bluuebunny/crossref_metadata_2025 huggingface dataset:
1611 Not All Polyps Are Created Equal: Schwann Cell Hamartoma Incidentally Found on Screening Colonoscopy
Authors: Tetangco Eula Geralyn , Rassameehiran Supannee , Yap John Erikson
Published: October 2019

INTRODUCTION:

Majority of colorectal polyps are epithelial in origin, such as adenomas (tubular, tubulovillous, and villous) and serrated polyps (hyperplastic, traditional serrated, sessile serrated). Mesenchymal polyps are rare, but detection is improving with high-quality screening colonoscopies. Mucosal Schwann cell hamartomas (MSCH) of the gastrointestinal tract are mesenchymal tumors that were first described in 2009. The median age at diagnosis is 59 years (range 34-88 years), with a slight female predominance.

CASE DESCRIPTION/METHODS:

A 70-year-old white male with coronary artery disease, persistent atrial fibrillation, and obstructive sleep apnea was referred for screening colonoscopy. This revealed 2 sessile polyps (Paris 0-1s) in the sigmoid colon, measuring 2 mm and 7 mm in size. The polyps were completely removed by cold biopsy polypectomy and cold snare polypectomy, respectively. The second polypectomy site oozed slightly and was closed using 2 hemoclips, with anticipation that the patient would be resuming anticoagulation the same day. Pathology of the polyps were consistent with mucosal Schwann cell hamartoma, staining positive for S-100 protein.

DISCUSSION:

MSCH are a group of neuronal polyps purely composed of Schwann cells that are positive for S-100 in a strong, diffuse pattern, with both nuclear and cytoplasmic staining. They typically cause no symptoms and may present as small polyps (1-8 mm) incidentally found during colonoscopy, predominantly in the rectosigmoid. They are not associated with any inherited syndromes. The diagnosis is made after excluding other lesions that resemble spindle cell proliferation and other neuronal tumors. These include neurofibroma, leiomyoma, and gastrointestinal stromal tumor (GIST). Neurofibromas, while also composed of Schwann cells, are often associated with neurofibromatosis type 1 (NF1). NF1 is usually accompanied by multiple cutaneous neurofibromas. Purely colorectal neurofibromas without skin manifestations are extremely rare. GIST can be easily excluded by negative immunoreactivity of c-Kit and CD117. Leiomyomas stain positive for smooth muscle actin. In summary, MSCH’s are rare lesions with a benign course and no known association with inherited polyposis syndromes. Diagnosis depends on pathology demonstrating lack of axons on pathology, and immunohistochemistry staining strongly for S-100 protein. Our case highlights that accurate diagnosis can prevent overly aggressive or unnecessary treatments.
1614 Asymptomatic Intestinal Spirochetosis With Colonic Ulcerations
Authors: Catinis Anna M. , Hudson Catherine T. , Stibbe Jason R. , Raines Daniel
Published: October 2019

INTRODUCTION:

Both the origin and commensal or pathogenic nature of intestinal spirochetes (IS) in humans are poorly understood. Colonization is predominantly found in homosexual males and in HIV patients.1 Homosexual males have shown colonization rates up to 20.6-62.5% leading scientists to hypothesize that IS could be sexually transmitted.2 Colonization can be associated with severe clinical symptoms like persistent diarrhea and rectal bleeding, especially in children.3 Therefore, a greater understanding of clinical presentation and risk factors is needed.

CASE DESCRIPTION/METHODS:

A 51-year-old asymptomatic male with compensated alcoholic cirrhosis presented for a screening colonoscopy. He denied NSAID use and a personal or family history of inflammatory bowel disease. Colonoscopy revealed multiple clean-based ulcers in the cecum and ascending colon. Histologic examination of the specimens on H&E stain revealed colonic mucosa with focal, acute inflammation and microorganisms consistent with spirochetes. No granulomas, crypt architectural distortion, or dysplasia were identified. The fuzzy, basophilic fringe-like microorganisms were positive for GMS and PAS stains and negative for FITE stain. The findings were consistent with IS and the patient was treated with metronidazole.

DISCUSSION:

The clinical significance of IS in humans is not well defined. Presentation may vary from asymptomatic to causing chronic diarrhea, rectal bleeding, abdominal pain, and weight loss. IS can be associated with immunodeficiency, alcoholism and drug abuse, poor hygiene, sexual practices, and concomitant bowel content stasis. Pathology reveals presence of spirochetes in the brush border. Transmission electron microscopy reveals spirochetes attached to enterocytes with associated shortened or depleted microvilli. Often endoscopy in IS-infected patients is normal, but in this rare presentation of intestinal spirochetosis, ulcerations of colonic mucosa were noted. Metronidazole is an effective treatment.4-5
1625 Colonic Schwannoma Identified in Asymptomatic Middle-Aged Female
Authors: Yeroushalmi Kevin , Hajar Rabab , Rizvon Kaleem
Published: October 2019

INTRODUCTION:

Schwannomas are typically benign tumors of the neural sheath. Schwannomas of the colon are extremely rare entities; in fact, when schwannomas occur in the gastrointestinal tract, the colon is considered the least likely site. Schwannomas of the colon were previously misdiagnosed as gastrointestinal stromal tumors; however, with advances in immunohistochemical staining, the number of cases of intestinal schwannomas has gradually increased. Colorectal schwannomas can be divided into three clinicopathologic types: spindle cell, epithelioid, and plexiform. Here, we present a unique case of a colonic spindle cell schwannoma encountered in an asymptomatic patient on routine colonoscopy.

