bluuebunny/crossref_metadata_2025 huggingface dataset:
2687 A Rare Case of Organoaxial Volvulus of the Stomach
Authors: Lopez Michell , Then Eric O. , Ofosu Andrew , Are Vijay S. , Culliford Andrea , Gaduputi Vinaya
Published: October 2019

INTRODUCTION:

Gastric volvulus is an uncommon and potentially life-threatening clinical entity characterized by rotation of the stomach along its long or short axis provoking variable degrees of gastric outlet obstruction. Clinical presentation varies between acute and chronic volvulus. Here we present a rare case of chronic organoaxial volvulus presenting with dysphagia.

CASE DESCRIPTION/METHODS:

The patient is an 87 year old male with a medical history of hypertension, obstructive sleep apena, multi-nodular goiter (with thyroid resection resulting in vocal cord paralysis) who was referred to the gastroenterology clinic for dysphagia. The patient states he had dysphagia to solids for one year. The patient denied associated nausea, vomiting, hematemesis, hematochezia, constipation or unintended weight loss. Complete blood count and comprehensive metabolic panel at that time were unremarkable. Physical exam was also unremarkable. Given his symptoms a barium swallow was ordered to further evaluate his gastrointestinal tract. This was done and showed no evidence of esophageal obstruction or esophageal mass, but did incidentally find organoaxial rotation of the stomach. The patient was scheduled to undergo upper esophagogastroduodenoscopy, but was non-compliant with the appointment and lost to follow up.

DISCUSSION:

Acute gastric volvulus usually presents with sudden onset abdominal or chest pain, severe retching with occasional vomiting, and epigastric distention. Chronic gastric volvulus on the in contrast can present with a complete absence of symptoms to non- specific symptoms, such as abdominal pain, dyspepsia, dysphagia, acid reflux, nocturnal cough, hiccups, non-bilious vomiting, weight loss, and anemia. Diagnosis of gastric volvulus is conventionally achieved with chest radiograph, upper barium studies or CT- scan. Regardging treatment of acute symptomatic gastric volvulus, nasogastric decompression is usually the first step, followed by surgery. Some patients at high risk for surgery, mainly elderly, can also be treated endoscopically with adequate decompression and reduction of the stomach and placement of a gastrostomy tube to gastropexy the stomach to the abdominal wall.
2690 Omental Infarct: A Rare Cause of Acute Abdomen
Authors: Singh Tejveer , Jarodiya Vijay , Khan Zarak H. , Misra Preeti , Iljas John
Published: October 2019

INTRODUCTION:

Omental infarct is a rare cause of acute abdominal pain resulting from vascular compromise of the greater omentum. This condition usually has a nonspecific clinical presentation with right lower quadrant being the most common location and is usually managed conservatively. We present a rare case of idiopathic omental infarct.

CASE DESCRIPTION/METHODS:

35-year-old obese caucasian male with past medical history significant for hypertension and GERD presented to the emergency department with chief complaint of right lower quadrant pain which started 3 days ago without any precipitating event. Initial labs were unremarkable with vital signs only significant for elevated blood pressure. CT of the abdomen and pelvis with contrast showed significant inflammation in the right side of the abdomen most likely representing omental infarct. On call general surgeon was consulted who suggested no acute surgical intervention and patient to be managed medically with ciprofloxacin and metronidazole. On call vascular surgeon was consulted; advised there was no immediate need for anticoagulation as there was no evidence of acute vascular issues such as embolization and/or dissection involving the celiac or the superior mesenteric arteries. Following day, the patient improved clinically and was discharged with total of 10 days of antibiotic treatment and to follow-up outpatient with general surgeon.

DISCUSSION:

Omental infarct is a rare cause of acute abdominal pain. Clinical presentation includes sudden onset of acute abdominal pain located mostly in the right lower quadrant with tenderness and absence of any other GI symptoms. Omental Infarction can be isolated event or in succession to omental torsion. A diagnosis of primary/idiopathic omental infarct is made when no identifiable etiology is determined. Secondary causes of omental infarction include hypercoagulability, vasculitis, abdominal adhesions, cysts, and tumors. Other contributing factors include obesity, local trauma, heavy food intake, coughing, sudden body movements, laxative use, and hyperperistalsis. CT of the abdomen may show focal area of fat stranding, swirling of omental vessels, omental torsion, and/or hyperdense peripheral halo. The disease is often self-limiting and managed conservatively. Complications such as abscess can occur which may require surgical or radiologically-guided drainage.
2694 Median Arcuate Ligament Syndrome: The Ambiguous Cause of Abdominal Pain
Authors: Zackria Rasiq , Hwang Andrew W. , Sagami Justin
Published: October 2019

INTRODUCTION:

Median Arcuate Ligament Syndrome (MALS) is often under-diagnosed due to its rarity and overlap of symptomatology with other abdominal pathologies. The pathology involves the median arcuate ligament compressing the celiac artery leading to chronic, postprandial abdominal pain, nausea, vomiting, and weight loss. Making the diagnosis is complicated by a lack of sensitive diagnostic modalities.

