bluuebunny/crossref_metadata_2025 huggingface dataset:
2615 Treating Gas With Gas: A Case of Benign Extensive Pneumatosis Intestinalis
Authors: Anugwom Chimaobi , Singh Dupinder , Levitt Michael
Published: October 2019

INTRODUCTION:

Radiological evidence of extensive gas collections in the bowel wall and, particularly, the portal vein commonly suggests a life-threatening process. We present a patient with massive intramural and portal gas that was adjudged to be of benign origin and managed conservatively with high flow nasal oxygen.

CASE DESCRIPTION/METHODS:

A 74-year-old male with a history of coronary artery bypass surgery and a 40 pack-year history of smoking was admitted with a two-week history of abdominal discomfort with food ingestion, bloating and belching. History was negative for gastrointestinal bleeding, prior abdominal surgeries or fever. On examination, he was afebrile, hemodynamically stable, and had no abdominal tenderness, rebound or guarding. Initial laboratory measurements were normal and notable for normal white blood cell count of 9180/mm3 and a lactic acid of 1.8 mmol/L. A stool exam for pathogens was obtained. A Computed tomography (CT) scan of the abdomen showed extensive pneumatosis involving the upper small intestine and the stomach, and a relatively massive collection of portal venous gas (see Figure 1). He was admitted to the hospital with the diagnosis of possible ischemia of the small bowel and/or stomach. Despite the ominous abdominal imaging findings, he had a normal physical exam and lack of evidence of sepsis which suggested a benign etiology of the pneumatosis. The patient was essentially asymptomatic throughout his 6-day hospital course. The stool screen for 20 pathogens revealed enteropathogenic E. coli. On the second day of hospitalization, high inhalational oxygen (>50%) via nasal cannula was instituted in addition to an elemental diet. A repeat CT scan on day 5 of hospitalization showed virtually complete resolution of intramural small bowel and gastric gas, and only small residual portal venous gas remained. He was discharged home on antibiotics for 3 weeks and has continued to do well

DISCUSSION:

Pneumatosis intestinalis should be recognized as a clinical sign and not a diagnosis and should warrant careful review of the clinical context, signs/symptoms and laboratory data. The counter-perfusion supersaturation theory has been proposed as the pathophysiology in most benign cases. It involves increased hydrogen production by intestinal bacteria which supersedes the nitrogen tension in the blood stream. High flow or hyperbaric oxygen may help in the establishment of a nitrogen gradient between intramural gas and blood with improvement of intramural gas
2616 Seronegative Adult Autoimmune Enteropathy
Authors: Lundholm Michelle D. , Wanta Kaitlin , Ding Xianzhong , Palmer Lena , Abegunde Ayokunle T.
Published: October 2019

INTRODUCTION:

Autoimmune enteropathy (AIE) is a rare disorder of the immune system characterized by 6 or more weeks of severe diarrhea with malabsorption and histologic changes on small intestinal biopsy. This condition is primarily seen in neonates and children, but rarely has been reported in adults.

CASE DESCRIPTION/METHODS:

A 75-year-old woman presented with 4 months of intractable diarrhea, vomiting, and 30-pound weight loss. Prior workup was unrevealing including celiac testing, stool enteric pathogens, Cytomegalovirus, Herpes simplex virus, Helicobacter Pyloritesting, and colonoscopy without biopsies. Non-specific acute and chronic inflammation without villous blunting was seen in duodenal biopsies. She was treated supportively but her symptoms progressed requiring admission. She appeared emaciated with stable vital signs and a benign abdominal exam. She had severe hypoalbuminemia and hypomagnesemia. C-reactive protein, liver and thyroid tests, anti-nuclear antibody, HIV, and immunoglobulin levels were normal or negative. Repeat esophagogastroduodenoscopy (EGD) showed duodenal scalloping and friability with contact (Figure 1). Colonoscopy appeared endoscopically normal to the terminal ileum. Biopsies of the duodenum and terminal ileum showed glandular destruction, epithelial apoptosis, and goblet cell depletion without significant intraepithelial lymphocytosis (Figures 2 and 3). Periodic acid-Schiff stain and random colonic biopsies were negative for Whipple's disease and microscopic colitis. Anti-enterocyte antibodies were negative. She was diagnosed with AIE and started on high-dose steroids with a prolonged taper. At her 2-month follow-up she had gained back 10 pounds with complete resolution of her nausea, vomiting, and diarrhea.

DISCUSSION:

AIE should be included in the differential diagnosis for adult patients with intractable diarrhea. Diagnostic criteria include partial or complete blunting of small intestinal villi, deep crypt lymphocytosis, increased crypt apoptosis and minimal intraepithelial lymphocytosis. Anti-enterocyte antibodies are positive in approximately 80% of cases. In this case, the small intestinal histopathology was not diagnostic for AIE 2 months into her symptomatology but was diagnostic on EGD 9 weeks later, highlighting the utility of repeat EGD and biopsy in patients with persistent symptoms. This emphasizes that villous blunting may be patchy and chronic inflammatory changes of AIE may evolve over time. More research is needed to better understand this emerging condition.
2621 Gastrointestinal and Hepatic Amyloidosis: An Unusual Cause for Abdominal Pain and Elevated Liver Enzymes
Authors: Rai Puja , Dhingra Rohit , Sterling Mark
Published: October 2019

INTRODUCTION:

Amyloidosis is a complex, multi-system disorder involving the extracellular deposition of insoluble protein fragments. Symptomatic gastrointestinal and hepatic involvement are relatively rare, often leading to a challenging and delayed diagnosis.