CASE DESCRIPTION/METHODS:

A 50-year-old female with no significant past medical history presented to gastroenterology clinic for routine colorectal cancer screening. The patient denied abdominal pain, nausea, vomiting, diarrhea, constipation, rectal bleeding, or weight loss. She also denied family history of neurofibromatosis. Physical examination was unremarkable. Laboratory studies showed that the patient had microcytic anemia (hemoglobin 10.9 g/dl, MCV 59 fL) but were otherwise unremarkable. A colonoscopy was subsequently performed and revealed a 6 mm sub-epithelial lesion in the sigmoid colon. Biopsy showed colonic mucosa with mild chronic inflammation and multiple spindle cell aggregates confined to the lamina propria (Figure 1). Cytological atypia, mitoses, and necrosis were identified in the biopsied specimen (Figure 2). Immunohistochemical assays demonstrated lack of reactivity to CD68, CD117, and DOG-1. The spindle cells were strongly positive for S100, confirming the diagnosis of mucosal Schwann cell hamartoma.

DISCUSSION:

Rectal bleeding, colonic obstruction, and abdominal pain are the three most common presenting symptoms for colorectal schwannoma; however, our patient denied any of these symptoms. The management of intestinal schwannomas remains controversial. Surgical resection with adequate margins remains the treatment of choice. Several sources question whether radical resection based on oncologic principles is necessary given the benign nature of these tumors. Our patient was managed conservatively with routine surveillance. Repeat colonoscopy performed approximately 3 months after the initial colonoscopy revealed no signs of recurrence or metastases. This case supports the notion that these rare mesenchymal tumors are commonly benign and aggressive therapeutic interventions are likely unnecessary.
1664 A Herald Bleed: A Case Report of an Aortoenteric Fistula Causing an Acute Lower Gastrointestinal Bleed
Authors: Bhatti Sundus , Omer Endashaw
Published: October 2019

INTRODUCTION:

Aortoenteric fistula (AEF) is a rare, life-threatening condition with an incidence of 0.007/million. Primary AEF arises de novo, secondary AEF (SAEF) occurs following abdominal aortic aneurysm (AAA) repair. Majority of AEF’s involve the duodenum, due to proximity to the aorta. It may present as an exsanguinating herald GI bleed, associated with high mortality rates. SAEF has a 45.8% mortality rate in the first month.

CASE DESCRIPTION/METHODS:

A 66-year-old female presented with sudden onset of large volume bright red blood per rectum (BRBPR). She denied any prior episodes of GI bleed, alcohol or NSAID use and had never had prior endoscopy. She mentioned cholecystectomy and hysterectomy as her only surgical interventions. On examination she was hemodynamically unstable, lethargic and had a midline abdominal scar. Digital rectal exam showed BRBPR. Her lab workup showed: Hgb 9.5, Hct 29%, platelets 147000, INR 1. An emergent EGD was negative. Colonoscopy showed a 5 cm, pulsatile submucosal mass with an actively bleeding ulcerated area. Epinephrine was injected for temporary hemostasis. A hemoclip was placed to mark the site for potential embolization, as the lesion was not amenable for definitive endoscopic intervention. A stat CT angiogram of the abdomen and pelvis revealed a large left external iliac artery (LEIA) pseudoaneurysm in the region of the clip placed during colonoscopy. Vascular surgery emergently placed a LEIA stent. It appeared the patient had an open aorto-bi-iliac bypass 15 years ago for a AAA which resulted in the development of SAEF. She did well post operatively.

DISCUSSION:

AEF is important to consider in older patients who present with large volume hematochezia. The presence of prior signs of abdominal surgery should raise suspicion for SAEF as it is difficult to diagnose because of its rarity. The commonest symptom of SAEF is gastrointestinal bleeding. Other symptoms are fever, sepsis, pulsating abdominal or groin mass, abdominal or back pain. CT and GI endoscopy are frequently used for diagnosis. Without treatment AEF often proves to be fatal. Treatment of AEF includes volume resuscitation, antibiotics, and aortic repair. Given our patient's bleed with tenuous clinical status, large body habitus, medical comorbidities, poor functional status as well as previous aorto-bi-iliac bypass, decision was made to approach the pseudoaneurysm endovascularly, despite possible presence of vessel-enteric fistula, as she was deemed unstable for an open approach.
1686 Laparoscopic-Assisted Endoscopic Submucosal Dissection of Early Gastric Adenocarcinoma
Authors: Kudaravalli Praneeth , Schaberg Kurt , Cavnar Michael , Gabr Moamen
Published: October 2019

INTRODUCTION:

A 69-year-old man underwent esophagogastroduodenoscopy (EGD) a year ago which showed intestinal metaplasia without dysplasia in the gastric antrum and incisura. A repeat EGD showed a single plague in the distal esophagus and erosive gastritis. Biopsies revealed high grade dysplasia (HGD) in the gastric cardia and extensive intestinal metaplasia in the rest of the stomach. A subsequent endoscopic ultrasound and CT imaging of chest, abdomen and pelvis revealed no evidence of extraluminal extension or distant metastasis. Given the tumor location surgical resection would require a total gastrectomy. After consultation with surgical oncology, a decision was made to attempt endoscopic submucosal dissection (ESD) with laparoscopic assistance.

