bluuebunny/crossref_metadata_2025 huggingface dataset:
1511 Epiploic Appendagitis After Rigorous Exercise in a Woman: An Easily Misdiagnosed Cause of Acute Abdomen
Authors: Zhao Weidan , Sanchez Antonio J.
Published: October 2019

INTRODUCTION:

Acute abdominal pain can be a surgical emergency. However, benign etiologies, such as epiploic appendagitis (EA), can present with similar symptoms. We report a case of an otherwise healthy woman, on oral contraceptives (OCP), presenting with severe abdominal pain related to epiploic appendagitis. Timely recognition of this condition is important to avoid misdiagnosis and unnecessary surgical interventions.

CASE DESCRIPTION/METHODS:

A 44-year-old woman with a past medical history of ovarian cyst and BMI 25 presented to the Emergency Department with a three-day history of sharp left lower quadrant (LLQ) pain. Patient reported that she started a vigorous aerobic exercise regimen 6 weeks before. Only medication was norgestimate-ethinyl estradiol for contraception. Vital signs normal. Physical exam showed tender LLQ without rebound tenderness or rigidity. Initial testing including complete blood count, basic metabolic panel, pregnancy test, urinalysis, and vaginitis panel were unremarkable. Given worsening pain, CT scan of abdomen and pelvis with contrast was obtained showing an encapsulated oval, pericolonic fatty nodule adjacent to the sigmoid colon, with surrounding fat stranding consistent with EA. Patient was discharged home with conservative pain management. Her OCP was discontinued. She had no symptom recurrence within a 3-year period.

DISCUSSION:

EA is an uncommon cause of acute abdominal pain that mimics serious medical or surgical emergencies such as acute diverticulitis, appendicitis, or, gynecological emergencies such as ruptured ectopic pregnancy. It is, generally, a self-limited ischemic infarction involving the epiploic appendices, which are normal outpouching fat of the lower colon and rectum. EA can be divided into primary versus secondary. The primary form is caused by either torsion or spontaneous venous thrombosis of an epiploic appendage central draining vein. It commonly occurs in men aged 20–50. Risk factors include obesity, hernia, and rigorous exercise. Secondary form is related to inflammation of adjacent organs. Although our patient does not match the typical profile for EA, rigorous exercise and probably OCP usage, a risk factor for thromboembolic phenomena, may have triggered this episode. Diagnosis of EA is by imaging via ultrasound or CT scan, and complete resolution typically occurs within two weeks with conservative management. Prompt identification of EA is essential in patients at risk, to avoid unnecessary surgical procedures.
1519 Portal Vein Thrombosis as an Initial Presentation of Crohn's Disease
Authors: Nguyen Minh , Helmstetter Nicholas J. , Sieloff Martin , Tariq Tooba
Published: October 2019

INTRODUCTION:

Inflammatory bowel diseases (IBD) are chronic and progressive conditions that can increase the risk of thromboembolism, including portal vein thrombosis (PVT). PVT are exclusively described in cases with confirmed IBD diagnosis and are more commonly related to ulcerative colitis. This report highlights a case of PVT as an initial manifestation of Crohn's disease.

CASE DESCRIPTION/METHODS:

A 38-year-old gentleman presented with worsening abdominal pain, watery diarrhea and weight loss of the last three months. His initial diagnosis was diverticulitis and a course of oral ciprofloxacin was prescribed. As symptoms persisted, a colonoscopy was performed and showed diverticulitis in the descending colon. The pathology demonstrated acute cryptitis from rectum to cecum. Due to ongoing symptoms, a computed tomography (CT) of the abdomen without contrast was obtained and showed wall thickening and inflammatory changes in the small bowel. Despite another course of antibiotics with the addition of oral steroids, his pain worsened and thus repeat imaging was performed as an abdominal CT with contrast. He was found to have a chronic PVT extending into the superior mesenteric vein (SMV) and was transferred to our institution for further management. Physical exam was notable for mild tenderness in upper abdominal quadrants. Laboratory studies revealed mildly elevated CRP and ESR but his liver function was normal. Hematologic workups including hypercoagulability and clonal disorders were noncontributory. He endorsed a history of tobacco abuse, but no history of abdominal surgery nor family history of IBD. A CT enterography showed skip lesions suggestive of Crohn's enteritis along with thrombus in the right main portal vein and SMV. The pathology report from a repeat colonoscopy showed chronic active colitis. The patient then improved with high dose oral steroids and he was discharged on a tapered steroid regimen with oral anticoagulation. Follow-up appointments were scheduled with hematology and gastroenterology.

DISCUSSION:

In summary, this case represents one of the handful reported cases of PVT being the initial presentation of Crohn's disease. In those with an established IBD diagnosis, PVT should be considered with persistent abdominal pain in the absence of active inflammation. Early recognition of portal vein thrombosis may expedite treatment and prevent the consequences of portal hypertension.
1523 Unintended Discovery of Enterobius vermicularis During Colonoscopy: An Uncommon Visualization
Authors: Randhawa Tejinder , Attar Bashar M. , Mutneja Hemant , Agrawal Rohit , Omar Yazan Abu , Vohra Ishaan
Published: October 2019

INTRODUCTION:

Enterobius vermicularis (pinworm) is the most common helminthic infection in the United States with an estimated prevalence of nearly 40 million people. Transmission of E. vermicularis occurs when its infective eggs, carried on contaminated hands, food, or environmental surfaces, are ingested. The eggs travel to the jejunum and hatch, maturing throughout the remainder of the gastrointestinal tract, until they reach their residence in the cecum. Females exit through the rectum and lay their eggs on the perianal skin. Though most infections are clinically silent; occasionally patients present with perianal itching, sleeplessness, hyperactivity, weight loss, abdominal pain and/or vomiting. Diagnosis is classically made by collecting the characteristic eggs from the perianal region using an adhesive coated surface and viewing the eggs microscopically. Here we present an unusual diagnostic finding of incidental pinworms during colonoscopy.