CASE DESCRIPTION/METHODS:

A 69-year-old female with a history of emphysema, scoliosis, and interstitial cystitis presented for severe postprandial abdominal pain, nausea, vomiting, and anorexia from fear of food. She had a standing diagnosis of chronic ischemic mesenteric colitis for years. On examination, she had diffuse abdominal tenderness with radiation down to her upper thighs, nausea, vomiting, and cachexia. The initial labs were unrevealing. CT abdomen demonstrated severe arteriosclerosis of the celiac artery with 75% stenosis, as well as moderate stenosis of SMA, IMA, and bilateral renal arteries. Despite an inconsistent physical exam, vascular surgery agreed with the reading of ischemic colitis and suggested that a celiac stent be placed. Upon further review of the CT and an interdisciplinary conference, her images were determined to be consistent with celiac artery compression. The patient is to be scheduled for the release of the median arcuate ligament with a possible celiac nerve block.

DISCUSSION:

When suspecting MALS, a triad of postprandial abdominal pain, weight loss, and abdominal bruit may be the only findings to suggest the diagnosis. With our patient not having a bruit and imaging showing severe stenosis, this only made the diagnosis of MALS even more discrete. Imaging may show a narrowing of the celiac artery for further clues followed by confirmation testing via:

• Inspiratory/Expiratory ultrasonography – may show an increased visible compression of the artery during expiration with the increased blood flow velocity.

• Gastric Tonometry – physiological testing, as well as measurements of arterial PaCO2 levels before and after exercise, may also be used to predict the success of decompression.

• Ganglion Nerve Block – percutaneous celiac ganglion block, using an anesthetic to block nerve fibers of celiac plexus, which may be diagnostic and therapeutic.

This case presents the difficulty of diagnosing MALS due to its overlap with the more common ischemic colitis. Having a keen clinical suspicion with a better understanding of the workup for MALS may prevent misdiagnoses and misguided therapies.
2698 Spontaneous Vasogenic Gastric Necrosis
Authors: Putnam Tyler , Turse Erica , Kadkhodayan Kambiz
Published: October 2019

INTRODUCTION:

Gastric ischemia is a potentially lethal condition which can lead to necrosis, perforation, and overall increased mortality. To our knowledge, this is the first report of spontaneous vasogenic gastric necrosis. We present a patient with spontaneous idiopathic vasogenic gastric necrosis leading to a positive outcome.

CASE DESCRIPTION/METHODS:

75-year-old female presented with a three day history of diffuse progressive abdominal pain, nausea, and bilious emesis. Physical exam was remarkable for diffuse abdominal tenderness, hyperactive bowel sounds and guarding. Labs revealed WBC 15.6 thousand/ul and Lactic Acid 2.9 mmol/L. CT abdomen showed gas in the gastric wall and portal vein (Figure 1). Upper endoscopy revealed diffuse necrotic gastric tissue without perforation (Figure 2). After noting this, the patient was taken to the OR where a total gastrectomy with roux-en-y esophagojejunostomy was performed. Pathology showed active chronic gastritis with ulceration and focal hemorrhagic necrosis, ruling out malignancy and H.pylori. The patient recovered well and was discharged to a short-term care facility.

DISCUSSION:

Spontaneous ischemic gastric necrosis is a rare and potentially life-threatening if improperly managed. Mortality rate is high for gastric ischemia (33-41%) and even higher for perforation (50-80%)3-4. 75% of cases are from local vascular causes, others being obstruction or hypoperfusion2. Commonly patients present with abdominal pain, GI bleeding and confusion4. The pathophysiology of acute idiopathic gastric mucosal damage is unclear. One hypothesis describes an overwhelming amount of gastric acid, bile salts and ischemia causing a marked decrease in mucosal blood flow to gastric tissue1,5. Given the acuity and rapid clinical progression, it's imperative to have a high degree of clinical suspicion when evaluating such patients. In this case, a prompt diagnosis and early management led to a positive outcome.
2699 An Uncommon Cause of Vomiting and Abdominal Pain in Pregnancy
Authors: Barlass Usman , Rzepczynski Allison , Naqshband Shezray , Lee Salina
Published: October 2019

INTRODUCTION:

Anisakis is a zoonotic parasitic disease that infects marine mammals. Gastrointestinal anisakiasis is caused by consumption of undercooked or raw seafood infected by nematodes of the Anisakis species. While it is common in Asia it is an uncommon infection in North America with only a few reported cases. Here we present a case of gastric anisakiasis in a pregnant woman complicating the diagnosis and management.

CASE DESCRIPTION/METHODS:

A 32 year old newly pregnant female presented to the infectious disease clinic with acute onset abdominal pain and emesis. She reported finding two mobile “worms” in raw salmon, after ingesting six ounces of the fish, a day before. A specimen was sent to the microbiology laboratory with the preliminary read concerning for roundworm. Given the concern for anisakiasis, pregnancy status and risk of perforation, she was directly admitted for upper endoscopy. This revealed a thin, translucent, 20 mm × 1 mm worm burrowed into the greater curvature of the proximal antrum. The worm was removed in entirety with cold biopsy forceps and sent to microbiology. Biopsies were taken from the site of burrow. Pathology was consistent with mild gastritis with focally increased eosinophils and no remnant of the parasite. The worm was identified as anisakis species. The patient’s symptoms resolved spontaneously. Her pregnancy limited evaluation of the remainder of her G.I tract for evidence of infection. Since she had no symptoms of obstruction, she was discharged with instructions to complete a bowel purge upon returning home.