CASE DESCRIPTION/METHODS:

We describe a case of gastroduodenal and hepatic amyloidosis in a 61-year-old male with a history of plasma cell myeloma with systemic AL (amyloid light chain) amyloidosis with cardiac involvement who presented with 3 months of epigastric pain associated with nausea, vomiting, and 20-pound weight loss. Laboratory testing revealed transaminitis including a significantly elevated alkaline phosphatase (ALP). Right upper quadrant ultrasound was normal. Computed tomography (CT) showed diffuse mesenteric haziness and heterogenous edematous appearance of the liver. Since his diagnosis of amyloidosis, the patient had been treated with cyclophosphamide, bortezomib, and dexamethasone (CyBorD) therapy with appropriate light chain suppression. Despite treatment, he continued to have persistent gastrointestinal symptoms. He therefore underwent upper endoscopy with biopsies of the esophagus, stomach and small intestine notable for positive Congo red staining, with classic green birefringence under polarized light, indicating extensive amyloid deposition within the lamina propria. Subsequent transjugular liver biopsy demonstrated marked centrilobular sinusoidal dilation and increased fibrosis with amyloid deposition within the vessels of the portal tract. His symptoms were medically managed, and he was continued on chemotherapy while undergoing evaluation for cardiac transplant prior to consideration for autologous stem cell transplant.

DISCUSSION:

Gastrointestinal and hepatic amyloidosis are unusual diagnoses that present with variable and nonspecific symptoms, and often late in the disease course. Clinicians should maintain a high index of suspicion of amyloidosis in patients with previously diagnosed plasma cell or inflammatory disease. Our case demonstrates that despite high-dose chemotherapy, patients may develop refractory disease with multi-organ involvement. Prognosis depends on the amyloid subtype, and whether there is gastrointestinal infiltration as these patients typically have worse outcomes, emphasizing the importance of prompt diagnosis. Management aims to treat the underlying amyloid type of pathology, with supportive therapy to alleviate the specific gastrointestinal symptoms.
2625 Intussusception After Classic Pancreaticoduodenectomy With a Roux-en-Y Pancreatico-hepaticojejunostomy
Authors: Alexandre Cassidy , El Jabbour Tony , Parsa Nour , Mansoor Muhammad Sohail , Gumustop Bora
Published: October 2019

INTRODUCTION:

Intussusception in adults is uncommon, accounting for 1%–5% of all intussusception cases. It usually occurs because of a lead point, frequently malignancy or adhesions from previous surgery. Here we report an exceedingly rare case of jejunal intussusception into the gastric lumen in a patient after classic pancreaticoduodenectomy with a Roux-en-Y pancreatico-hepaticojejunostomy.

CASE DESCRIPTION/METHODS:

A 49 year-old male with Down syndrome, celiac disease and surgical history significant for classic pancreaticoduodenectomy (Whipple procedure) with a Roux-en-Y pancreatico-hepaticojejunostomy for pancreatic mass with distal bile duct stricture and duodenal stricture presented with one-day history of abdominal pain. He was minimally verbal due to Down's syndrome however pointed to his upper and lower abdomen. Associated symptoms included mild nausea but no emesis, melena or hematochezia. Abdominal examination was negative for any mass or peritoneal signs. Initial labs were remarkable for only mild anemia; while blood cell count and lactic acid were normal. A CT scan demonstrated an approximately 7-cm length of jejunum protruding into the lumen of the stomach at the gastrojejunostomy site concerning for intussusception, but no high-grade mechanical obstruction observed. EGD showed intussusception of the blind jejunal limb with healthy appearing mucosa and jejunum biopsies were obtained to rule out ischemia; examination of gastrojejunal anastomotic site and the jejunum (efferent limb) was otherwise normal. Endoscopic reduction of intussusception was attempted but was unsuccessful. Remaining hospital course was uneventful. He was tolerating diet, having proper bowel movements and his abdominal pain resolved. No surgical intervention for repair was planned as he continued to improve clinically and he was safely discharged home. He was seen in surgery clinic a few months later and remained asymptomatic.

DISCUSSION:

Intussusception is a rare entity in adults and only a few cases have been reported after Whipple procedure. Diagnosis of intussusception in adults, regardless of previous surgeries, is primarily through imaging because presenting symptoms are often vague and nonspecific. Surgical management is often required. However, in our patient, due to the absence of bowel obstruction or ischemia, surgical intervention was not needed. This case highlights that intussusception should be considered as a potential diagnosis in patients with history of Whipple presenting with vague abdominal symptoms.
2627 Small Bowel Adenocarcinoma With Right Atrial Metastasis: A Case Combining Two Rare Entities
Authors: Wang Patty , Weinberg Richard B.
Published: October 2019

INTRODUCTION:

Small bowel adenocarcinoma comprises less than 2% of all gastrointestinal malignancies. Given its rarity, little is known about its clinical features, treatment modalities, or prognosis. Early diagnosis remains a challenge due to the absence or nonspecific nature of its symptoms. The heart is a rare site for metastasis of any malignancy, and cardiac metastases are likewise often clinically silent. Here we present a case of jejunal adenocarcinoma with metastasis to the heart that was ultimately diagnosed by pancreatic protocol CT imaging.