CASE DESCRIPTION/METHODS:

A 36-year-old male was admitted with a three-day history of bright red blood per rectum and an intermittent history of melena over the past six months. History was remarkable for active alcohol abuse and alcoholic Childs A cirrhosis. On examination, the patient was hemodynamically stable, abdomen was soft and non-tender, rectal exam was without blood. Patient underwent upper endoscopy and colonoscopy for bleeding site identification. During colonoscopy a white serpiginous organism was found attached to the mucosa of the ascending colon (Figures 1 and 2). It was actively moving around over the colonic mucosa. The specimen was collected, and after pathology it was confirmed that the parasite was E. vermicularis. The remainder of the endoscopic investigation revealed both large esophageal varices and large internal hemorrhoids as likely culprits for the gastrointestinal bleed.

DISCUSSION:

Direct visualization of pinworm eggs collected from the perianal region of suspected infected individuals has been essential to the diagnosis of intestinal parasite infections. Routine screening for pinworms in asymptomatic patients is not standard practice. Nevertheless, as an increasing number of colonoscopies are performed each year, we may encounter more incidentally diagnosed pinworm infections.
1524 Using Transillumination to Aid Dilation of a Severe Colorectal Anastomotic Stricture
Authors: Nasir Umair M. , Delle Donna Paul , Rodgers Brandon , Salimi Qasim M. , Ahlawat Sushil
Published: October 2019

INTRODUCTION:

Colorectal anastomotic strictures are common complications of low anterior resection. Strictures in the lower rectum can be treated with direct digital dilation, but if in the upper rectum, endoscopic balloon dilation or electrocautery can be done. However, both procedures depend on the advancement of the wire through the circumferential scar/narrowed lumen. We present a unique case of endoscopic dilation of a severe anastomotic stricture using an innovative method.

CASE DESCRIPTION/METHODS:

A 44-year-old male with a history of rectal adenocarcinoma s/p low anterior resection with colorectal anastomosis and loop ileostomy formation presented to the GI clinic for constipation. Barium enema study revealed a stricture at the anastomotic site. A flexible sigmoidoscopy confirmed a severe anastomotic stricture, which could not be traversed nor lumen distal to the stricture visualized. And despite multiple attempts the guidewire could not pass through the stricture. Ten weeks after surgery, a pediatric colonoscope was passed through the ileostomy and advanced to the area of the stricture. Position was confirmed with fluoroscopy. At the same time an adult upper endoscope was inserted into the rectum and advanced to the stricture. The pediatric colonoscope was used to transilluminate the stricture and a needle was then used to puncture through the stricture under direct visualization. A guidewire was advanced through the newly created lumen retrograde and the tract was dilated up to 8 mm. A double pigtail plastic stent was inserted across the newly created tract. On repeat colonoscopy three weeks later, the double pigtail stent was removed and the stricture was dilated up to 15 mm. On subsequent colonoscopy, the stricture was dilated to 18 mm and the patients loop ileostomy reversed. The stricture was dilated again to 20 mm via Flexible sigmoidoscopy a month after the reversal after which constipation and bowel habits significantly improved.

DISCUSSION:

In patients who develop severe colorectal anastomotic strictures after a low anterior resection, endoscopic dilation can be challenging. In such patients ileoscopy and colonoscopy can be done simultaneously and using transillumination, position can be confirmed and a needle can be used to create a lumen through which a guide wire can be passed, allowing for serial dilation. Endoscopic dilation, should be tried and exhausted before considering surgical correction of a stricture, which can be difficult and increase morbidity.
1532 Colorectal Metastasis of Ovarian Cancer: A Case Report
Authors: Chowdhary Tarika , Tazi Karim , Bishara Tarek , McFall Tim
Published: October 2019

INTRODUCTION:

A 38-year-old Caucasian female with a history of stage IV clear cell carcinoma of the ovaries with metastasis to the liver presented with anemia. The patient presented to clinic for evaluation of symptomatic tachycardia and shortness of breath. She was found to have a hemoglobin of 6.2 at that time. On further questioning, the patient stated that she had been having bloody diarrhea for several days which had gradually been improving. She endorsed some lower abdominal pain along with increased swelling in her abdomen. The patient was admitted for a GI bleed at that time. The patient was on treatment with Abraxane and Carboplatin and was due for a second cycle, which was delayed due to significant cytopenias.