CASE DESCRIPTION/METHODS:

In this video report, an initial EGD was performed which confirmed a superficial gastric ulcer in the cardia. A laparoscopic gastrotomy with placement of the 15mm laparoscopic port was performed. The endoscope with a cap was introduced through the port directly into the stomach. The lesion in the gastric cardia was visualized in a retrograde direction. ESD was performed using a Dual-J Knife. A 15mm area was resected. The ESD site was examined for any perforation, bleeding or defects and none were noted. Following the endoscopic portion of the procedure, the abdomen was re-insufflated and inspected for signs of perforation and none were found. The gastrotomy was then closed. On gross pathologic examination the gastric cardia specimen measured 1.9 × 1.7 × 0.3 cm. Microscopic examination revealed well differentiated (G1) focal intramucosal adenocarcinoma arising in a background of intestinal metaplasia with HGD. Tumor invaded lamina propria but no invasion of muscularis mucosa was identified. All margins were uninvolved by carcinoma and dysplasia. The final pathologic stage of the resected specimen was pT1a. Given the findings, lymph node disease was determined to be extremely low and less invasive ESD was expected to be curative 1, 2. A follow up EGD 2-months post-procedure showed no evidence of recurrence.

DISCUSSION:

In conclusion, tumors of the gastric cardia are among the most technically difficult lesions to be removed by ESD with curative rates around 66% 3. This decreases further with tumors located in the anterior hemisphere or have deep submucosal invasion. Laparoscopic assistance provides a head on view for a full thickness ESD. Our case demonstrates this technique is safe and effective.

Watch the video: http://bit.ly/2LuEe7N.
1703 Hematemesis: A Turn of the Screw
Authors: Prakash Sameer , Mirza Asadullah , Salagundla Nethuja , Shepherd Kaylee
Published: October 2019

INTRODUCTION:

Anterior cervical discectomy and fusion (ACDF) in combination with locking plates is considered the standard treatment for cervical spinal trauma, tumors and degenerative disc disease. We present a case of upper gastrointestinal bleed resulting from delayed pharyngoesophageal perforation due to loosened screw in the presence of normally positioned hardware.

CASE DESCRIPTION/METHODS:

A 43-year-old male with hypertension, bradycardia status post pacemaker, cervical stenosis status post C3 -C6 fusion 1 year prior came to the ER with chief complaint of throat and chest pain followed by one episode of hematemesis noticing a 2 cm screw in vomitus. Initial vitals showed T 36.4, HR 78, BP 139/94, RR 18, and SpO2 96% on RA. Cervical spine x-ray showed intact plate of cervical spine with missing screw. Patient was admitted to the ICU and gastroenterology was consulted. Gastrografin swallow study did not show extravasation of contrast and subsequent endoscopy showed extensive soft tissue swelling in the left hypopharynx without purulent exudate. Bedside fiberoptic laryngoscopy showed left pharyngeal posterior wall prominence extending from inferior to tonsil to tip of epiglottis with intact overlying mucosa. Head and neck surgeon recommended non-operative intervention, so the patient was started on broad spectrum antibiotics through the PICC line. He was started on clear liquid diet and advanced to full liquids. His blood count remained stable and he had no further hematemesis. Outpatient follow up showed satisfactory recovery.

DISCUSSION:

Pharyngoesophageal injuries following ACDF are rare with an incidence of <2%. Most perforations are identified in immediate or early postoperative period and result from iatrogenic injury during the procedure and carry high mortality rates. Early local symptoms include neck swelling, dysphagia, fever and subcutaneous emphysema leading to mediastinitis. Fistula formation, microcytic anemia and neck mass are the most common late presentations. Xray of the neck, contrast swallow studies and flexible endoscopy can help locate perforation. When conservative treatment fails or there is systemic involvement, this requires hardware removal, debridement and suture closure of the defect with or without sternocleidomastoid muscle, superior omohyoid muscle, or pertoralis major flap enforcement to reduce the risk of failure. Patients presenting with upper GI bleed, signs of neck infection, and history of cervical spine plating should be evaluated for hardware-related complications.
1708 Case of Secondary Achalasia Presenting Several Years After Nissen Fundoplication With Improvement After Endoscopic Dilatation: “Rare but Not Forgotten”
Authors: Bhardwaj Gaurav , Nawaz Waqas , Guddati Harish , Hertan Hilary
Published: October 2019

INTRODUCTION:

Secondary Achalasia is an esophageal motor disorder presenting with clinical, radiographic and manometric features that mimic those of primary achalasia except that it has a known etiology such as gastroesophageal junction (GEJ) tumor, antireflux surgery, gastric banding or gastrectomy. We present a rare case of secondary achalasia as a remote consequence of a laparoscopic Nissen fundoplication (LNF).

CASE DESCRIPTION/METHODS:

A 59 year old woman with a history of diabetes mellitus, gastroesophageal reflux disease (GERD), hiatal hernia status post LNF with hernia repair eight years ago, presented with dysphagia to solids and liquids with a 24-pound weight loss over the last 3 months. On presentation, physical exam and initial laboratory data were unremarkable. Computerized tomography of the chest showed esophageal dilatation with an obstruction at the GEJ. Upper endoscopy revealed a large amount of impacted food in the lower third of the esophagus which was removed with a Roth net, and the GEJ was traversed by the scope with significant resistance. On retroflexion evidence of a Nissen fundoplication was found at the GEJ with a tight appearing wrap. The GEJ was dilated using Savary dilators over a guide up to a diameter of 14 mm with remarkable improvement of the symptoms. An esophagogram done post dilatation showed transit of the barium contrast through the GEJ.