DISCUSSION:

Gastric anisakiasis is uncommon in the U.S. In addition, this case was complicated by the patient’s pregnancy, precluding the use of imaging techniques such as CT scans to help narrow the diagnosis in suspected anisakiasis and exonerate complications. Obstruction is a commonly reported complication for which there has been reported success with Albendazole therapy, undesirable in this case, being pregnancy category C. Another reported and somber complication includes perforation from the burrowing of untreated parasites. To minimize adverse outcomes with imaging and antiparasitic therapy, our patient underwent curative endoscopic therapy followed by a bowel purge to empirically purge remaining parasites from the distal G.I tract. With globalization of cuisine and increasing consumption of raw fish in the west, physicians should have a heightened suspicion of parasitic infections such as anisakis given the significant sequalae of untreated infection.
2705 Incidental Finding of Gastric Adenocarcinoma on Random Gastric Biopsy: A Call for Methodical Examination of the Gastric Mucosa
Authors: Tetangco Eula Geralyn , Coles Michael , Little Leonard , Schubert Moonkyung
Published: October 2019

INTRODUCTION:

Gastric cancer is the 5th most common neoplasm and the 3rd most deadly cancer worldwide. Adenocarcinomas account for 95% of cases. It is more prevalent and has a higher mortality in males. We present a case of gastric adenocarcinoma detected incidentally on random gastric biopsy.

CASE DESCRIPTION/METHODS:

A 73-year old white male underwent upper endoscopy for reflux. He had a 55-pack year smoking history, no significant alcohol use, and normal BMI. Esophagogastroduodenoscopy (EGD) revealed a 4 mm hypopigmented area in the incisura and was otherwise normal. Random gastric biopsies included the area. One of 6 specimens revealed intramucosal adenocarcinoma in a background of intestinal metaplasia, and H. pylori organisms. It involved the lamina propria and was suspicious for invasion. On repeat EGD 11 days later, previous biopsy sites were seen showing some fibrosis, likely given the short interval between endoscopies. Frozen section biopsy of the incisura confirmed cancer. Due absence of a visible lesion, the site was biopsied extensively and tattooed prior to surgical referral. The patient underwent distal gastrectomy with Roux en Y reconstruction and lymphadenectomy. The surgical specimens showed no residual malignancy, negative and viable margins, and benign lymph nodes. Quadruple therapy successfully eradicated H. pylori.

DISCUSSION:

The incidence of gastric cancer in North America is 5.6 per 100,000, higher than that for esophageal cancer. The 5-year survival rate in the US is 31%, reflecting that most diagnoses are made when the cancer has metastasized. This rate increases dramatically to 94% and 88% when stage IA and IB tumors are surgically treated, respectively. Early gastric cancer can be subtle in appearance and may be missed during routine endoscopy. Retrospective studies comparing examination time for EGD reveal that endoscopists with longer mean exam (longer than 7 min in the US, 3 min in Korea) detect more neoplastic lesions than shorter exams. The European Society of Gastrointestinal Endoscopy to recommends an examination time of 7 minutes from intubation of the esophagus to extubation. This case highlights (1) that a comprehensive systematic exam must be consistently performed to investigate the entire stomach, (2) the importance of NBI with near focus mode to closely examine mucosal vascularization and pit pattern in order to diagnosis of a small malignant lesions, and (3) the need for targeted biopsies to be placed in separate jars.
2707 Gastric Mucosa-Associated Lymphoid Tissue Lymophoma Treated by Endoscopic Mucosal Resection
Authors: Kim Seong-Taeg , Young Na Soo
Published: October 2019

INTRODUCTION:

Primary low-grade gastric Mucosa-associated lymphoid tissue (MALT) lymphoma is a distinctive type of B-cell lymphoma. Endoscopic appearances of low-grade gastric MALT lymphoma are quite varied and polypoid or subepithelial type (exophytic) is rare. Here, we reported the case of H. pylori negative gastric MALToma presenting as an exophytic subepithelial tumor, diagnosing and treating by endoscopic mucosal resection (EMR).

CASE DESCRIPTION/METHODS:

A 53-year-old man was referred to our hospital because of a large subepithelial tumor of the stomach, which was incidentally found on an endoscopy for a routine checkup in outside hospital. Initial outside endoscopic biopsy was a simple chronic gastritis. Physical examination and laboratory results were unremarkable. On endoscopic examination, a 2.0 cm sized round and hard exophytic subepithelial tumor was seen on the great curvature side of high body of the stomach. The tumor showed a well-demarcated smooth border without any erosion and ulceration. An abdominal pelvic CT demonstrated an enhancing subepithelial tumor without regional lymphadenopathy, such as gastrointestinal stromal tumor. EUS showed a hypoechoic and heterogeneous mass in the 2nd and 3rd layer with ill-defined internal margin. EMR was done for both the definite diagnosis and the treatment without complications because the tumor had a semipedunculated morphology. Results of a histopathologic examination of the resected tumor showed diffuse lymphocytic proliferation in the submucosa mimicking a subepithelial tumor with lymphoepithelial lesions. Dense lymphocytic infiltration composed of mainly B cells forming vague follicular colonization. Immunohistochemical stain of cytokeratin also showed presence of lymphoepithelial lesions. The Ki-67 was positive in 7%. Histologically, no H. pylori was observed in the luminal side. Finally, the patient was diagnosed as a H. pylori–negative extranodal marginal zone B-cell lymphoma (MALToma) (stage EI1). No additional treatment such as chemotherapy or radiation was performed. The follow-up endoscopic examination showed no recurrence until 2 years after EMR.