CASE DESCRIPTION/METHODS:

An 82-year-old female with a history of atrial fibrillation presented with a left middle cerebral artery stroke after her warfarin was held due to iron deficiency anemia. She underwent successful thrombectomy, but her initial evaluation with a transthoracic echocardiogram incidentally revealed a 4 cm × 3.9 cm right atrial mass. Further evaluation with a cardiac MRI and a standard CT of the chest/abdomen/pelvis showed a large hypoattenuating mass in the right atrium that extended into the inferior IVC and left hepatic vein; no tumor primary was identified. Cardiac biopsy found a moderately differentiated adenocarcinoma positive for CK-20 and CDX-2, suggesting a GI origin. She then underwent an EGD and colonoscopy, neither of which found evidence of a malignancy, although the EGD noted a prominent ampulla with normal biopsies. Given this finding and the presence of an adenocarcinoma of unknown origin, she was scheduled for an EUS and capsule endoscopy. However, before these procedures were performed, a CT with pancreas protocol revealed a 5 cm circumferential mass in the proximal jejunum causing low grade obstruction; the morphology was consistent with adenocarcinoma. The patient was treated with radiation therapy.

DISCUSSION:

To the best of our knowledge, this is the first case report of a small bowel adenocarcinoma metastatic to the heart. After the discovery of an atrial adenocarcinoma, a small bowel origin was not initially considered given its rarity and nonspecific presentation. The first CT scan may have failed to detect a jejunal primary for the same reason, although differences in contrast infusion technique may have played a role. Cardiac metastases are similarly very rare and have most often been reported in lung cancer, melanoma, lymphoma, breast cancer, sarcoma, and renal cell carcinoma. This case suggests that although rare, small bowel adenocarcinoma should be considered in patients found to have cardiac metastatic disease.
2628 Incidental Isolated Small Intestinal Melanoma in a Patient With Newly Diagnosed Celiac Disease
Authors: Amornsawadwattana Surachai , Huebner Elizabeth
Published: October 2019

INTRODUCTION:

It is believed that patients with Celiac disease (CD) are at increased risk of certain malignancies. However, CD patients are not associated with cutaneous malignant melanoma and thus additional screening is not indicated. We report an unusual case of a patient with first diagnoses of simultaneous CD and isolated small intestinal melanoma.

CASE DESCRIPTION/METHODS:

A 55-year-old female without history of malignant melanoma (MM) presented with chronic diarrhea. Physical exam and laboratory results were unremarkable except a tissue transglutaminase IgA antibody was elevated at 126.4 units (normal 0.00–19.99.). An esophagogastroduodenoscopy was performed and demonstrated scalloping of the duodenal folds. A hyperpigmented mass was incidentally found in the proximal jejunum (Figure). Duodenal biopsies showed villous blunting, chronic inflammation and increased intraepithelial lymphocytes, which was consistent with CD. Biopsies of the jejunal mass revealed a densely pigmented nodule of atypical cells with large hyperchromatic nuclei, abundant cytoplasm, and mitoses. An immunohistochemical stain was positive for Melan-A and S100, which confirmed a diagnosis of MM of the small bowel.Additional imaging revealed no signs of metastatic disease. Subsequently, the patient underwent laparoscopic resection of the small bowel mass and the pathology showed malignant MM with negative margins. Then, she was started on Trametinib and Dabrafenib for about 5 months, but was discontinued due to side effects. Currently, the patient remains disease-free 36 months after surgery. Diarrhea is also much improved after starting a gluten free diet.

DISCUSSION:

Small bowel malignancies are rare, accounting for 3% of GI neoplasms and the majority of small bowel neoplasms represent metastatic disease. The small intestine is also considered the most common site of melanoma metastases to the GI tract. Primary small intestinal MM is characterized by MM of the small bowel without evidence of a primary extra-intestinal lesion. Whether this represents a true primary malignancy or a metastatic disease from an unrecognized or a regressed lesion elsewhere remains debatable. The main treatment of primary small intestinal melanoma is surgical resection. Although patients with CD in general have increased risk of malignancy, there is no known association between CD and MM. This case highlights a rare incidental primary small intestinal melanoma in the setting of a patient who is symptomatic from CD.
2635 Gastrointestinal Hereditary Angioedema Causing Recurrent, Self-Resolving Abdominal Pain
Authors: Gupta Kamesh , Mayigegowda Kavya K. , Hassan Tuyyab
Published: October 2019

INTRODUCTION:

Hereditary angioedema (HAE) is a type of bradykinin-mediated isolated angioedema, characterized by temporary swelling that can affect skin or walls of hollow viscera such as the oropharynx, or gastrointestinal tract (in 43 to 93% of HAE cases respectively) and occurs without pruritus. This case is reported due to its rare presentation that often results in unnecessary invasive procedures.

CASE DESCRIPTION/METHODS:

A 25-year-old female with a past medical history of hypothyroidism and asthma presented with acute on chronic intermittent abdominal pain and vomiting for a day bearing no relation with meals or defecation. She had recurrent hospitalizations for similar complaints but workup till date showed enteritis on imaging and exploratory laparoscopy showed adhesions with colonic biopsy negative. Extensive history taking revealed prodromal symptom of anxiety and a previous episode of self-resolving finger swelling, retrospectively suspected to be due to angioedema. Labs showed leukocytosis and elevated CRP. Repeat CECT abdomen displayed thickening of jejunal wall. Given her history of prodromal symptoms, finger swelling and a family history of similar self-resolving abdominal pain of unclear etiology in her mother prompted further testing for complements due to concern for hereditary angioedema, which was positive with low C4 and C1 inhibitor. She was referred to an allergy specialist for further management.