DISCUSSION:

GERD is the most common pathologic condition affecting the upper gastrointestinal tract. While most patients respond to medical therapy, LNF has become the gold standard for antireflux surgery in patients with medically refractory disease. Transient dysphagia occurs in 40% to 70% of patients after LNF in the early postoperative period due to edema, slipped, migrated or too tight fundoplication or a missed diagnosis of primary achalasia and nutcracker esophagus. However, it can also occur many years after the operation due to hiatal stenosis secondary to severe fibrotic reaction and anterior angulation of the GEJ. EGD is a good initial diagnostic tool and resistance or inability to pass a gastroscope through the EGJ should raise suspicion of secondary achalasia with a background history of LNF. GEJ tumor should always be ruled out with careful examination. Dilatation of the GEJ is done using wire guided Savary dilators or through the scope balloon dilators. Our case highlights the importance of an aggressive evaluation and careful interpretation of a patient presenting with dysphagia with a remote history of fundoplication.
1739 Mediastinal Syndrome: A Rare Etiology of Dysphagia
Authors: Then Eric O. , Chishti Umair Shafiq , Ofosu Andrew , Are Vijay S. , Maddika Srikanth , Gaduputi Vinaya
Published: October 2019

INTRODUCTION:

Breast cancer with metastasis involving the esophagus is a rare phenomenon. Most cases involve metastasis to the mediastinum resulting in esophageal compression. Less commonly these cases will metastasize directly to the mucosa or submucosa of the esophagus. Here we present a rare case of breast cancer metastasizing to the mucosal layer of the esophagus in addition to the mediastinum, resulting in esophageal compression.

CASE DESCRIPTION/METHODS:

Patient is a 73 year old female with a medical history of left breast cancer with known metastasis to the lung, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), hypothyroidism, and osteoporosis who presented to the emergency department complaining of worsening dysphagia for the past 3 months. She began having dysphagia to solids that slowly progressed to include liquids. Notable workup included a complete blood count with a hemoglobin of 10.9 gm/dL. The gastroenterology service was then consulted and performed an upper esophagagastroduodenoscopy which showed severe narrowing in the mid to lower esophagus with unhealthy appearing mucosa with contact oozing and desquamation. Multiple biopsies were taken from this area which returned showing metastatic carcinoma, consistent with breast primary. Immunohistochemical stains showed the neoplastic cells were positive for ER, and negative for p63, supporting the diagnosis. The patient then underwent PET scan which showed hypermetabolic posterior mediastinal lymphadenopathy causing extrinsic esophageal compression. During her admission the patient was able to tolerate pureed diet and was discharged to follow with oncology where she would undergo further treatment with Fulvestrant and Palbociclib.

DISCUSSION:

Breast metastases of mucosal and submucosal layers of the esophagus are extremely rare as esophageal involvement is usually secondary to mediastinal carcinosis. Diagnosis of breast cancer metastasizing to the esophagus is difficult as esophageal involvement can occur without clinical symptoms in a considerable number of patients with breast cancer. The most common clinical manifestations include dysphagia, accompanied by weight loss, anorexia and vocal dysfunction. Chemotherapy and hormonal therapy are the initial treatment of choice given that they significantly affect survival. Endoscopic placement of a stent should be reserved to those patients who do not have a significant improvement of dysphagia after treatment, or in cases of trachea-esophageal fistulas.
1825 Esophageal Stricture Due to Esophageal Lichen Planus and Its Successful Management Using Local Corticosteroid Injection
Authors: Jencks Kara J. , Abdulla Hamza , Qiu Suimin
Published: October 2019

INTRODUCTION:

Lichen planus is an inflammatory disease that typically involves the skin, nails, oral cavity and the genital areas. Involvement of the esophagus is rare. We report a case with severe progressive esophageal lichen planus treated with submucosal injection of triamcinolone into the esophagus with symptomatic improvement and decreased need for esophageal dilation.

CASE DESCRIPTION/METHODS:

A 64-year-old Caucasian female presented to the GI clinic for evaluation of progressive dysphagia of 1 year. She has been doing well until she had a severe choking episode while swallowing a tablet. Physical examination revealed red, atrophic plaques on the buccal mucosa as well as vaginal erythema and atrophy. Tongue biopsy was performed which showed lichenoid inflammation with dermatitis and spongiosis consistent with the diagnosis of lichen planus (Oral-Gingival-Vaginal syndrome). The patient was started on 75mg of prednisone for 1 month followed by a slow taper. A barium swallow showed a short, smoothly marginated stricture of the proximal esophagus at the C6-C7 level with approximately 75% narrowing. EGD showed a stricture in the proximal esophagus at 18cm. Remaining upper and mid esophagus showed multiple lesions with peeling of mucosa and areas of mucosal hemorrhage. Biopsies of the stricture showed small fragments of squamous mucosa with lymphocytic infiltrate and necrotic keratinocytes (Civatte bodies). Esophageal bougie dilations were performed for management of dysphagia. As the upper stricture required repeated dilations [every 1-2 months] and other management options were either ineffective or not tolerated, local sub mucosal corticosteroid injection (Kenalog-40) into the proximal stricture was attempted along with esophageal dilations. This resulted in decrease the average frequency of dilations and ultimately she became symptom free since except for occasional pain with swallowing food and intermittent esophageal spasms.

DISCUSSION:

The diagnosis of esophageal lichen planus is often difficult. However, this disease should be suspected amongst middle age to older women presenting with progressive dysphagia. Treatment with systemic corticosteroids remains the mainstay of treatment in esophageal lichen planus. However, in those unable to tolerate steroids due to side effects, non-responsive progressive disease or individuals who are experience frequent relapses after discontinuation of systemic steroids, corticosteroid injection is a safe and effective alternative therapy.
1828 CryoDilation: A Novel Treatment for Benign Esophageal Strictures Using Liquid Nitrogen Spray Cryotherapy
Authors: Roccato Mary Kathryn , Duh Erica , Mai Daniel , El Hage Chehade Nabil , Hashimoto Rintaro , Samarasena Jason
Published: October 2019

INTRODUCTION:

Liquid nitrogen spray cryotherapy (SCT) was developed for endoscopic treatment of Esophageal Cancer and Barrett’s Esophagus. It has been shown to be a safe and effective therapy. Pulmonologists and thoracic surgeons have used SCT for treatment of benign tracheal strictures and stenoses with reduced severity of airway narrowing and symptomatic improvement. We describe the successful use of SCT in a recurrent, benign esophago-gastric anastomotic stricture, highlighting its potential as a new alternative treatment modality.