CASE DESCRIPTION/METHODS:

A colonoscopy was performed and the patient was found to have two ulcerated masses at 40 and 20 cm from the anal verge which were biopsied. CT chest abdomen pelvis was done upon admission and showed liver lesions, pelvic lymphadenopathy, small right ischiorectal fossa nodule and subcutaneous lesions concerning for metastatic disease. There were also lesions seen adjacent to the bladder concerning for drop metastasis. The patient also had a gastrograffin enema and was found to have scalloping of the margin of the distal sigmoid colon concerning for a mass. The pathology report and immunochemical stain evaluation revealed the adenocarcinoma to be positive for cytokeratin 7, negative for cytokeratin 20, negative for CDX2, and negative for WT-1 which argued against a colorectal primary. Surgical biopsy and pathology were also consistent with metastatic clear cell ovarian cancer. The patient did have an elevated CA-125 of 440.3.

DISCUSSION:

Four percent of ovarian carcinoma metastases are to the colorectal region. Isolated rectal metastasis is even more rare. Immunochemical stains are helpful in determining the primary lesion and source of malignancy. Cytokeratin 7 positive and cytokeratin 20 negative immunostaining is almost 100% specific for primary ovarian origin.
1
The patient was transfused blood and her hemoglobin improved with no further bleeding and she was discharged home. She was started on Carboplatin-Taxol every 3 weeks for six cycles and was going to be tested for the BRCA gene.
1534 Concomitant Clostridium difficile and Immunotherapy-Induced Colitis: A Case Report
Authors: Sidhu Tahnee , Almeqdadi Mohammad , Krishnan Sandeep
Published: October 2019

INTRODUCTION:

For patients on immunotherapy a possible serious side effect includes immunotherapy-induced colitis, which often results in termination of treatment. However, it is important to rule out other etiologies such as infectious causes in the setting of immunosuppression. We report a case of concomitant Clostridium difficile colitis and ipilimumab-induced colitis, treated with simultaneous oral vancomycin and systemic steroids.

CASE DESCRIPTION/METHODS:

A 54-year-old man with 3-year history of clear cell metastatic renal carcinoma with distant metastases (stage IV) status post right nephrectomy on palliative ipilimumab and nivolumab presented with 15 nonbloody watery bowel movements a day for 10 days after finishing his third course of immunotherapy. Medical history was significant for a recent 3-month use of steroids for cervical spinal metastasis. He had abdominal cramping relieved with bowel movements, a 15-20 pound weight loss, and fatigue. White blood cell count was 10.8 × 103/υl and creatinine was 1.2 mg/dl. Clostridium difficile PCR was positive in the stool and he was initiated on oral vancomycin. Infectious work-up was completed and negative for giardia, cryptosporidium, stool ova, and parasites. Stool lactoferrin was positive. Abdominal/Pelvic CT did not show evidence of toxic megacolon. He did not improve significantly with oral vancomycin, and was started on simultaneous systemic steroid taper for presumed immunotherapy-induced colitis secondary to ipilimumab, with significant improvement thereafter.

DISCUSSION:

Immune related adverse colitis is an important consideration for patients on immunotherapy, specifically those medications well known to cause it such as ipilumumab. It is crucial to consider infectious causes but it also is important to continue to consider immunotherapy-induced colitis, which may coexist with the infection. There are no clear guidelines on treatment for concomitant Clostridium difficile colitis and immunotherapy colitis. Review of the literature revealed one case of simultaneously treating both Clostridium difficile colitis and ipilumumab induced colitis. Additional review of the literature revealed that patients with inflammatory bowel disease who are on corticosteroids for a flare and develop Clostridium difficile, concurrent corticosteroids is supported by expert opinion. This case supports the notion of using systemic steroids for treatment of suspected immunotherapy-induced colitis, while simultaneously treating an infectious colitis.
1536 An Uncommon Case of Small Bowel and Pan-Colonic Varices
Authors: DiCarlo Vick S. , Ravi Sujan , Shoreibah Mohamed , Kamath Patrick
Published: October 2019

INTRODUCTION:

We present a case of idiopathic varices in the small bowel and colon discovered after extensive work up for iron-deficiency anemia and portal hypertension.

CASE DESCRIPTION/METHODS:

41-year-old with no known medical history underwent esophagogastroduodenoscopy (EGD) and colonoscopy for evaluation of iron-deficiency anemia. EGD was normal. Colonoscopy revealed diffuse colonic varices extending from the cecum to the rectum (Figure 1). Computed tomography enterography showed numerous varices of the mid jejunum. Magnetic resonance imaging of the abdomen showed patent portal circulation and no other abnormalities. Echocardiogram did not show any evidence of right heart failure. Transjugular liver biopsy showed a portosytemic pressure gradient of 4 mm of Hg indicating the absence of portal hypertension. Liver biopsy only showed mild steatosis and no fibrosis. A direct measurement of portal pressure was 3 mmof Hg again indicating the absence of portal hypertension.