DISCUSSION:

HAE is an autosomal dominant disease that is due to decreased or impaired C1 Inhibitor. Typical GI symptoms are recurrent abdominal pain, vomiting and diarrhea caused by transient small bowel edema. Inciting events include stressful situations like fasting and infections and medicines like ACE-inhibitors. Diagnosis is clinical from history of skin swelling or respiratory distress during attacks, documenting possible triggers and family history of HAE. Physical exam and imaging is useful only during acute attacks. Recommended lab tests include C4 levels, C1 inhibitor antigenic levels, and C1INH functional levels. Endoscopy is not recommended as it may precipitate laryngoedema. Treatment includes C1 INH replacement or icatibant (bradykinin receptor antagonist) for acute attacks and attenuated androgen or lanadelumab for prophylaxis. HAE should be considered when tackling cases of undiagnosed abdominal pain in the right clinical context to prevent years of suffering, unnecessary invasive procedures and life-threatening complications from laryngeal edema or hypovolemic shock.
2636 Brunner's Gland Hyperplasia: A Massive Duodenal Lesion
Authors: Bhatti Sundus , Omer Endashaw
Published: October 2019

INTRODUCTION:

Brunner’s glands are alkaline-fluid secreting duodenal glands in the proximal duodenum submucosa. Brunner’s gland hyperplasia is a rare entity that accounts for 10% of all benign duodenal tumors, with an estimated incidence of 0.008%. Underlying etiology is postulated to be secondary to excessive acid secretion, H. pylori infection or inflammation.

CASE DESCRIPTION/METHODS:

A 57-year-old male with PMH of Myasthenia Gravis, GERD and esophageal strictures with prior dilations, presented with melena and intermittent abdominal pain for a few weeks and labs notable for iron deficiency anemia. EGD showed a large 5 cm polypoid mass in the proximal duodenal bulb with shallow surface ulcerations and a thick stalk causing ball-valve like obstruction of the pyloric channel. CT abdomen showed an elongated tubular mass arising from the proximal duodenum projecting antegrade within the duodenal lumen, measuring 5.3 × 1.7 × 1.5 cm, with no evidence of metastasis. Endoscopic ultrasound (EUS) showed the lesion appeared to be arising from the submucosal layer, with a large blood vessel feeding the lesion. A fine needle biopsy revealed benign histology. Due to its large size, the lesion was not amenable to endoscopic removal. He underwent laparotomy with pyloroplasty, duodenotomy and partial duodenal resection due to concern for premalignant potential. Surgical pathology showed Brunner’s gland hyperplasia and hamartoma that was negative for malignancy. The patient is doing well with resolution of abdominal pain.

DISCUSSION:

Brunner’s gland hyperplasia is usually an incidental finding during endoscopy. Symptomatic presentations include gastrointestinal bleeding and intestinal obstruction. Literature search shows reports of Brunner’s hyperplasia usually 1–2 cm in size, there are few reported that are larger than 5 cm. Diagnosis requires histological examination of the mass, usually by endoscopy with excision or biopsy. CT scan and EUS can demonstrate the submucosal origin of the mass. Mode of excision depends on the size, location and presentation of the lesion. Upper gastrointestinal endoscopy with polypectomy is preferred. Laparoscopic polypectomy is also an option. Laparotomy is reserved for large, sessile tumors, failure of endoscopic approach or unstable bleeding patients. Few cases reported in literature have been managed with laparotomy. The potential cause of our patient’s large Brunner’s gland mass could be gastric acid hypersecretion as he had severe GERD with peptic esophageal strictures.
2637 An Unusual Cause of Persistent Abdominal Pain and Hematochezia an Adult Male; Small Bowel Meckel’s Diverticulum Causing Intussusception
Authors: Dharmadhikari Neal D. , Fine Sean
Published: October 2019

INTRODUCTION:

Symptomatic Meckel’s diverticulum (MD) in adults is extremely rare. The prevalence of MD in the entire population ranges from 0.3%–-2.9% with a lifetime incidence of symptoms at 4.2%. The common presentations of symptomatic MD are obstruction, gastrointestinal (GI) bleed, and inflammation; these complications are significantly more frequent in childhood. This case report highlights direct observation by traditional colonoscopy of small bowel MD as a lead point of intussusception in an adult.

CASE DESCRIPTION/METHODS:

A 25-year-old male presented to the hospital with acute on chronic periumbilical abdominal pain worsening over several days. He reported intermittent watery diarrhea and an episode of hematochezia. He was also hospitalized earlier in the year for bowel obstruction of unknown etiology, but found to have intussusception status-post diagnostic laparotomy and partial ileal resection. His vital signs were stable and the physical exam revealed peri-umbilical tenderness. Laboratory data resulted with fecal calprotectin 517.7 mg/kg, hemoglobin 10.2 g/DL, WBC 11.6 × 10exp9/L, ESR 33 mm/h, CRP 78.51 mg/L, and a negative Clostridium difficile PCR test. A CT abdomen/pelvis revealed mild thickening and mucosal hyperenhancement of the terminal ileum. A colonoscopy was performed due to concern for GI bleed and inflammatory bowel disease. On colonoscopy, the colon was normal, but a partially obstructing, mobile, villous mass was noted in the ileum. Subsequently, an exploratory laparotomy found recurrent small bowel intussusception. The ileal mass was resected and pathology showed ectopic gastric and pancreatic tissue confirming MD. An ulcer and acute inflammation were noted on the mass. His follow-up course was unremarkable and the patient’s symptoms have since improved.

DISCUSSION:

The symptoms of MD are significantly more common in other etiologies. In addition, symptomatic MD is rarely diagnosed in adulthood which makes the diagnosis of MD in adults a challenge. MD is often diagnosed by imaging modalities or direct observation during surgery. Balloon-assisted enteroscopy and capsule endoscopy are other diagnostic measures being explored. Endoscopy is indicated in patients presenting with GI bleed and was completed in this patient. A large portion of this patient’s distal ileum was previously resected and his altered anatomy allowed the direct observation of MD by colonoscopy. This case highlights a unique endoscopic finding that endoscopists should be aware as the etiology for GI bleed.
2639 A Curious Case of Abdominal Pain
Authors: Balarajah Sharmili , Martin Tracey , Wan David
Published: October 2019

INTRODUCTION:

Median arcuate ligament syndrome (MALS) is a rare condition where compression of the coeliac artery and ganglia by the median arcuate ligament results in gastrointestinal symptoms. Whilst 13–15% of the population exhibit radiological features of celiac artery compression, only a fraction is symptomatic. We present a case of a frail patient investigated for chronic abdominal pain that was ultimately attributed to MALS.