DISCUSSION:

We suggest that EMR may be an alternative treatment modality in the diagnosis and the treatment of gastric MALT lymphoma in cases of submucosal or polypoid morphology type, especially when H. pylori is negative. Further study in terms of feasibility, efficacy, and long-term safety of EMR as a curative treatment would be warranted.
2716 A Rare Case of Gastric Glomus Tumor
Authors: Ghimire Subash , Yang Tsujung , Shah Harshil , Sarker Ashit , Srivatana Ukorn
Published: October 2019

INTRODUCTION:

Glomus tumors are benign mesenchymal neoplasms found predominantly in the extremities. Involvement of the GI tract is rare (<2%). Stomach is the most common site in GI tract.(1) Clinical presentation is usually nonspecific and diagnosis is made based on pathological study after surgical resection. We describe the case of a 35 year old male presenting with upper GI bleeding found to have glomus tumor during endoscopy.

CASE DESCRIPTION/METHODS:

A 35 years old male with past medical history of musculoskeletal low back pain, who was on meloxicam for past several weeks presented to the hospital with complaints of black tarry stool and lightheadedness. This was associated with weight loss. On examination, he was hemodynamically stable, was found to have pallor, there was no icterus. He had mild epigastric tenderness. Esophagogastroduodenoscopy (EGD) was done that showed moderate inflammation with edema, erythema, friability and granularity around the gastric body and the gastric antrum. It revealed a large submucosal non-circumferential mass in the gastric body with no bleeding and no stigmata of recent bleeding (Figure 1). Contrast enhanced CT scan was obtained that revealed a 3 cm enhancing soft tissue mass. Endoscopic ultrasound (EUS) showed an intramural lesion in the body of stomach that appeared to originate from within the muscularis propria (layer 4) (Figure 2). Fine-needle aspiration (FNA) was performed that was positive for neoplastic cells. He underwent laparoscopic resection of gastric mass (3 cm × 3 cm). Biopsies showed a basaloid proliferation of cytologically bland cells growing in nodules with focal areas of fibrosis, some tumor cells showed cytoplasmic clearing. Tumor cells were positive for smooth muscle actin, calponin, h-caldesmon, synaptophysin, desmin. Final diagnosis of glomus tumor of the stomach was made.

DISCUSSION:

Diagnosis of glomus tumor should be considered in a patient with gastric submucosal mass. The diagnosis is usually by pathology and immunohistochemistry (2). Most of the tumors are benign in nature, malignant changes are rare. They need long term follow up to look for recurrence.
2718 Gastric Pneumatosis in the Setting of Underlying Gastric Ulcer: An Uncommon Case Report Presentation
Authors: Figueredo Carlos , Boroda Konstantin , Hertan Hilary
Published: October 2019

INTRODUCTION:

Gastric Pneumatosis (GP) is a rare entity that is usually caused by emesis with forceful retching and inoculation of intraluminal gas into the stomach wall. GP is divided into two subtypes: emphysematous gastritis (EG) and gastric emphysema (GE). EG is a result of both direct inoculation and hematogenous dissemination of gas forming bacteria in the setting of immunosuppression, alcoholism, diabetes mellitus, and NSAID use. The clinical outcome tends to be septic shock and death. GE is less fatal and is diagnosed radiographically as air within the stomach wall. Conservative management is the treatment of choice. GE is commonly associated with gastric outlet obstruction, pulmonary injury, and other traumatic events.

CASE DESCRIPTION/METHODS:

A 56-year-old male nursing home resident, with Wernicke’s encephalopathy was sent to the ED after multiple episodes of hematemesis. On presentation, vital signs of HR:116, RR: 26. Physical exam exhibited diffuse abdominal tenderness, distension, decreased bowel sounds with noted involuntary guarding, but no rebound or rigidity. Decline in mental status and respiratory failure, prompted intubation. Initial labs showed leukocytosis of 15.2, normal Hb of 16.2, and AKI with Creatinine: 2.93. CT scan revealed severely distended stomach with gastric pneumatosis; distended small bowel loops, with a decompressed distal ileum and no discrete transition zone. CT showed also showed a large stool burden in the colon (Figure 1). EGD was initially deferred given high risk of gastric perforation. The patient was treated with bowel rest, NG tube decompression, IV fluids, PPI drip, and empiric Ceftriaxone and Metronidazole. Consequently, CT scan with IV contrast repeated on day 4 showed resolution of GP with patent mesenteric vasculature (Figure 2). EGD done on same day with evidence of diffuse moderate inflammation characterized by congestion (edema) in the entire stomach, and one non-bleeding linear gastric ulcer in the upper body, with a clean ulcer base (Forrest Class III) (Figure 3). Biopsies showed signs of chronic inflammation and reactive changes, as well as focal intestinal metaplasia in stomach antrum.

DISCUSSION:

Self-resolution of gastric pneumatosis after medical management is consistent with the benign course of GE, with reported positive clinical outcomes and low risk of recurrence. In this case, the patient’s gastric ulcer and vomiting associated with constipation contributed to his gastric emphysema. Absence of hepatoportal venous gas was a good prognostic sign.
2726 Dilemma of Hypercalcemia and Persistent Peptic Ulcer Disease: Case Report and Literature Review
Authors: Bella Saif , Najar Hatem , Shumeyko Mark
Published: October 2019

INTRODUCTION:

Hypercalcemia has been linked to peptic ulcer disease (PUD), but between the two is not well understood. We are presenting a case of PUD that did not respond to long term twice daily PPI but did improve when the hypercalcemia was corrected with parathyroidectomy.