CASE DESCRIPTION/METHODS:

A 52-year-old female with stage T1 esophageal adenocarcinoma status-post laparoscopic thoracoscopic Ivor-Lewis esophagectomy presented to clinic 3 months following surgery for dysphagia. An esophagogastroduodenoscopy (EGD) revealed an esophago-gastric anastomotic stricture. Over the next 4 years, the stricture recurred despite monthly EGDs with dilations, steroid injections, and stent placement. Her course was complicated by dysphagia, food impactions, and severe protein-calorie malnutrition requiring total parenteral nutrition (TPN). The decision was made to perform Cryodilation. The patient then underwent seven EGDs with cryodilation over seven months. During the procedure, liquid nitrogen spray was administered for 20 seconds, followed by 60 seconds of thaw time, for a total of three freeze-thaw cycles and stricture then dilated up to 18mm. Prior to the first EGD with cryoablation, she recorded her lowest weight within 5 years at 49.4 kg (BMI 16.4). After initiating these procedures, the patient experienced marked functional and clinical improvement. After only three cycles, she began eating soft foods again. After five cycles, her weight peaked at 58.9 kg (BMI 19.7), which she maintained for 8 months. After six cycles of therapy she was able to discontinue TPN. Since cryodilation, she has had no further weight loss nor episodes of food impaction and the time between endoscopic dilation procedures has lengthened considerably.

DISCUSSION:

This case demonstrates a severe recurrent esophago-gastric anastomotic stricture which was unresponsive to aggressive, frequent traditional management. This novel and previously unreported method of serial cryotherapy with dilation greatly improved this patient’s symptoms and functional status. This method is a potential safe and effective primary treatment or adjunct modality for refractory benign esophageal strictures.
1902 Small Bowel Tumor: The Answer to Unexplained Overt Gastrointestinal Bleeding
Authors: De La Guerra Ramiro , Kulkarni Abhijit , Narula Arshjyot
Published: October 2019

INTRODUCTION:

The rarity of small bowel tumors often makes diagnosis difficult due to nonspecific and variable presenting symptoms. This can result in a delay of diagnosis and consequent poor treatment outcome. Small bowel tumors can be either malignant (adenocarcinomas, lymphomas, sarcomas, and neuroendocrine tumors) or benign (adenomas, leiomyomas, and lipomas).

CASE DESCRIPTION/METHODS:

We present the case of a 58-year-old male, who presented to the hospital with dizziness, lightheadedness, and dyspnea on exertion for 3 days. History was significant for GERD, and iron deficiency anemia. Recent outpatient evaluation of weakness and fatigue revealed hemoglobin of 10 g/dL, decreased from 16.3 g/dL one year prior. An outpatient colonoscopy was scheduled for the following month but presented to the hospital because of multiple episodes of melenic stools. He denied any hematochezia, abdominal pain, weight loss, dysphagia, nausea, vomiting or hematemesis. He denied any family or personal history of malignancy or inflammatory bowel disease. He was tachycardic on examination. Initial lab work revealed hemoglobin of 8.2 g/dL. During his hospitalization, the patient experienced frank hematochezia and required transfusion of several units of blood due to acute blood loss. The patient underwent endoscopic evaluation, which revealed a small hiatal hernia with normal stomach and normal examined duodenum. A colonoscopy revealed red blood in the entire examined colon as well as the distal ileum. The patient then underwent video capsule endoscopy (VCE), which localized a source of bleeding in the proximal jejunum. A subsequent small bowel enteroscopy revealed a large infiltrative, polypoid, submucosal and ulcerated mass in the proximal jejunum. A CT scan revealed the location of the mass. The patient ultimately went to the operating room. Intraoperative visualization noted the mass to be exophytic, approximately 5 cm in diameter with mild purulence into the peritoneal cavity but without evidence of carcinomatosis.

DISCUSSION:

Adequate diagnosis of small bowel tumors, which present with varied and nonspecific symptoms, can inform early and appropriate treatment. In this case, endoscopic evaluation with EGD, colonoscopy, and VCE, resulted in the localization of the tumor and facilitated its surgical excision. This case exemplifies a practical algorithmic approach to the evaluation of an unexplained overt gastrointestinal bleed in a patient with nonspecific symptoms.
1970 Spontaneous Page Kidney as a Cause of Gastric Variceal Bleed
Authors: Morales Alvarez Martha Catalina , Lio Jeffrey , Chuang Philip , Kheyfits Arkadiy , Dinani Amreen
Published: October 2019

INTRODUCTION:

Gastric variceal bleeding occurs in 15–50% of patients with non-cirrhotic portal venous thrombosis but can also occur in cases of splenic vein thrombosis (SVT) due to the formation of isolated gastric varices (IGV). We present the first reported case of a page kidney causing splenic vein compression, thrombosis, and subsequent gastric variceal bleeding.