CASE DESCRIPTION/METHODS:

An 86-year-old lady presented with a two-year history of post-prandial nausea, abdominal pain and unintentional weight loss. She was an ex-smoker and denied any alcohol intake or NSAID use. Clinical examination was unremarkable. Initial lab workup was within normal limits and H. pyloriserology negative. An EGD demonstrated duodenal erosions and superficial ulcerations. A gastric emptying study was unremarkable. CT enterography and an MR angiography demonstrated focal narrowing of the celiac artery by the median arcuate ligament (
Figures 1 and 2
). Vascular duplex demonstrated altered celiac artery velocities with respiration (
Figure 3
). A provisional diagnosis of MALS was made. The patient underwent celiac plexus block (CPB) with which her symptoms resolved. She later underwent celiac plexus neurolysis and remains symptom-free.

DISCUSSION:

MALS is an uncommon diagnosis typically characterised by a triad of post-prandial abdominal pain, weight loss and abdominal bruit. There are currently no proven pathophysiological mechanisms though ischaemic and neuropathic mechanisms have been hypothesized. MALS is a diagnosis of exclusion and a difficult one to make given its rarity and lack of specific symptoms. The gold standard for diagnosis is with conventional angiography. Given our patient’s frailty, we opted for minimally-invasive radiological investigations and provocative physiological testing with CPB. The mainstay of management is with open surgical decompression but this is associated with high rates of post-operative complications and prolonged hospital stays. Celiac plexus neurolysis is an alternative option that could be considered in frail patients for both diagnosis and management. MALS is a rare but important diagnosis to consider in patients with chronic abdominal pain and proves to be a diagnostic challenge. Our case demonstrates the use of non-invasive investigations and provocative physiologic testing to diagnose MALS in a frail patient and highlights celiac plexus neurolysis as a treatment option.
2643 A Rare Presentation of Duodenal Adenocarcinoma Concealed by Membranous Nephropathy
Authors: Naser Jwan A. , Al Nimri Sarah M. , Mousa Omar Y.
Published: October 2019

INTRODUCTION:

Duodenal adenocarcinoma is rare and often has a vague clinical presentation. Therefore most patients have advanced disease (stage III or IV) at the time of diagnosis, which heralds poor prognosis. Membranous nephropathy can be associated with solid tumors; however duodenal adenocarcinoma presenting as membranous nephropathy has not been reported in the literature.

CASE DESCRIPTION/METHODS:

A 78-year-old male presented with worsening dyspnea, nausea and anorexia over a period of several months. Further workup revealed proteinuria secondary to biopsy-proven membranous nephropathy. PLA2R antibodies were negative, which initiated an evaluation for secondary membranous nephropathy. Physical examination revealed anasarca. His creatinine was 3.4 mg/dL, and extensive workup for a secondary cause of membranous nephropathy, including ANA, C3, C4, and hepatitis B and C testing was negative. CT of the abdomen showed upper abdominal and mesenteric adenopathy. His presentation was complicated by gastrointestinal bleeding with a hemoglobin of 5.3 g/dL. Esophagogastroduodenoscopy revealed a large villous, infiltrative sessile mass in the third portion of the duodenum [Figure 1]. Biopsies showed moderately differentiated adenocarcinoma. Endosonographic ultrasound showed malignant-appearing lymph nodes and fine needle aspiration of the largest celiac lymph node confirmed metastatic adenocarcinoma. Therefore surgical resection was not recommended. The patient was started on 5-fluorouracil and oxaliplatin. Membranous nephropathy was due to a paraneoplastic syndrome and its resolution was dependent on the course of the duodenal adenocarcinoma. Unfortunately, his course was complicated by worsening renal failure and he required intensive care with continuous renal replacement therapy and non-invasive ventilation for respiratory failure. He recovered slowly and was discharged home on hemodialysis. Follow up imaging periodically over the following year revealed peritoneal, lung and liver metastasis. The patient eventually pursued palliative care and he passed away.

DISCUSSION:

The unusual presentation of duodenal adenocarcinoma in the form of membranous nephropathy led to a delayed diagnosis with poor candidacy for surgical resection. Age- and risk-appropriate assessment for malignancy is recommended in secondary membranous nephropathy without a clear etiology. Gastrointestinal malignancy should be in the differential especially when anemia is present.
2645 Small Bowel Bleeding Due to Solitary Metastatic Ovarian Clear Cell Carcinoma: A Case Report and Review of the Literature
Authors: Keihanian Tara , Pena Polanco Nathalie A. , Jordan Scott , Pearson Joseph M. , Barkin Jodie A.
Published: October 2019

INTRODUCTION:

Small bowel bleeding (SBB) accounts for 5–10% of gastrointestinal bleeding cases. Common causes of SBB are inflammatory bowel disease, angioectasias, ulcers, & primary & metastatic neoplasms. The aim of this case report & literature review is to present ovarian clear cell carcinoma (CCC) as a rare cause of SBB.