DISCUSSION:

Given the extensive workup with no evidence of portal hypertension, patient is thought have idiopathic varices in the small bowel and colon. Ectopic varices, especially in the colon are rare and are usually associated with portal hypertension. Idiopathic colonic varices in association with small bowel varices are even more infrequently described in existing literature. Clinical presentation has been reported with massive hemorrhage, recurrent bleeds and even as incidental findings in endoscopies and imaging performed for other reasons. Management options include conservative frequent follow up or surgery if there is evidence of recurrent bleeds or massive hemorrhage.
1537 Colonic Gallstone Obstruction in the Setting of Cholecystocolonic Fistula
Authors: Doniparthi Meghana , Shah Natasha , Brasky Jeffrey
Published: October 2019

INTRODUCTION:

Gallstone ileus is a relatively rare complication of cholelithiasis, estimated to account for approximately 1%-4% of all cases of mechanical intestinal obstruction. Cholecystoenteric fistulas form as a result of an inflamed gallbladder adhering to adjacent small bowel or colonic tissue, opening a channel by which gallstones can enter the intestinal tract. Fistula formation is most commonly to the duodenum (32.5-96.5%) but can also infrequently occur in the colon leading to gallstone impaction past the ileocecal valve.

CASE DESCRIPTION/METHODS:

Our patient is a 63 year old female who presented to the emergency room with one week of nonradiating stabbing left lower quadrant abdominal pain and constipation. She reported associated anorexia, and nausea without emesis. She was afebrile and hemodynamically stable. On exam, she was tender to palpation in the lower quadrants. No stool was present in the rectal vault. She had a negative Murphy's sign. Labs revealed WBC count 18.6 thousand/mcL, normal AST, normal ALT, and alkaline phosphatase 158 unit/L. Computed tomography (CT) scan abdomen/pelvis revealed gallbladder wall thickening with pneumobilia, cholelithiasis, normal common bile duct, and a large curvilinear hyperdensity in the distal colon (A). This was suspected to be a displaced gallstone in the sigmoid colon related to a fistula between the gallbladder and hepatic flexure (B). Removal of the stone was attempted by flexible sigmoidoscopy with snare and basket but was unsuccessful. She was then taken for exploratory laparotomy, transverse colotomy with extraction of 5 × 3.4 cm gallstone, loop transverse colostomy, and ventral hernia repair (C). She received IV antibiotics for 5 days and was discharged home.

DISCUSSION:

This case highlights a rare etiology of colonic gallstone obstruction in a patient without risk factors including underlying malignancy, colonic stricture, or diverticulum. Optimal surgical management of gallstone ileus with associated fistula is still being defined as few cases have been reported in the literature. One large retrospective survey found enterotomy with stone extraction to be associated with improved survival outcomes and decreased postoperative complications compared to surgery with fistula closure and bowel resection. Our patient had stable gallbladder changes and persistent cholecystoenteric fistula on CT scan over the next three months and expressed several gallstones through her colostomy without requiring further surgery.
1539 Drug-Induced Colitis as a Side Effect of Calcitonin Gene-Related Peptide (CGRP) Antagonist for Migraines
Authors: Hansen Daniel J. , Linzay Catherine , Kale Hemangi
Published: October 2019

INTRODUCTION:

Drug-induced colitis is a documented though relatively uncommon side effect of several drug classes, and is under-recognized and under-reported. In May 2018, an injectable calcitonin gene-related peptide (CGRP) antagonist, erenumab, was approved by the FDA for migraine prophylaxis. In the following case, this new medication is implicated as a possible cause for severe colitis resembling an inflammatory bowel disease-like picture both clinically and endoscopically.

CASE DESCRIPTION/METHODS:

A 33-year-old Caucasian female presented with complaints of rectal bleeding, diarrhea, and abdominal pain 2 weeks after starting a CGRP antagonist, erenumab, for chronic refractory migraine headaches. Pertinent laboratory studies showed leukocytosis with bandemia. CT Abdomen/Pelvis showed diffuse colonic wall thickening. Stool studies did not indicate any infectious etiology and an IBD panel was negative. She underwent a colonoscopy that showed severe, deep punched out ulcerations throughout the entire colon. Biopsy showed active colitis. She had a prior colonoscopy in 2009 for work up of IBS, which was endoscopically and microscopically normal. The patient's symptoms and clinical findings resolved after discontinuing the drug. A follow up colonoscopy performed one month after discharge showed evidence of ulcer healing with no new areas of inflammation.

DISCUSSION:

Blocking CGRP receptors of the central nervous system may reduce headaches, however blocking those of the enteric system can promote breakdown of the colonic mucosal barrier and induce a systemic inflammatory reaction. In animal models, extensive mucosal damage was noted in the subjects receiving CGRP receptor antagonists. This case implies that certain patients may be at risk for developing mucosal barrier disruption from the blockade of the calcitonin gene-related peptide receptor with erenumab or similar drugs. Further research may be needed to elucidate risk factors that may contribute to susceptibility to these deleterious effects. Once those patients that are more at risk are identified, there may be a role for endoscopic surveillance in certain patients taking these medications. While drug-induced colitis is likely to be an uncommon manifestation of blocking CGRP, clinicians should be aware of this potential side effect of targeted therapy and counsel patients receiving this therapy.
1554 An Unusual Cause of Hematochezia: Anorectal Inflammatory Myoglandular Polyp
Authors: Peng Frederick B. , Tan Mimi C.
Published: October 2019

INTRODUCTION:

Colorectal polyps are an unusual cause of hematochezia and usually result from overlying ulcerations on adenomas or cancers. Non-adenomatous polyps, such as inflammatory polyps, may be a rare cause of gastrointestinal bleeding. Here, we present a case of a patient with painless hematochezia found to be originating from a bleeding anorectal inflammatory myoglandular polyp related to rectal prolapse.