CASE DESCRIPTION/METHODS:

A 31-year-old stuntman presented with epigastric pain and worsening exertional dyspnea over 3 weeks. History was notable for melena and anemia with no reported ulcers on endoscopy. On admission, he had hemoglobin of 4.1 g/dl with severe iron deficiency and elevated reticulocyte count. There was no serologic evidence of hepatic or renal disease. A computed tomography (CT scan) of the abdomen revealed a large left-sided perirenal collection consistent with page kidney, splenomegaly and decreased caliber of the mid and distal splenic vein suggestive of nonocclusive SVT. His liver was normal. Initial endoscopy revealed an IGV type 1 and mild portal hypertensive gastropathy (Figure 1). CT angiography did not reveal a splenorenal shunt to pursue a balloon retrograde transvenous obliteration (BRTO). While admitted, he developed hematemesis and worsening anemia. Ultimately, underwent IR splenic vein stenting with a bare-metal stent and subsequent decompression of the gastric varices with brisk flow of the portal vasculature (Figure 2).

DISCUSSION:

Gastric varices are classified primarily by location with most involving the gastroesophageal junction due to portal hypertension. The incidence of bleeding is highest in IGV, typically associated with SVT. Common etiologies of SVT include pancreatitis, malignancy or trauma. Our case described an extrinsic splenic vein compression and subsequent thrombosis due to a sub-capsular renal hematoma possibly of unclear etiology. Treatment for GV often depends on local expertise, but commonly consists of cyanoacrylate injection, banding (especially in type 1 gastro-esophageal varices), transjugular intrahepatic portosystemic shunt (TIPS) placement, BRTO, and even splenectomy. More recently, in cases of IGV due to isolated SVT, splenic vein stenting has been increasingly utilized. In our case, TIPS would not address the pre-hepatic portal hypertension and cyanoacrylate was not available. Splenic vein stenting was thus chosen to decompress the IGV with excellent response seen on subsequent follow-up (Figure 1).
1973 Management of Duodenal NET With Significantly Low Hemoglobin Level on a Jehovah’s Witness Patient
Authors: Karim Syed S. , Jacob Bobby , Tackling Gary , Prasa Jarin , Rizvon Kaleem , Mustacchia Paul
Published: October 2019

INTRODUCTION:

Neuroendocrine tumors (NETs), historically known as carcinoid tumors, can arise throughout the gastrointestinal tract. However, duodenal NETs are very rare; the incidence is only 0.19 / 100,000 in the US. We present a patient who identifies as a Jehovah’s witness presenting with acute on chronic anemia and occult gastrointestinal bleeding due to a bleeding mass which was biopsied and confirmed as a duodenal NET.

CASE DESCRIPTION/METHODS:

A 69 year-old African American female, Jehovah’s witness, with medical history of end stage renal disease on hemodialysis and anemia of chronic disease who was brought to the hospital for asymptomatic acute on chronic anemia with a hemoglobin of 5.6 g/dL (baseline 9–10 g/dL). Rectal exam revealed melena. Patient underwent upper endoscopy which revealed a 2 cm duodenal bulb mass which was biopsied and pathology revealed neuroendocrine tumor. Patient had elevated serum gastrin level of 250 pg/mL and chromogranin A level of 1963 ng/mL. Octreotide scan confirmed radiotracer uptake in the duodenum and in no other areas. The patient refused blood products adamantly and was managed with darbepoetin alfa. Her hemoglobin gradually trended up several months later to 10 g/dL. For her NET, she was referred to a tertiary center for EUS, for staging and surgical evaluation.

DISCUSSION:

Duodenal NETs can be divided upon proliferative activity, (well differentiated and poorly differentiated) as well as upon hormonal capabilities (gastrinoma, somatostatinoma, nonfunctional, and paragangliomas). Most patients are incidentally diagnosed during endoscopy or present with late complications of an indolent tumor. Carcinoid syndrome only occurs in less than 10 % cases, when there is metastasis to the liver. Diagnosis is based upon histological staining for neuroendocrine tissue, such as chromogranin and synaptophysin along with checking for proliferative activity with Ki-67 staining. Our patient’s biopsy confirmed well differentiated neuroendocrine tumor, positive for the above markers and low Ki-67 staining. Serum chromogranin A is elevated in 80% of NETs, as in this case. Gastrin level was below 1000 pg/mL, ruling out a functional tumor. CT and octreotide scan excluded any metastasis. NETs which are nonfunctional, without metastasis, and are less than 1 cm can be endoscopically resected. Our patient’s mass was 2 cm, and therefore she was sent for surgical evaluation. Her hemoglobin improved gradually with erythropoietin therapy and her outcome did not change despite her beliefs.
1996 Rectal Syphilis Presenting as Painless Hematochezia
Authors: Ching Patrick R. , Rubin Jonah N. , Twaddell William S. , Kim Raymond E.
Published: October 2019

INTRODUCTION:

Diagnosing syphilis is challenging and rectal syphilis is a rare presentation. Patients with rectal syphilis can be asymptomatic or have anal pruritus, tenesmus, urgency of defecation, or anal discharge. We describe a case of rectal syphilis presenting with painless hematochezia.