CASE DESCRIPTION/METHODS:

A 51 year old woman with dual primary stage IIB CCC of bilateral ovaries & uterus, & stage IA, grade 1 endometrioid adenocarcinoma underwent total laparoscopic hysterectomy, bilateral salphingo-oophorectomy, bilateral pelvic lymph node dissection, & omentectomy. Pathology from the right pelvic side wall peritoneum was positive for CCC involving fibroadipose tissue. She completed 6 cycles of chemotherapy with paclitaxel & carboplatin. Following treatment, she achieved clinical remission for 14 months until computed tomography (CT) scan performed for new abdominal pain & constipation showed a 6.3 × 4.6 cm heterogeneously enhancing lobular mass lesion within the pelvis in close contact with the sigmoid colon without definite invasion. A month later, she was admitted with lower abdominal pain & bloody stools. Colonoscopy showed blood in the entire colon & terminal ileum (TI), without active source of bleeding identified. CT Angiography showed no evidence of active bleeding, but revealed increasing pelvic mass size (6.5 × 6.4 cm). No lymphadenopathy was noted on CT scan. Upper endoscopy was unrevealing. Video capsule endoscopy (VCE) showed an actively bleeding mass likely in the distal small bowel, without VCE passage beyond the mass or cecal intubation. Exploratory laparotomy revealed an 8cm mass arising from the distal TI adherent to the epiploica of the rectosigmoid, not involving the vaginal cuff or prior resection sites. A portion of distal TI was resected with a side-to-side ileo-ascending colon anastomosis. TI pathology was positive for CCC, with negative omental & lymph node pathology. Chemotherapy with carboplatin & doxorubicin was initiated without further bleeding.

DISCUSSION:

Ovarian cancer is thought to metastasize via direct invasion, lymphatic or hematogenous infiltration, or peritoneal dissemination. Solitary metastasis of ovarian CCC to the small bowel without peritoneal carcinomatosis or lymphatic involvement is a rare phenomenon. Our literature review revealed only one other published case report describing this entity. Solitary CCC metastases should be added to the list of potential neoplastic causes of SBB.
2646 Ischemic Colitis Secondary to Sumatriptan Overuse Along With Estrogen
Authors: Thyagaturu Harshith S. , Jha Samir , Demeria Dennis
Published: October 2019

INTRODUCTION:

Sumatriptan, a 5-HT1B/1D (5-hydroxytryptamine-1B/1D) receptor agonist is the first line medication currently available for migraine and cluster headaches. The drug acts by selectively constricting the intracranial blood vessels. Also, studies have shown that estrogen modifies the levels of MAO-A (Monoamine oxidase-A) in the body thereby decreasing the metabolism of sumatriptan. In the past few decades, there has been a handful of reported cases of coronary vasospasm, myocardial infarction and ischemic colitis associated with sumatriptan use. We report a 57-year-old female who developed ischemic colitis in the setting of usage of increasing doses of sumatriptan along with estrogen.

CASE DESCRIPTION/METHODS:

A 57-year-old woman with a history of migraine headache, fibromyalgia, hypertension, diet-controlled diabetes mellitus, diverticulitis presented to the emergency room with sudden onset of left sided abdominal pain and 5 episodes of Bright red blood per rectum for one day. Medications included sumatriptan, estradiol, enalapril, venlafaxine, aspirin, and atorvastatin. On examination, left lumbar and left iliac quadrants tenderness was noted. Negative for peritoneal signs. Labs showed WBC 19.6 [3.7–10.6 cells/ul], Hb 15 [11.5–15.5 cells/ul], glucose 106 [70–139 mg/dL], lactic acid 3.2 [0.5–2.2 mmol/L], ESR 18 [<=30 mm/hr], CRP 10.2 [0.3–1.0 mg/dL]. CT abdomen and pelvis revealed findings suggestive of colitis extending from the hepatic flexure to sigmoid colon. Of note, she was using increasing doses of sumatriptan [100 mg tabs, at least 3 to 4 times a day] in the past few weeks for increased frequency of migraine headaches. Endoscopic findings are suggestive of ischemic colitis versus the others. Pathology of the mucosal biopsy showed hallmarks of ischemic colitis. Sumatriptan and estrogen were discontinued. The patient was followed up for a few weeks to months. She reported remarkable improvement of symptoms without any recurrence.

DISCUSSION:

Sumatriptan is a commonly prescribed abortive medicine for migraine, while ischemic colitis is one of its rare side effects. We aim to emphasize the synergistic effect of increasing doses of sumatriptan along with estrogen in causing ischemic colitis. Physicians should consider the diagnosis of sumatriptan-induced ischemic colitis in patients taking increased doses of this medication with concurrent estrogen usage, who develop severe abdominal pain, hematochezia and potentially counsel patient on cautious use of 5HT1 receptor agonist.
2653 Solitary Peutz-Jeghers Polyp Presenting as Iron Deficiency Anemia
Authors: Hamilton Daniel P. , Brown J. Andrew , Beyer Ryan J.
Published: October 2019

INTRODUCTION:

A sporadic hamartomatous polyp in the duodenum is an uncommon finding, with occurrence of solitary Peutz-Jeghers polyps only reported in singular or small case series. Typical presentation of Peutz-Jeghers type polyps occurs in patients with Peutz-Jeghers syndrome (PJS), which is a rare, autosomal-dominant disorder consisting of the simultaneous presentation of multiple hamartomatous polyps in any part of the alimentary tract and mucocutaneous pigmentation deposits [1]. We present a case of a solitary Peutz-Jeghers type polyp causing anemia found in the duodenum of a patient without any other characteristic findings of PJS.