CASE DESCRIPTION/METHODS:

A 51-year-old man with alcohol abuse and hepatitis C presented with fatigue and light-headedness along with 7-8 years of small volume painless hematochezia with bowel movements. He endorsed straining with bowel movements and something protruding from his anus that he would push back in. On physical exam, he was hemodynamically stable with a normal abdominal exam and a rectal exam revealing a palpable rectal mass without overt signs of bleeding. His lab work was notable for a hemoglobin of 5.5 g/dL. Magnetic resonance imaging (MRI) of the pelvis revealed rectal wall thickening and an enhancing mass abutting the anal sphincter (Figure 1). Colonoscopy revealed left-sided diverticulosis without bleeding and an ulcerated, vascular mass in the anal canal, best seen on retroflexion (Figures 2 and 3). Biopsies of the mass were consistent with an inflammatory myoglandular polyp thought to result from intermittent rectal prolapse. The mass was resected via transanal excision with complete resolution of hematochezia.

DISCUSSION:

Inflammatory myoglandular polyps are rare, non-neoplastic pedunculated polyps that are predominantly incidental findings during enemas or endoscopy but can present with hematochezia. While concentrated mostly in the distal colon, they can be seen in the descending and transverse colon as well. The etiology remains unknown, but there may be an association with mucosal prolapse and sigmoid diverticulosis. Specifically, it is hypothesized that chronic trauma from intestinal peristalsis may distort colonic crypt architecture, which results in muscularization of the lamina propria. This leads to subsequent redundancy and passive venous congestion that contributes to prolapse of these lesions. Generally, symptomatic inflammatory myoglandular polyps require endoscopic or surgical resection, which is curative. In this case, given the patient's symptoms along with the size and location, surgical management was indicated.
1559 Chronic Peri-Oral Dermatitis as the First Manifestations of Crohn's Disease
Authors: Isseh Mahmoud , Ghanimeh Mouhanna Abu , Naffouj Sandra , Horton Nicholas , Isseh Nazih , Kaur Nirmal
Published: October 2019

INTRODUCTION:

Oral manifestations (OM) have been reported in crohn's disease (CD). The prevalence of these manifestations ranges between 0.5%-50% in adults and 10%-80% in pediatrics. OM of CD may coincide with the intestinal manifestations, or less commonly precede them. Aphthous ulcers, angular cheilitis, swelling of the lips and gingiva, cobblestoning of the mucosa, deep linear ulcers and periodontal disease have been reported in the literature.

CASE DESCRIPTION/METHODS:

An 18-year-old female with no significant history presented to her PCP with recurrent lip swelling and dryness. She was diagnosed initially with angioedema without urticaria. History of an environmental exposure was inconsistent and testing for hereditary angioedema, including C1 esterase and C4 levels were unremarkable. She was referred to a dermatologist who diagnosed her with peri-oral dermatitis. Treatment with antihistamines, topical steroids, antifungals, antibiotics and petroleum jelly were unsuccessful. She was treated with PO prednisone for a presumed pemphigus vulgaris with symptomatic improvement, but with relapse two weeks after weaning steroids. Due to chronicity of symptoms, a lip biopsy was done and showed a psoriasiform dermatitis with a granulomatous inflammation. Direct immunofluorescent testing was unremarkable. Results were concerning for CD versus cheilitis granulomatosa. She denied GI symptoms, weight loss or family history of IBD. Further testing revealed a normal ferritin, vitamin B12, folate, ANCA, and QuantiFERON-TB. She was referred to GI for further evaluation. An EGD showed a normal esophagus, stomach and examined duodenum. Biopsies from stomach and duodenum were unremarkable. A colonoscopy showed a normal perianal area, colon and terminal ileum. Biopsies from the left colon showed a focal active colitis, foci of neutrophilic cryptitis and focal epithelioid granuloma without dysplasia. Stains for acid fast bacilli and fungi were negative. Biopsies from the right colon and terminal ileum were unremarkable. MRE showed no evidence of active small bowel CD. Given the early onset and widespread distribution, the decision was to start adalimumab. Her OM improved significantly. A repeat colonoscopy with biopsies was unremarkable.

DISCUSSION:

The recognition of OM can play an important clue in diagnosis and management of CD, especially that an isolated oral disease is uncommon as a first presentation. Infections, nutritional deficiencies and medication side effects are important to consider as differential diagnosis.
1563 Lower Intestinal Bleeding Caused by a Left Ventricular Assist Device (LVAD) Driveline
Authors: Kaminsky Thomas J. , Gessel Luke
Published: October 2019

INTRODUCTION:

Gastrointestinal bleeding (GIB) is a common symptom in patients with advanced cardiovascular disease. Among those at highest risk are patients with non-pulsatile left ventricular assist devices (LVADs).1 This has been attributed to multiple factors including therapeutic anticoagulation, degradation of von Willebrand factor,1 formation of angiodysplasias and advanced age.2,3 Such conditions predispose bleeding from arteriovenous malformations (AVMs) as well as other commonly occurring lesions. However, an overlooked cause of bleeding in these patients is direct injury from tunnelization of the LVAD driveline. Here we review a case of overt GIB, months after direct colonic injury from an LVAD driveline.

