory criteria to differentiate these diagnoses.
3168 Acute Liver Failure, Rhabdomyolysis, and Acute Kidney Injury Secondary to Influenza A Infection
Authors: Ghanim Marcel , Ghazaleh Sami , Nehme Christian , Awad Mohammed , Nesheiwat Zeid , Nawras Ali
Published: October 2019

INTRODUCTION:

Influenza A is considered a self-limiting pulmonary infection with a constellation of respiratory symptoms. However, it is sometimes associated with unfortunate complications with high morbidity and mortality. We present a case who suffered from rhabdomyolysis, acute kidney injury, and acute liver failure secondary to influenza infection.

CASE DESCRIPTION/METHODS:

A 22-year-old male presented with red urine for one day associated with muscle pain in the thighs, back, neck, and extremities. He also had fever, chills, sore throat, and dry cough for 4 days. Past medical and surgical histories were unremarkable. Family history was insignificant. He did not take medications. He denied cigarette, alcohol, or IV drug use. He denied headache, nausea, vomiting, diarrhea, chest pain, hematemesis, or hemoptysis. On exam, the patient was in no acute distress. Vital signs were within normal limits. Abdominal exam showed a soft, non-tender, and non-distended abdomen without organomegaly. Initial testing revealed an elevated creatinine of 2.02 mg/dL. Urinalysis was significant for the presence of blood, but RBC count was 0/HPF. CK was elevated at 407,176 U/L and myoglobin elevated at 33,673 ng/ml. AST was elevated at 1540 U/L and ALT at 286 U/L. Respiratory pathogen panel was positive for influenza A. The patient's acute kidney injury was believed to be secondary to rhabdomyolysis. Extensive testing to look for the cause of elevated liver enzymes came back negative including viral hepatitis, iron studies, HIV, liver ultrasound, and abdominal CT. Similarly, no cause for rhabdomyolysis was found and autoimmune workup was negative. The patient's labs continued to worsen over his hospital course. His creatinine peaked at 8.69 mg/dL and he eventually needed dialysis. His CK continued to trend up and peaked at 1,271,160 U/L. His liver enzymes also trended up with AST peaking at 4100 U/L and ALT at 1043 U/L. Eventually, his liver enzymes and CK trended down to normal levels and he did not require liver transplantation. Unfortunately, his kidney function did not completely recover, and he still required dialysis.

DISCUSSION:

Although rare, extrapulmonary involvement of influenza A infection can happen and rhabdomyolysis is exceedingly rare. In our case, rhabdomyolysis was believed to be due to influenza A infection. As a result, he developed acute kidney injury requiring dialysis. His acute liver failure was believed to be multifactorial secondary to influenza infection and/or rhabdomyolysis.