CASE DESCRIPTION/METHODS:

Our patient was a 37 yo female with h/o pulmonary embolus on anticoagulation who had undergone workup of iron deficiency anemia by an outside gastroenterologist. After negative EGD and colonoscopy, a capsule enteroscopy showed a polypoid lesion in the small bowel, and she was referred for push enteroscopy. Anticoagulation had been held for the procedure. The push confirmed a 2.5 cm pedunculated polyp in the third portion of the duodenum, which was resected with snare cautery, and removed using a Roth net. No bleeding was seen, but as the patient was to resume anticoagulation, 2 hemoclips were applied to the resection site. Pathology showed Peutz-Jeghers type polyp. On follow-up the patient’s hemoglobin had returned to normal levels, confirming the polyp as the cause of anemia.

DISCUSSION:

Solitary PJ polyps are extremely rare and are typically found in case reports with presentation on the spectrum from asymptomatic finding to dyspepsia, abdominal pain, intussusception and melena. To our knowledge, our patient’s case consists of the first reported case of a solitary PJ-type polyp presenting solely as iron deficiency anemia.
2658 Henoch-Schonlein Purpura Duodenitis
Authors: Kaila Vishal , Sudhekar Nivedita , Feldman Mark
Published: October 2019

INTRODUCTION:

Henoch-Schonlein Purpura (HSP) is an IgA mediated systemic, small and medium vessel vasculitis that typically presents with palpable purpura, arthralgias, abdominal pain and hematuria. Gastrointestinal manifestations occur in about 20% of patients prior to skin involvement. We report a case of a 51-year-old woman that presented with HSP duodenitis.

CASE DESCRIPTION/METHODS:

A 51-year-old female presented with a several week history of nausea, vomiting and epigastric abdominal pain. In addition, she had been experiencing dysphagia, arthralgias, fever and, later on, a palpable, petechial and purpuric rash on her face, ears and all extremities. She had no previous medical history. Physical exam showed an extensive palpable, ecchymotic and purpuric rash involving her arms, face, right ear and purpura on plantar surface of her feet (See Figure 1). Her wrist, elbow, knee and ankle joints were tender to palpation, warm and swollen. She had epigastric tenderness to palpation with no rebound or guarding. Laboratory workup was notable for a white blood cell count of 18.32 M/μL (4.20–5.60 M/μL). Computed tomography of the abdomen showed bowel wall thickening at the junction of duodenum and jejunum with fat stranding in the central mesentery. Biopsy of the skin showed features of leukocytoclastic vasculitis with associated perivascular necrotizing inflammation and hemorrhage (See Figure 2). EGD showed diffuse circumferential erythema with boggy mucosa as well as friability with touch bleeding consistent with ischemic type changes from distal bulb to the second portion of the duodenum (See Figure 3). Biopsies of the duodenum showed evidence of intramucosal hemorrhage, a mixed inflammatory infiltrate of neutrophils, lymphocytes and some plasma cells within the lamina propria. There were also fragments of advanced necrosis with evidence of small vessel thrombosis and vasculitis. Her abdominal pain and oral intake improved after treatment with 1 g methylprednisone for three days. The patient was discharged from the hospital with an oral steroid taper.

DISCUSSION:

HSP is rare in adults with roughly 20-fold fewer cases than in children. The range of endoscopic findings includes gastritis, ulceration, duodenitis, and submucosal hemorrhage with the second portion of the duodenum being involved more than the duodenal bulb. The end capillaries of small intestinal villi are particularly susceptible to ischemic injury. HSP is a self-limiting disease and majority of the patients improve spontaneously.
2659 A Rare Occurrence: Anal Squamous Cell Carcinoma With Metastasis to Duodenum Causing Duodenal Stricture and Gastric Outlet Obstruction
Authors: Yuridullah Ruhin , Kaur Parminder , Estifan Elias , Sanchez Jessimar , Kapoor Ashima , Singhal Monisha
Published: October 2019

INTRODUCTION:

Squamous cell carcinoma (SCC) of the anal canal is a rare entity encompassing only 2–4 percent of all colon, rectal, and anal cancers. SCC of the anal canal tends to be loco-regional and in the event of rare metastasis, most common sites of secondary seedlings are liver and lung. To our knowledge, metastatic spread from primary anal SCC to small bowel has been reported only once before. We report a rare case of SCC of anal canal with duodenal metastases in a 49-year-old female.

CASE DESCRIPTION/METHODS:

A 49-years-old female with 8-month history of anal SCC Stage IIIA, status post chemo-radiation therapy and loop ileostomy creation, was seen for complaints of vague abdominal pain, nausea, vomiting, and anorexia. Physical examination was significant for mild periumbilical tenderness. Computed tomography (CT) of the abdomen and pelvis with contrast revealed distended stomach with food contents and distended proximal duodenum. Esophagogastroduodenoscopy (EGD) showed moderate gastritis with duodenal edema resulting in narrowing of the second portion of the duodenum. An upper gastrointestinal series revealed distended stomach with air-fluid level and marked narrowing at the junction of the distal descending and transverse duodenum with "U-shaped" appearance and normal appearing jejunum. Colonoscopy via the stoma revealed normal colon proximal to diverting colostomy, normal terminal ileum, narrowed and scarred rectal vault. Biopsy from the duodenal stricture revealed duodenal mucosa with scattered malignant cells and malignant cell clusters within lymphatic spaces. Immunohistological staining demonstrated malignant cells positive for CK7, p16, p63 and negative for CK20, CDX2, GATA-3, CA19.9, TTF-1, Napsin A and PAX-8 favoring a metastatic anal SCC.