CASE DESCRIPTION/METHODS:

A 72 year old man with history of end stage heart failure underwent placement of an LVAD in January of 2019. His post-operative course was tumultuous and complicated by polymicrobial driveline infection. He recovered gradually and was discharged to medical rehabilitation in February with therapeutic warfarin and low dose aspirin. In April the patient presented to the Emergency Department after a syncopal episode and subsequent dizziness. He was found to have heme positive stool and hemoglobin of 7.8 g/dL (from 9.0 g/dL one month earlier). Other labs revealed iron deficiency with serum Iron level of 48 ug/dL and international normalized ratio (INR) elevation to 1.9 with warfarin therapy. Gastroenterology was consulted for evaluation of gastrointestinal blood loss with anemia. The patient underwent EGD and colonoscopy. EGD showed only retained gastric contents and no active bleeding. Colonoscopy revealed a linear, rigid foreign body penetrating the colonic wall and traversing the lumen (Figure 1). Review of prior CT scans confirmed the LVAD driveline had penetrated and passed through the transverse colon (Figures 2 and 3). The patient was subsequently taken to surgery for transverse colon resection with washout and exteriorization of the contaminated LVAD driveline.

DISCUSSION:

Gastrointestinal bleeding is common in cardiac patients following LVAD placement.1 Contributing factors include the use of anticoagulation and acquired von Willebrand disease, which most commonly causes bleeding from from AVMs.1,2 However, this case describes late bleeding after direct mucosal injury with LVAD driveline placement. Although a rare occurrence, this complication should be considered in LVAD patients, especially those with history of prior driveline infection.
1564 Hyper Progressive Disease (HPD) in a Colon Cancer Patient on Pembrolizumab
Authors: Lakkasani Saraswathi , Kollimuttathuillam Sudarsan , Dacosta Theodore , Guron Gunwant , Shaaban Hamid S. , Patel Kinjal
Published: October 2019

INTRODUCTION:

Anti-programmed death one (PD1) and anti-programmed death ligand one (PDL1) has changed the prospective in the management of patients with advanced cancer. Where studies have shown significant response in some cases, a subset of patients might instead suffer from tumor flare. HPD is a term used to refer a drastic flare up of tumor with worsening clinical status in patients treated with PDL1 and PD1.

CASE DESCRIPTION/METHODS:

A 48-year African American female came with complaints of fatigue, abdominal pain and weight loss for four months. The CT scan of abdomen showed an extensive eccentric mass involving the terminal ileum and lymphadenopathy (LAP) along the portal caval space. She was diagnosed with stage IIIc adenocarcinoma colon with K-RAS wild type. A right hemicolectomy was performed. Patient received various regimen of adjuvant chemotherapy for 15 months. The disease gradually progressed to stage IV, with metastasis to liver, mesentery and retroperitoneal LAP. Meanwhile patient was diagnosed with Lynch syndrome with genetic testing positive for MSH-6 and EGFR/CEP7 2.47. She was started on pembrolizumab. The repeat CT scan of abdomen after five weeks of the first dose of pembrolizumab showed new and enlarging metastatic disease. Previous 51 × 48 mm metastatic lesion now measures 76 × 66 mm along with worsening of retroperitoneal and mesenteric LAP. As this could be pseudo progression, patient received two more doses. The CT scan of the abdomen revealed persistently enlarging liver metastasis along with enlarging mesenteric and retroperitoneal LAP. Further treatment was held. Unfortunately, patient deceased in few weeks after receiving the third dose of pembrolizumab due to HPD.

DISCUSSION:

Definition, incidence, pathogenesis and predictive factors of HPD are yet to be understood. Studies are available where parameters like tumor growth rate, tumor growth kinetic and time to treatment failure were used to define HPD, but no universally accepted definition exist. In the first study of HPD by Champiat in 2016, HPD was defined as a progression by RECIST criteria at first evaluation with a greater than or equal to two-fold increase in TGR from baseline (before treatment). Studies showed an association of HPD with age >65 years, MDM2/MDM4 amplification and EGFR alteration. Further knowledge about the pathogenesis and predictive factors of HPD may help to better understand the group of individuals that will likely benefit.
1565 Goblet Cell Carcinoid: An Unusual Presentation of Acute Abdominal Pain
Authors: Lakhani Komal , Bergagnini Isabella , Hogan Dan , Kesar Varun , Swaminath Arun
Published: October 2019

INTRODUCTION:

Goblet Cell Carcinoid (GCC) is a rare neoplasm comprising 0.3-0.9% of appendectomy specimens and less than 14% of all malignant masses of the appendix. While abdominal pain is a common presenting complaint of GCC, rarely does it manifest as an acute perforated appendicitis, as depicted in the case below.

CASE DESCRIPTION/METHODS:

A 66 year old male with a medical history of hypertension, heart failure, endocarditis, chronic alcoholic pancreatitis presented with RLQ pain 3 days prior with associated fevers, chills, nausea, vomiting and maroon colored stools. His vitals were stable with exam notable for diffuse lower abdominal tenderness and no rebound tenderness. Labs demonstrated a mild leukocytosis of 11.7 and negative blood cultures. CT abdomen and pelvis revealed a small appendiceal abscess and acute appendicitis for which he was treated with intravenous fluids and antibiotics, then was discharged on day 3 with oral antibiotics. 7 days later, he was readmitted with intractable nausea and vomiting. Repeat CT revealed mild improvement in acute appendicitis with labs notable for a leukocytosis of 14 for which he was restarted on antibiotics. Six days later, he underwent a laparoscopic appendectomy as repeat CT was concerning for persistent appendicitis with necrosis (Figure 1). Intra-operatively, the appendix was found to be ruptured. Pathology of appendiceal specimen revealed GCC (Figure 2). His hospital course was also complicated by septic shock and respiratory failure requiring intubation, and acute tubular necrosis requiring hemodialysis. The patient eventually improved and underwent a staging right hemicolectomy which identified lymphovascular invasion and node positivity (Figure 3).