CASE DESCRIPTION/METHODS:

A 48-year-old male patient underwent one yearlong evaluation for persistent abdominal pain. His evaluation included three CT scans, EGD as well as octreotide and parathyroid scans. Initially, it was believed that his symptoms were related to severe PUD that did not respond to prescribed medical treatment due to poor patient compliance. He presented to the ED complaining of epigastric pain. Abdominal imaging revealed inflammation and narrowing of the entire duodenum as well as non-obstructive nephrolithiasis. His Calcium level was 11 mg/dl. An EGD revealed many non-bleeding cratered duodenal ulcers in the entire duodenum. An acquired non-obstructing, benign-appearing, intrinsic stenosis was found in the third portion of the duodenum. Biopsies were negative for H. pylori infection. He denied NSAID use. He was discharged on oral PPI therapy twice daily. Two months later, he returned with recurrent abdominal pain after running out of his PPI. CT scan showed persistent inflammatory changes involving the entire duodenum to the jejunum. Serum gastrin level was 201 pg/ml. Calcium level was 10.4 mg/dL. He was treated symptomatically with plans for outpatient push enteroscopy. The patient’s clinical course was complicated by obstructive nephrolithiasis requiring bilateral ureteral stents. Almost one year later, he returned with abdominal pain. Another CT scan showed persistent duodenitis. His labs showed evidence of Hypercalcemia 12 mg/dl. Gastrin Level 382 pg/ml. Octreotide scan was performed and was negative for any active neuroendocrine tumor. Parathyroid scan revealed parathyroid adenoma. The patient underwent parathyroidectomy and did well. He was discharged home on PPI twice daily. He was seen in follow-up and denied any PUD symptoms.

DISCUSSION:

This patient with severe non-resolving peptic ulcers. Removal of the parathyroid adenoma resulted in complete resolution of his symptoms. The gastric secretory response to hypercalcemia may be responsible for the occurrence of peptic ulcer disease in patients with hyperparathyroidism. In conclusion, serum calcium level must be considered among the usual tests in patients with rare and/or non-specific abdominal symptoms and part of the workup for persistent PUD.
2729 An Unusual Location of a Mucosal Schwann Cell Hamartoma
Authors: Rojas Patricia Guzman , Gonzaga Ernesto Robalino , Macias Kathlyn Camargo , Parikh Jignesh
Published: October 2019

INTRODUCTION:

Nerve sheath tumors are rarely found in the gastrointestinal tract andhave been seen only in association with inherited syndromes such as neurofibromatosis type I (NF-1), multiple endocrine neoplasia type 2B (MEN 2B) and Cowden syndrome. Mucosal Schwann cell hamartoma (MSCH) is a new entity described by Gibson et al. in 2009 and has mostly been described in the colorectal area.

CASE DESCRIPTION/METHODS:

A 59-year-old man with no pertinent past medical history visited the gastroenterology clinic as a scheduled appointment for a long-standing history of GERD. He denied any nausea, vomiting, early satiety, abdominal pain or unintentional weight loss. His diagnosis was made on a clinical basis, and for this reason, an EGD was recommended. The EGD showed no abnormalities and esophageal mucosa was not erythematous (Figure 1). Multiple biopsies were taken. Pathology results showed mucosal Schwann cell hamartoma features in the antral biopsies (Figure 2).

DISCUSSION:

The exact incidence of MSCH is not known but it is mostly seen in female patients. MSCH has specific histological characteristics: lack of circumscription, absence of peripheral lymphoid cuff, crypt entrapment and strong positive stain for S-100. It is important to differentiate it from other spindle cell tumors since this will affect the management, prognostication and monitoring of possible associated complications. Differential diagnosis includes gastrointestinal stromal tumors (GISTs), carcinoid tumor, leiomyoma, schwannoma, mucosal neuroma, neurofibroma and ganglioneuroma. GISTs are the most common spindle cell tumors in the GI tract, however they have immunoreactivity to C-KIT and CD 117. GI schwannomas are mostly found in the stomach, but these have peripheral lymphoid cuffs and Antoni-A and Antoni –B regions. MSCH presents as a polypoid lesion in the colon and patients are typically asymptomatic. However, they can also present with rectal bleeding when the tumor is located in the colorectal area. This tumor follows a benign course and there is no need for treatment or extraction. Given its recent discovery and rarity, there is only one case report in the literature describing gastric affectation of the MSCH tumors. We describe this case due its unusual location as this is the 2nd case in the literature describing gastric affectation. Furthermore, a correct histological characterization is recommended since it will be crucial for the management and prognostication of these patients.
2737 An Over-the-Scope Clip Rescue of a Perforation During a Conversion Form ESD to EMR of a Symptomatic Large Bleeding Duodenal Lipoma
Authors: El Douaihy Youssef , Alsheikh Mira , Andrawes Sherif
Published: October 2019

INTRODUCTION:

Lipomas are the second most common benign GI tumors. Their distribution varies vastly among different sections of the digestive system and their management is dictated by the location, size and whether they cause symptoms or not. Traditionally they were removed surgical but with the advancement of the technology and third space endoscopy, endoscopist are more experienced in endoscopic therapy of such lesions.