DISCUSSION:

Primary rectal squamous cell carcinomas (SCC) are very rare tumors. Additionally, either primary or metastatic SCC of the gastrointestinal tract is extremely rare with very few cases reported in the literature. In our case, the patient with established 8-month history of anal SCC stage IIIA, status post chemotherapy, radiation, and status post loop ileostomy creation presented with a rare duodenal metastasis, which has only been reported once before. The possibility of primary SCC of the small bowel was excluded with duodenal stricture biopsy showing scattered malignant cells and malignant cell clusters within lymphatic spaces and positive immunohistological staining favoring a metastatic lesion.
2665 Choledochoduodenal Fistula as the First Sign of Metastatic Ovarian Cancer
Authors: Mirza Muhammad U. , Misra Deeksha , Vangimalla Shiva S. , Waleed Muhammad , Mukhtar Kashif
Published: October 2019

INTRODUCTION:

Choledochoduodenal fistulas (CDF) account for 5–25% of all internal biliary fistulas. They arise from duodenal ulcers or choledocholithiasis. Clinical presentation is non specific, therefore diagnosis necessitates use of imaging modalities. Most tumors that cause obstructive jaundice originate in the biliary tree, however there have been reports of biliary metastasis arising from distant cancer sites. We present the first case of CDF as the initial presentation of metastatic ovarian cancer after years in remission.

CASE DESCRIPTION/METHODS:

An 83 year old African American female with untreated Hepatitis C, chronic kidney disease, and high grade ovarian serous carcinoma status post exploratory laparotomy and chemotherapy 10 years ago, was admitted to the hospital with undocumented fever and abdominal pain for 4 days. She had right upper quadrant tenderness. Total bilirubin (TB) was 1.3 mg/dl and direct bilirubin (DB) was 0.5 mg/dl. CT scan abdomen showed dilation of the intra and extra hepatic bile ducts. ERCP showed a 13 mm duodenal ulcer superior to the duodenal major papilla with a common bile duct (CBD) stricture. Sphincterotomy and plastic stent placement in CBD was done after which she was discharged home. One month later, she was readmitted with melena for 3 days. Heart rate was 120 beats per minutes with hemoglobin of 5.6 mg/dl from a baseline of 9–10 mg/dl. CA 125 was 162.2 U/ml and alpha-fetoprotein was 7.6 ng/ml. EGD showed a 2 cm necrotic ulcer in the first part of duodenum with a fistulous tract. MRI abdomen showed a fluid collection around the duodenum with a choledochoduodenal fistula. Due to concerns about cancer, a repeat EGD was done for biopsy of the ulcer that showed a poorly differentiated carcinoma with immunoprofile positive for CK7, PAX8, ER and P53, consistent with ovarian cancer. PET scan was negative for any other metastasis. After discussion with the family, no further therapy was planned after which she was discharged home with palliative treatment.

DISCUSSION:

There have been cases of CDF arising from metastatic cancer invading the biliary tree. Colon adenocarcinoma and other neoplasms of the bile duct have been shown to cause CDF. Ovarian cancer has not been known to metastasize to the duodenum. Our patient was the first ever case of ovarian cancer metastasis to the duodenum that caused a CDF years after remission. Hence, we strongly recommend keeping a high index of suspicion when treating rare conditions like CDF in patients with a history of malignancy.
2666 Disseminated Renal Cell Carcinoma Presented as Obscure Gastrointestinal Bleeding
Authors: Curras-Martin Diana , Mehta Amit , Wan David
Published: October 2019

INTRODUCTION:

Metastatic disease to the gastrointestinal tract is frequently observed in patient with known disseminated malignancies. Among those, melanoma, breast and lung cancer are commonly reported. Renal cell carcinoma (RCC) metastasis to small bowel is rare and the presentation varies from obstructive symptoms, intussusception, as well as, gastrointestinal bleeding.

CASE DESCRIPTION/METHODS:

A 85 years old male with medical history of pulmonary embolism on apixaban and progressive stage IV RCC despite multiple lines of therapy on lenvatinib, presented with progressive fatigue and melenic stools. Denied abdominal pain, change in bowel habits, prior episodes of bleeding, or NSAIDs use. Vital signs were unremarkable. Physical exam was pertinent for non-tender abdomen, no distention, active bowel sounds, no rebound or guarding, and a rectal exam that revealed melenic stools. Labs: Hemoglobin of 6.8 g/dL (Baseline 10.3 g/dl), electrolytes, kidney and liver function tests were unremarkable. Computerized tomography (CT) of the abdomen and pelvis revealed multiple hepatic, retroperitoneal and mesenteric metastases. He received two units of packed red blood cells with appropriate response. Apixaban was held and he was admitted for workup of gastrointestinal bleeding. Esophagogastroduodenoscopy was unrevealing, while colonoscopy showed a few non-bleeding colonic and rectal angioectasias. A subsequent capsule endoscopy demonstrated an actively bleeding jejunal lesion (Figure 1). He continued to have large melenic bowel movements, and his hemoglobin decreased to 5.5 g/dL. A computed tomography angiography showed a blush of contrast in the jejunum, near the site of a tumor implant (Figures 2 and 3). An interventional radiology embolization was performed, with successful hemostasis.

DISCUSSION:

One autopsy series reported that only 2 out of 44 metastatic tumors to the small intestine were duodenal implants of RCC. In recent years, however, the number of published reports of RCC small bowel metastasis has been increasing. Retrograde venous spread to the paravertebral vessels has been propose as the route of dissemination of RCC to the intestine and solitary, bulky hypervascular lesions might be diagnostic if seen on CT scan. Luminal evaluation may localize the bleeding and offer potential treatment, however, angiography with embolization is the preferred therapeutic approach for small intestine lesions. Small bowel metastases must be considered as an etiology of bleeding when patients with RCC present with melena.