DISCUSSION:

GCC, a rare appendiceal malignancy of both neuroendocrine and glandular histological features, accounts for less than 5% of all primary tumors of the appendix. Presentation varies from no symptoms to overt gastrointestinal bleeding, with acute appendicitis as the most common initial manifestation. While GCC is of a more aggressive phenotype compared to its benign carcinoid tumor counterpart, prognosis is generally favorable. However in 15-30% of cases, metastasis to the ovaries, pelvis, abdominal cavity, ribs, vertebra and lymph nodes has been observed. Surgery is typically the treatment of choice with tumors <2 cm confined to the appendix requiring only an appendectomy. For larger tumors with nodal involvement, right hemicolectomy within 3 months after appendectomy followed by chemotherapy is warranted.
1570 A Less Recognized Cause of Checkpoint Inhibitor-Induced Diarrhea
Authors: Javed Saad , Al-Obaid Lolwa , Farwell Kristen
Published: October 2019

INTRODUCTION:

Immune checkpoint inhibitors (ICPIs) are increasingly being used for the treatment of a number of malignancies. These immunomodulatory antibodieshave substantially improved the prognosis for patients with advanced cancers. ICPIs have been associated with immune-mediated colitis causing diarrhea and often hematochezia, with significant inflammation on endoscopic evaluation. We present an unexpected adverse event in a patient being treated with an ICPI.

CASE DESCRIPTION/METHODS:

A 58-year-old male with stage-4 lung adenocarcinoma, on pembrolizumab presented with abdominal pain, nausea and diarrhea. His symptoms had been ongoing for 6 months. He endorsed 10 lb weight loss over two months. He had completed his 22nd cycle of pembrolizumab 1 week prior to presentation. On examination, he was tachycardic and had mild tenderness in bilateral lower quadrants. Labs revealed Hgb of 19 g/dl, BUN 26, with a mild hyponatremia. He had mild leukocytosis and a CRP of 73.8 mg/L. Infectious work up was negative and the patient started loperamide. Colonoscopy revealed a normal appearing mucosa without evidence of mucosal inflammation or ulceration. Pembrolizumab was held and he was started on IV methylprednisolone with improvement in the frequency of his bowel movement. He was discharged home on an oral prednisone. Pathology from the random biopsies demonstrated surface epithelial damage with increased intraepithelial lymphocytes without significant crypt distortion, consistent with lymphocytic colitis. The patient was switched from prednisone to budesonide because of the lower rate of response associated with prednisone. He completed a taper with resolution of his symptoms.

DISCUSSION:

ICPIs are associated with a unique spectrum of side effects termed immune-related adverse events. Diarrhea is a common clinical complaint in patients this patient population, with immune-mediated colitis being a common cause. Typically endoscopic and histopathological features of immune checkpoint inhibitor-induced colitis are similar to inflammatory bowel disease (IBD) flare rather than microscopic colitis as seen in this case. The data on clinical, endoscopic, and histologic characteristics as well as management strategies for immune checkpoint induced microscopic colitis, is limited. Our case, suggests a unique form of gastrointestinal toxicity associated with pembrolizumab (PD-1 blocker) and highlights successful management with IV and oral corticosteroids, which permitted the patient to continue pembrolizumab without interruption.
1573 Ixekizumab-Induced Gastritis and Colitis in an Elderly Female With Plaque Psoriasis
Authors: Imam Zaid , Patwardhan Soumil , Qu Zhenhong , Ghaith Gehad
Published: October 2019

INTRODUCTION:

Psoriasis and inflammatory bowel disease (IBD) share common pathogenesis pathways including cytokine mediated inflammation. Interleukin-17 (IL-17) monoclonal antibodies such as ixekizumab have demonstrated excellent results in moderate to severe plaque psoriasis and psoriatic arthritis. Antagonism of IL-17 has been demonstrated in animal models to induce or worsen existing inflammatory colitis. We hereby present a case of ixekizumab-induced gastritis and colitis in a 63-year old Caucasian female with severe plaque psoriasis successfully treated with prednisone.

CASE DESCRIPTION/METHODS:

A 63-year old Caucasian female with history of severe plaque psoriasis and peptic strictures presented with severe bloody diarrhea, generalized abdominal pain, and tenesmus few weeks after receiving 3 doses of ixekizumab. She had no personal or family history of IBD. Her medications included 81-mg ASA, omeprazole, metoprolol, cetirizine and levothyroxine. She denied NSAID use. A colonscopy 2-years prior showed two tubular adenomas, and a gastroscopy 3 months prior to ixekizumab therapy was normal. Her diagnostic evaluation revealed (a) normal CBC, kidney function and liver chemistries, (b) negative stool cultures, microscopy and C. Difficile testing, (c) a gastroscopy demonstrating diffuse gastritis involving the body and antrum (d) a flexible sigmoidoscopy demonstrating a diffuse area of atrophic, eroded and friable mucosa with contact bleeding and thickened mucosal folds in the recto-sigmoid colon. Gastric and colonic biopsies demonstrated focal mucosal erosions with architectural distortion concerning for a drug induced gastritis and colitis. H. Pylori testing was negative. Ixekizumab was discontinued and treatment with IV steroids was started. Symptom resolution was noted by day five of therapy and she was converted to an oral steroid taper.