CASE DESCRIPTION/METHODS:

53 yo male with PMHx of morbid obesity had a recent admission for acute blood loss upper GI bleeding (UGIB) with profound acute anemia and a hemoglobin of 6.3 requiring several blood transfusions. On gastroscopy he was found to have an ulcerated 6 cm duodenal pedunculated lesion with a recent bleeding described as a pigmented spot (Forrest IIc).

Procedure:

The endoscope with a distal cap attached was advanced into the stomach. In order to prevent possible GI hemorrhage, an endoloop was successfully placed on the base of the stalk. An attempt to snare the pedunculated mass with a large hexagonal snare failed given the size of the mass. Subsequently, submucosal dissection was started. Using the SB knife a alternating coag and cut modes were utilized to perform safe dissection. A shiny layer of fat was exposed in the middle of the polypoid lesion. Then the SB knife was switched to an IT knife to complete the dissection. Coag grasper was used to achieve hemostasis, the mass was captured and taken out with a snare. Ex vivo it measured 5.4 cm. After the dissection a 1 cm partial perforation was noted. The dual grasper was used to approximate the defect and a 12 mm OVESCO type was deployed to succefully close the defect. the scope was then withdrawn. The patient was admitted for monitoring and a contrast small bowel series. A gastrografin small bowel series confirmed a contained leak in the duodenum. The patient was NPO for 24 hours. A repeat study at that point showed resolution of the leak. A clear liquid diet was started and the patient was monitored for another 24 hours then was discharged home.

DISCUSSION:

With the emergence of new tools, technology and technics, third space endoscopy is leading to more invasive resection. This comes at a cost of increased complications. None the less these new advancement are putting at the endoscopist tools to manage these complications independently.
2753 Got the GIST: Multidisciplinary Management of an Acute Bleeding Gastrointestinal Stromal Tumor
Authors: Baliss Michelle , Clark August , Dayah Rawan , Guturu Praveen
Published: October 2019

INTRODUCTION:

Gastrointestinal stromal tumors (GISTs) account for 1%-3% of all gastrointestinal tumors. They most commonly arise in the stomach followed by the jejunum/ileum. Presentation varies from incidental discovery during autopsy or endoscopy to acute gastrointestinal (GI) bleeding or bowel obstruction. We report a case of this rare neoplasm in a patient with an acute GI bleed, treated endoscopically with hemostatic spray and ultimately with arterial embolization and surgical resection.

CASE DESCRIPTION/METHODS:

A 67-year-old female with a family history of colorectal cancer presented to the emergency department for hematemesis and left lower quadrant abdominal pain for 1 day. Physical examination was notable for left lower quadrant tenderness to palpation. Initial laboratory data showed a hemoglobin of 12.8 g/dL from 14.4 g/dL 8 months prior. A CT scan of the abdomen demonstrated a 3.2 × 4.1 cm well-circumscribed mass along the lesser curvature of the stomach arising from the gastric wall. Overnight, she had an episode of large volume hematemesis and became tachycardic and hypotensive. Her hemoglobin dropped to 7 g/dL. An esophagogastroduodenoscopy (EGD) showed LA Grade D esophagitis and a submucosal ulcerated gastric tumor on the lesser curvature of the stomach to which Hemostatic powder spray was applied. She initially refused surgical intervention and remained hemodynamically stable for ∼12 hours after EGD. She then had multiple episodes of hematemesis with hypotension despite blood transfusions. She underwent embolization to the left gastric artery after which hemostasis was achieved. She then decided to proceed with surgical resection of the gastric mass. Pathology confirmed the diagnosis of GIST, spindle-cell type with strongly positive stains for DOG-1 and CD117.

DISCUSSION:

GISTs are rare tumors that originate from mesenchymal stem cells. Although 40% of gastric GISTs present with GI bleeding, there are no clear guidelines on the management of these lesions. Therapeutic endoscopy and arterial embolization are effective methods used in the management of GISTs with acute bleeding. Hemostatic spray, an inorganic powder that concentrates clotting factors on bleeding surfaces, can be used adjunctively to other methods for the management of bleeding GISTs especially when traditional endoscopic techniques are challenging or when surgery is not an option. This case highlights the importance of a multidisciplinary approach in the management of these rare tumors.
2754 A Gaping Hole in the Stomach - A Rare PEG Tube Complication
Authors: Gupta Nikita , Likhtshteyn Michelle , Kancharla Pragnan , Iqbal Sadat , Al-Ani Firas , Grossman Evan
Published: October 2019

INTRODUCTION:

Up to 200,000 gastrostomy tubes (PEG) are placed in the United States each year, with a success rate over of 95%. Here we present a patient with complaints of abdominal pain and discharge from the PEG site, who was found to have an interesting EGD finding.

CASE DESCRIPTION/METHODS:

A 52 year old cachectic woman with a history of opioid abuse, roux-en-Y gastric bypass for obesity 14 years prior, and PEG placement due to inadequate oral intake almost 3 months prior to her admission, presents to the ED with worsening abdominal pain, nausea, intermittent vomiting and discharge of fecal like material from PEG site for the last few days. On exam patient appeared cachectic, disheveled, and had diffuse erythema of her abdominal wall. Vital signs were significant for hypothermia to 91.3 F, and bradycardia. Labs were significant for sodium of 152. CT abdomen and pelvis showed the PEG tube in satisfactory position. She was started on IV fluids and antibiotics but soon became hypoxic and tachycardic requiring medical ICU care. Subsequently, bleeding around the PEG tube was noted. Hemoglobin dropped from 9.8 to 7.2 within 9 hours. Lavage of the PEG tube revealed coffee ground material. Due to patient’s tenuous respiratory status, it was decided to perform an upper endoscopy by accessing the stomach via the gastrostomy fistula. The PEG tube balloon was deflated and the endoscope was easily inserted without resistance. The peritoneum was immediately visualized, which contained undigested food (Figure 1). The endoscope was withdrawn and was navigated into the body of the stomach, via a large opening. A significant amount of undigested material was seen in the remnant stomach (Figure 2). There was an opening between the remnant stomach and the gastric pouch (Figure 3), which was traversed with the endoscope. The gastric pouch was severely ulcerated and the gastrojejunal anastomosis could not be identified. The patient was then transferred to the hospital where her previous surgery and PEG tube were placed. There, her hospital course was complicated by ARDS requiring intubation. She eventually underwent replacement of PEG tube and after 50 days of hospitalization, she was discharged home.

DISCUSSION:

Procedure related complications such as perforation can occur anywhere from <0.5-1.8%. In this case, although the PEG tube may have initially been placed in the stomach, the replacement balloon PEG tube may have been inserted into the peritoneum. Complications such as these should always be a consideration.
2755 Metastatic Melanoma of the Stomach
Authors: Leung David , Miles Michelle , Chandradas Sajiv
Published: October 2019

INTRODUCTION:

The GI tract is rarely affected by secondary tumors. One of the most common primary malignancies is melanoma, however, the stomach is a rare location for metastasis of malignant melanoma. We present a rare case of a patient who developed metastatic melanoma to the stomach.

CASE DESCRIPTION/METHODS:

An 82-year-old male with a prior history of melanoma presented with a chief complaint of hematemesis. Two weeks earlier, the patient had discovered an enlarged left axillary lymph node. His oncologist acquired a PET scan which demonstrated lower lobe pulmonary nodules and left axillary adenopathy. A biopsy of the axillary lymph node revealed metastatic melanoma. On the day of admission, he had several episodes of dark bloody emesis. Initial laboratory workup revealed a hemoglobin of 4.4. The patient was resuscitated and subsequently underwent an endoscopy. Innumerable black nodules were found scattered throughout the duodenum and stomach (Figure 1) along with a large ulcerating nodule with a depressed black center in the body of the stomach (Figure 2). Multiple cold biopsies revealed infiltration of the duodenal and gastric mucosa with discohesive malignant cells, abundant mitotic figures, and focal pigment formation. Immunohistochemical stains showed the cells to be positive for SOX10 and Melan-A (Figure 3). This confirmed metastatic melanoma within the upper GI tract and oncology was consulted for further management.

DISCUSSION:

The most common gastrointestinal metastatic sites from melanoma are the small bowel, followed by the colon, rectum and then stomach. The stomach is a rare location with a reported incidence of only 7%. Patients often present at an advanced stage of disease and prognosis is dismal. Median survival period from diagnosis is 4-6 months. Diagnosis is not commonly made before endoscopy as associated symptoms are non-specific and rarely present. Endoscopically, gastric melanomas are classified into 3 main morphological types: ulcerated melanotic nodules, submucosal masses with ulcerations, and mass lesions with necrosis and melanosis. The classic appearance is multiple, small nodules that can be pigmented or ulcerate to produce a bulls-eye appearance. The mechanisms underlying metastatic melanoma to the stomach are unclear. Four pathways may be involved in the metastatic spread of primary cancers to the stomach which includes peritoneal dissemination, hematogenous dissemination, lymphatic spread, and direct tumor invasion.
2758 Lymphocytic Gastritis With Hypoproteinemia Treated With Helicobacter pyloriEradication
Authors: Murthi Mukunthan , Murali Rangan
Published: October 2019

INTRODUCTION:

Lymphocytic gastritis with hypoproteinemia is a rare condition and has been associated with Helicobacter pylori infection. We present the case of a 59-year-old female with hypoproteinemia associated with lymphocytic gastritis. The hypoproteinemia resolved after eradication of H. pylori.

CASE DESCRIPTION/METHODS:

The patient is a 59-year-old female who presented with complaints of early satiety. She had lost fifteen pounds over a period of six months. The patient had no other significant past medical history, and her clinical examination was normal except for minimal epigastric tenderness. She had no signs of malnutrition and did not have chronic diarrhea. On routine workup, she was found to have low total protein and normal albumin. Total protein on initial presentation was 5.4 g/dL. Eight weeks later, her total protein was still low (5.5 g/dL) with slightly low albumin (3-4 g/dL) as well. She had normal liver function tests and a negative celiac screening. Upper endoscopy revealed some patchy erosion of the antrum and thick gastric folds in the proximal body. Biopsies from the antrum and body revealed severe lymphocytic gastritis with chronic active inflammation. There were significant surface and foveolar epithelial infiltration by T lymphocytes (more than thirty lymphocytes per 100 epithelial cells). Immunohistochemical staining did not show Helicobacter pylori, but she did have positive H. pylori antibodies in the serum. The patient was treated with triple therapy for two weeks. Six weeks after eradication of H. pylori, her total protein increased to 7.5 g/dL. She also gained six pounds and was asymptomatic.