CASE DESCRIPTION/METHODS:

A 40-year-old man with a history of HIV not on antiretroviral therapy and multiple sexually transmitted diseases presented with 7 days of painless hematochezia. He reported that 17 years ago he was infected with Chlamydia, gonorrhea and syphilis, which were all treated. He last had anal intercourse one-year prior. Starting 8 months ago, the patient had daily 7–10 non-bloody formed bowel movements that decreased the week prior to presentation to 3–5 bowel movements daily when his hematochezia began. Over the past month he has had progressive fatigue limiting his functional capacity and a 10-lb weight loss. He did not have nausea, vomiting, abdominal pain, constipation, or fever. Upon presentation, vital signs were within normal limits. He was well-developed and well-nourished with unremarkable abdominal, perianal and digital rectal examinations. CBC showed normocytic anemia. CD4 count was 204 with HIV viral load of 1.5 million copies/mL. CMV viral load was undetectable. Testing for Chlamydia and gonorrhea were negative. Notably his rapid plasma regain (RPR) was non-reactive. Stool studies including culture, ova and parasites were unremarkable. CT scan of the abdomen and pelvis showed mild asymmetric rectal thickening. A colonoscopy was performed which was significant for a 4-mm rectal submucosal nodule with ulceration and surrounding erythematous tissue. Hematoxylin and eosin stain of the biopsy was negative for malignancy, but Warthin-Steiner (silver) stain was positive for spirochetes. There was concern for rectal syphilis and the patient was referred for treatment.

DISCUSSION:

The differential diagnosis of spirochetes in the intestines include Treponema and Brachyspira. Patients with successfully treated syphilis can have reactive non-treponemal and treponema serum testing, but the titers wane over time. In HIV and syphilis co-infected patients serum testing has a lower sensitivity and specificity. Therefore despite the findings of blood testing, direct visualization helps with diagnosis. If there is any concern for syphilis, such as in this patient, treatment with penicillin is used to prevent sequelae of the disease (e.g. neurosyphilis or gummas).
2055 A Case Report of Rectal Mesalamine-Induced Myopericarditis
Authors: Luft Suzannah , Siegel Corey A.
Published: October 2019

INTRODUCTION:

Inflammation of the pericardium, myocardium or both is a rare but known side effect of 5-aminosalicyclic acid (5-ASA) containing medications. While most reports in the literature of this side effect have occurred with oral mesalamine, our patient developed myopericarditis approximately 3 weeks after initiation of rectal mesalamine suppositories.

CASE DESCRIPTION/METHODS:

A 37-year-old man with a history of hypertension, GERD, irritable bowel syndrome and proctitis on rectal mesalamine suppositories presented to the emergency department with acute onset pleuritic chest pain and was found to have elevated troponin and non-specific ST segment changes on electrocardiogram. Initially he was evaluated for possible acute coronary syndrome; however given positional and respirophasic nature of the pain, his symptoms were felt to be more consistent with myopericarditis. Transthoracic echocardiogram showed a small pericardial effusion without tamponade and no significant wall motion abnormities. Cardiac MRI was consistent with myocarditis. Evaluation for infectious or autoimmune etiologies of myopericarditis was unrevealing, including negative ANA and Lyme antibody. He had been started on rectal mesalamine suppositories 3 weeks prior to presentation after colonoscopy showed proctitis concerning for possible ulcerative colitis. Later review of his colonoscopy findings and chronic gastrointestinal symptoms was more consistent with irritable bowel syndrome than ulcerative colitis. The rectal mesalamine was felt to be the most likely etiology of his myopericarditis and was stopped during the hospitalization. He was treated with a course of naproxen and colchicine with rapid resolution of chest pain.

DISCUSSION:

Myocarditis and pericarditis are well-described and potentially lethal side effects of drugs containing 5-ASA, although the mechanism for cardiac toxicity is not clear. Symptoms usually manifest within 28 days of drug initiation and may resolve with drug cessation alone. While the absorption of oral mesalamine is estimated to be around 20-45%, rectal mesalamine absorption is variable and likely depends of a variety of factors including retention time and degree of underlying rectal disease. Our case suggests that rectal absorption alone may be sufficient to cause cardiac toxicity and that rectal mesalamine may not be safe in patients who have previously had cardiac or other toxicity on oral 5-aminosalicyclic acid containing drugs.
2063 A Stellar Case of Stelara in the Treatment of Lymphocytic Colitis
Authors: Abughazaleh Shaadi , Glassner Kerri , Wilhite Amanda , Abraham Bincy
Published: October 2019

INTRODUCTION:

Lymphocytic colitis is a chronic inflammatory disease manifesting with chronic, watery, non-bloody diarrhea. Patients have a normal appearing colon with biopsies showing histological changes. Medications are believed to be typical culprits, however data on causality is lacking. Treatment is focused on symptom management, however in refractory cases budesonide has been shown to provide both clinical and histological remission. There is limited data to guide practitioners for patients who fail to have improvement on budesonide. We present a case of a female who failed budesonide and was treated with ustekinumab for her lymphocytic colitis.

CASE DESCRIPTION/METHODS:

A 54-year-old woman with a history of indeterminate colitis presented with diarrhea, severe fatigue, and abdominal pain in January 2019. She was presumably diagnosed with ulcerative colitis (UC) in 2000 but without evidence of endoscopic or histologic findings. Her diagnosis was subsequently changed to Crohn’s disease (CD) in 2008 based on serologic markers alone again without evidence of endoscopic inflammation. Previous colonoscopy in 2015 showed endoscopically normal mucosa with biopsies suggestive of lymphocytic colitis (Figure 1). Due to her symptoms, she was started on ustekinumab. At that time, ustekinumab levels were found to be 9.9 (Inform Tx). At presentation, she was on ustekinumab q8 weeks, budesonide, and methotrexate. She was started on azathioprine while continuing budesonide and stopping methotrexate. After 3 months (March, 2019), her symptoms persisted, so her ustekinumab level was checked and was found to be low at 2.2. Therefore, she received a booster 90 mg SQ dose of ustekinumab. Budesonide was discontinued. Colonoscopy in May 2019 revealed endoscopic and histologic remission of the lymphocytic colitis.