DISCUSSION:

The temporal association, the histology and the improvement with discontinuation of the medication strongly support the diagnosis of a drug induced colitis. This case is unique in the sense that it is the first in the literature to report ixekizumab-induced gastritis and colitis. Whether the patient will require long-term immunosuppression and will manifest later with IBD is to be observed. Despite the rarity of colitis associated with IL-17 inhibitors, counseling patients on this severe adverse effect is integral to the discussion between specialists and their patients prior to initiating therapy.
1574 An Unusual Finding of Non-Hodgkin's Lymphoma in the Gastrointestinal Tract
Authors: Gangireddy Mounika , Shrimanker Isha , Goel Siddharth , Vanjarapu Jagan , Charan Mohan , Nookala Vinod
Published: October 2019

INTRODUCTION:

Primary gastrointestinal lymphomas include a small proportion of gastrointestinal cancers but rarely involve the ileocecal valve. Even though early detection and diagnosis is prudent in the care as it is associated with favorable therapeutic options, diagnosis with colonoscopy requires a high suspicion and precision. We report an unusual presentation of B-cell lymphoma at the ileocecal valve diagnosed on colonoscopy.

CASE DESCRIPTION/METHODS:

A 55-year-old female with no significant past medical history presented with a positive fecal occult blood test at her primary care office. Her brother was recently diagnosed with colon cancer at the age of 58. Physical examination was unremarkable and laboratory tests revealed mild iron-deficiency anemia with hemoglobin of 11 gm/dl. Colonoscopy revealed a tubular adenoma in the ascending colon. Colonoscopy is done after five years revealed a prominent ileocecal valve. Histopathological examination of the biopsy showed diffuse infiltration of mononuclear cells with large malignant cells along with pleomorphic vesicular nuclei and prominent nucleoli. A diagnosis of malignant follicular B type lymphoma was made and the patient is scheduled for treatment with an oncologist.

DISCUSSION:

Gastrointestinal non-Hodgkin's lymphomas are usually detected in the stomach and duodenum. As per our knowledge, this is the first case of B-cell lymphoma involving the ileocecal valve with no major derangement or deformity on the macroscopic exam. Clinicians must be wary of the clinical presentation and consider the possibility of a primary lymphoma at the ileocecal valve with minor changes in appearance, especially in patients with a family history of malignancy.
1582 A Case of Complicated Diverticulitis Masquerading as Crohn's Disease: A Diagnostic Dilemma
Authors: Bhardwaj Gaurav , Nawaz Waqas , Hertan Hilary
Published: October 2019

INTRODUCTION:

Diverticular disease can have a complicated course in patients younger than 40 years of age and may mimic Crohn's disease (CD), thus presenting a diagnostic challenge. We report a case of a young adult presenting with complicated diverticulitis which was initially mistaken as CD.

CASE DESCRIPTION/METHODS:

A 31 year old man was admitted for left flank pain for 6 months and a flank mass for a week associated with weight loss, fever and fatigue. Exam showed a tender palpable mass in the left flank. Initial laboratory data showed leukocytosis of 13.7 k/uL with elevated ESR and CRP. Inflammatory bowel disease (IBD) serology was consistent with CD. Abdominal CT showed mural thickening of the descending and sigmoid colon with multiple fistulae extending into the left flank muscles and a diagnosis of CD was suggested by radiology. Colonoscopy showed erythematous mucosa in the descending colon with normal terminal ileum and biopsy showing stromal fibrosis with lymphoid aggregates. CT guided incision and drainage (I&D) was performed and patient was treated with antibiotics. Within 4 weeks of his discharge he had a similar presentation requiring repeat I&D. The clinical presentation, patient's young age, positive serology and radiological findings led to a presumptive diagnosis of CD. Infliximab was started but he continued to have hospitalizations for recurrent retroperitoneal abscesses. Finally, a left hemicolectomy was done. Pathology showed acute and chronic diverticulitis with mural scarring and abscess formation without any evidence of granulomas, ulcerations and crypt abscesses to suggest IBD.

DISCUSSION:

Diverticular disease has been described as not only rare but virulent in young patients. 25% of patients with diverticulitis develop complications including perforation, fistulae, obstruction or a stricture which can mimic CD. Although a common site of involvement in diverticulitis, the sigmoid colon is also involved in 70% of cases in Crohn's colitis. Radiologic findings can mimic the features of CD in complicated diverticulitis. IBD serology can be misleading due to its low specificity. Histologically, granulomas are only seen in 30% of cases in CD. No response to CD therapy can sometimes be the only clue to review the diagnosis. Differential may also include segmental colitis associated with diverticulosis that can develop into CD. This case highlights the virulent course of diverticulitis in young patients and serves as a reminder to have a high index of suspicion in this population.