DISCUSSION:

Very few cases of lymphocytic gastritis-associated hypoproteinemia that resolved after eradication of H. pylori have been described in literature. Previous reports indicate that eradication of H. pylori is associated with prompt and significant improvement of hypoproteinemia as well as eventual disappearance of lymphocytic gastritis. Studies have suggested that lymphocytic gastritis condition is likely a rare and specific immune response to H. pylori. Links have also been described between lymphocytic gastritis and celiac disease as well as between lymphocytic gastritis and varioliform gastritis. This case serves to further establish an etiological link between H. pylori infection and lymphocytic gastritis accompanied by a protein-losing state.
2760 A Case of Collagenous Gastritis: A Rare Entity
Authors: Cortez Nathaly , Mahfouz Mahmoud , Berzosa Manuel , Bloom Michael
Published: October 2019

INTRODUCTION:

Collagenous gastritis (CG) is a rare histopathologic entity that involves marked subepithelial collagen deposition in the gastric mucosa. Endoscopic findings can be diverse such as mucosal erythema, nodularity and ulceration. The presentation is very diverse such as abdominal pain, weight loss, gastrointestinal bleeding and dyspepsia. Its treatment remains unclear.

CASE DESCRIPTION/METHODS:

71-year-old with long history of dyspepsia was referred to our institution due to a 6-month history of epigastric discomfort, profound weight loss (50 lb) and early satiety. Symptoms were mildly improved with sucralfate and smaller and more frequent meals. Tissue transglutaminase antibody was negative. Endoscopy at other institution suggested collagenous gastritis but biopsies were not conclusive. Endoscopic ultrasound at our institution was done for further characterization of the stomach layers and revealed a tubular J-shape stomach deformity with diffuse atrophic mucosa in the gastric body. Localized submucosal wall thickening was visualized endosonographically in the entire body of the stomach which measure up to 5 mm in thickness in the gastric wall. Random gastric biopsies could not confirm CG diagnosis. Persistent symptoms led to further work up including MRI enterography and gastric emptying study, all negative. Eight months later, “well type” biopsies were taken from the gastric body and antrum. Pathology report revealed antral glands atrophy with pyloric hyperplasia, prominent smooth muscle hyperplasia in the lamina propia, along with gastric corpus and antrum with thickened subepithelial collagen layer on hematoxylin and eosin, confirmed on trichrome stain. These features were consistent with a diagnosis of collagenous gastritis. Although limited evidence on the treatment of this disease, patient was started on budesonide therapy (9 mg/day). Future endoscopic surveillance and clinical follow up is planned to assess symptomatic improvement.

DISCUSSION:

Collagenous gastritis is a rare entity as only 60 cases have been reported in the literature. We need more awareness of this disease for early recognition and reduction of unnecessary work up. Clinical presentation is very diverse and endoscopic findings can be very subtle. High clinical suspicion is necessary to allow proper biopsy techniques. The well technique permits deep tissue sampling by taking multiple samples from the same site and has been advocated for use in subepithelial lesions, avoiding the need for full thickness biopsy or surgery.
2762 Median Arcuate Ligament Syndrome: A Rare but Overlooked Cause of Post-Prandial Abdominal Pain
Authors: Tayel Hussam , Tayel Hesham , Mehta Sagar V. , Duarte-Chavez Rodrigo , Kim Brian , Bahirwani Janak , Martinez-Tapia Ana , Modi Ronak , Chaput Kimberly J. , Martins Noel B. , Geme Berhanu , Matin Ayaz
Published: October 2019

INTRODUCTION:

Median arcuate ligament syndrome (MALS), also known as celiac artery compression syndrome or Dunbar syndrome, is defined as chronic recurrent abdominal pain related to compression of the celiac artery by the median arcuate ligament. The median arcuate ligament is a fibrous arch that crosses the aorta and links the crura of the diaphragm. This ligament typically passes superior to the origin of the celiac artery, however about 10% of the population (with strong female predominance) has a low-lying ligament that causes compression of the celiac trunk that is usually asymptomatic. We report a case of median arcuate ligament syndrome presenting similar to chronic mesenteric ischemia but without the typically associated cardiovascular risk factors.

CASE DESCRIPTION/METHODS:

A 54-year-old woman with no significant past medical history presented to the emergency department with a 6-month history of post-prandial abdominal pain associated with nausea, nonbilious emesis, sitophobia and a 60lb weight loss in the past 6 months. Vital signs were unremarkable. Her physical exam was entirely benign aside from mild epigastric tenderness to deep palpation. Labs were significant for a WBC 11.4, Hb 19.0 (baseline 13-15), K + 2.9. Gastroenterology was consulted and the patient underwent EGD which showed normal appearance of the esophagus, stomach, and duodenum with negative biopsies. Due to concern for mesenteric ischemia, the patient underwent CT Angiography of the abdomen which demonstrated 70% stenosis of the proximal celiac artery highly suggestive of median arcuate ligament syndrome. All other vessels were patent.

DISCUSSION:

Median arcuate ligament syndrome is a rare cause of post-prandial abdominal pain and weight loss that can often be challenging to diagnosis unless suspected by the clinician. Many patients undergo extensive workups for abdominal pain before being diagnosed. This syndrome presents similar to chronic mesenteric ischemia however many of these patients lack the typical cardiovascular risks factors associated with mesenteric ischemia as the demographic for MALS is typically middle-aged females ranging from age 40-60 years old. Patients are also often misdiagnosed with functional dyspepsia. Patients diagnosed with this disease should undergo laparoscopic celiac artery decompression which cures the majority of the patients with symptom recurrence occurring in approximately 6% of patients.