DISCUSSION:

First line treatment options for lymphocytic colitis include avoidance of culprit medications and symptomatic treatment. In patients with persistent symptoms, budesonide has been effective in inducing clinical and histological remission in 6 weeks. In cases refractory to budesonide, there is very limited data on alternative treatment options. Although immunomodulators and biologics have been used for CD and UC, their utility in microscopic colitis remains unknown. Case reports have described varying success using agents such as azathioprine, infliximab, adalimumab, and mercaptopurine. We present a case of lymphocytic colitis successfully treated with a combination of ustekinumab and azathioprine.
2185 69-Year-Old Male After Gastric Bypass With Choledocholithiasis Treated With EDGE Procedure Complicated by LAMS Dislocation
Authors: Kloska Michal , Vaze Reema , Buckshaw Ricky , Shah Hiral
Published: October 2019

INTRODUCTION:

With the alarming increase in the prevalence of obesity, more people are undergoing bariatric surgeries of which most common is Roux-en-Y gastric bypass (RYGB). This altered anatomy poses challenges in accessing the papilla for ERCP in the setting of biliary pathology. Until recently enteroscopy or surgery assisted ERCP were the two main treatment options. Today, EUS-directed trans-gastric ERCP (EDGE) procedures have emerged as a promising treatment option in such circumstances.

CASE DESCRIPTION/METHODS:

A 69-year-old male with history of RYGB, cholecystectomy, Barret’s esophagus, CAD and CKD was admitted with one day history of vomiting and RUQ abdominal pain. On initial evaluation the patient was afebrile, normotensive with scleral icterus. Labs were significant for leukocytosis (14.2 10^3/µL), elevated transaminases (AST 254 U/L; ALT 231 U/L) and signs of biliary obstruction (ALP 252 U/L; bilirubin 3.3 mg/dl). Abdominal imaging (CT, US) revealed dilated intra and extra hepatic biliary ducts with the CBD measuring 1.4cm. For further evaluation, an EDGE procedure was performed within 24 hours. After injecting water to form a fluid collection in the stomach and confirming no blood flow in the path, a 20mm Hot Axios LAMS was successfully deployed under EUS guidance. The gastric lumen was confirmed after dilatation to 18mm. The duodenoscope was advanced and subsequent cholangiogram revealed several large stone filling defects along with dilated hepatic ducts. A sphincterotomy was performed, 9-12mm followed by 12-15mm extraction balloons were advanced over the wire and after multiple sweeps, 5 large stones were removed with resolution of biliary obstruction. During the ERCP, the LAMS dislodged into the native stomach over the scope but was able to be successfully removed by rat-tooth forceps. Finally, the fistula was closed using endo-clips and the patient reported resolution of his symptoms and LFTs normalized.

DISCUSSION:

Choledocholithiasis after RYGB is not unusual as nearly 50% of patients develop biliary stones within two years after surgery. The most common complications after EDGE procedure are bleeding from the fistula site, persistent fistula formation, perforation or adverse events related to ERCP. We present a rare case of LAMS dislocation into the stomach during EDGE which was successfully removed with the snare. Being able to recognize and immediately treat this potential complication may help providers anticipate it during EDGE procedures.
2198 Not an Ordinary Cause of a Biliary Stricture: The Case of a Surgical Clip Migration After Open Cholecystectomy
Authors: Poola Shiva , Jampala Nannaya , Mudireddy Prashant
Published: October 2019

INTRODUCTION:

Cholecystectomy is the mainstay treatment for gallstone disease. Post-operative complications include bile leaks, duct injury, abscess, and retained stones. Migration of surgical clips are a rare complication of cholecystectomy which is rarer in open cholecystectomy. Migrated clips may be asymptomatic to cholangitis. This case highlights a biliary stricture from a surgical clip after an open cholecystectomy that was endoscopically treated.

CASE DESCRIPTION/METHODS:

A 77-year-old Male presented with a 2-year h/o progressive abdominal fullness, lethargy and fatigue. He denied fevers, nausea, vomiting, or appetite changes. Initial work up found an elevated bili of 2.3 and an intrahepatic gallbladder (Figure 1). He was referred to surgery for concerns of gallbladder cancer and underwent a lap converted to open cholecystectomy with IOC. Pathology showed chronic cholecystitis with fibrosis and no malignancy. After two weeks he represented with worsening fatigue, low grade fevers, and dark urine. He had a leukocytosis, transaminitis, direct hyperbilirubinemia, and on imaging a hepatic abscess and intrahepatic biliary ductal distention. An ERCP demonstrated a dilatation of the upper third of the main bile duct with a single severe stenosis at the location of surgical clips on fluoroscopy. Spyglass cholangioscopy was performed and a clip with surrounding inflammation and stenosis was noted (Figure 2). The clip was removed with spybite forceps. A 10 F × 9 cm transpapillary plastic stent was placed through the left hepatic duct. The patient had downtrending LFTs and was discharged. Repeat ERCP at 6 weeks showed persistence of the stricture. The stricture was dilated and a 10 mm × 8 cm fully covered metal stent was placed. Repeat ERCP at 4 months showed resolution of the stricture with good biliary drainage (Figure 3). Patient continues to do well 2 months post procedure with improving LFTs.

DISCUSSION:

This is a case of a biliary stricture caused by a surgical clip post cholecystectomy that was managed endoscopically with clip removal and serial biliary ductal stenting. Intrabiliary foreign body is rarely described in the literature. Studies have described clip migration after cholecyestomy with the median time of presentation at 26 months. This patient presented at 14 days after cholecystectomy. One study found 70% of post-cholecystectomy clip migration was managed with ERCP. This patient had complete resolution of his biliary stricture after clip removal, balloon dilation, and stent placement.