bluuebunny/crossref_metadata_2025 huggingface dataset:
2553 A Rare Discovery of Duodenal Noncaseating Granulomas
Authors: Contino Krysta , Weiss Alexandra , Mohan Neena , Enriquez Miriam , Griech-McCleery Cynthia , Giordano Samuel
Published: October 2019

INTRODUCTION:

Duodenal involvement of sarcoidosis is infrequently reported. It can manifest with a spectrum of symptoms and mimic other gastrointestinal diagnoses.

CASE DESCRIPTION/METHODS:

This is the case of a 59-year-old man with a history of pulmonary sarcoidosis on hydrochloroquine and deep venous thrombosis on apixaban who presented with weight loss with associated abdominal pain, decreased appetite, early satiety, and intermittent dysphagia to both solids and liquids. He reported a colonoscopy 2 years prior that was normal. Labs were notable for a hemoglobin of 11.5 with an MCV of 77. CMP, TSH and HIV were normal. Physical exam revealed a thin male, unremarkable vital signs and normal cardiac, pulmonary and abdominal evaluations. He underwent upper endoscopy and was found to have white esophageal plaques suggestive of candidiasis, gastritis with gastric nodularity, and a normal duodenum. Gastric biopsies were consistent with gastritis with positive staining for H.pylori for which he was subsequently treated. He underwent abdominal CT revealing diffuse small bowel wall thickening and enlarged retroperitoneal and mesenteric lymph nodes. Decision was made to proceed with repeat upper endoscopy as well as endoscopic ultrasound. Upper endoscopy noted gastritis and new duodenitis. Gastric biopsies showed chronic gastritis, negative staining for H.pylori, and positive CD20 and CD3 staining consistent with a reactive process. Duodenal biopsies showed noncaseating granulomas and villous blunting (Figure 1). EUS was unrevealing except for peripancreatic and porta hepatis lymphadenopathy for which he underwent fine needle aspiration. Flow cytometry was negative. The patient was started on high dose steroids given the duodenal involvement of his sarcoidosis followed by a taper over a few months. During the taper, he returned with worsening anemia and diarrhea. Repeat upper endoscopy revealed more extensive involvement of the duodenum with severe inflammation and plan for outpatient colonoscopy and follow up with his sarcoidosis specialist to discuss treatment regimen.

DISCUSSION:

Although duodenal sarcoidosis is rare, it is important to include this in the differential diagnosis in the appropriate clinical setting. It's symptoms and pathology can have overlap with some common diseases such as celiac, Crohn's disease, and even lymphoma. Tissue acquisition is imperative to confirm the diagnosis and can be performed at the time of endoscopy with treatment aimed at management of the underlying disease process.
2557 Duodenal Duplication Cyst—A Rare Congenital Anomaly
Authors: Then Eric O. , Flores Carlos , Ofosu Andrew , Are Vijay S. , Culliford Andrea , Gaduputi Vinaya
Published: October 2019

INTRODUCTION:

Enteric duplication cysts are uncommon congenital abnormalities of the gastrointestinal tract that arise from a disruption in the normal recanalization of the developing gut. Most frequently they are located in the jejunum or ileum, rarely will an enteric duplication cyst present in the duodenum. Here we present a rare case of an enteric duplication cyst in the duodenum.

CASE DESCRIPTION/METHODS:

Patient is a 48 year old male with a medical history of alcohol abuse who presented to our emergency department (ED) complaining of severe epigastric pain and non-bloody vomiting for 1 day. The patient reported drinking 3 beers daily and had one previous episode of similar symptoms one year prior. Notable workup in the ED included an elevated Lipase of 6443 U/L. A computed tomography (CT) scan of the abdomen without contrast was also done and showed inflammatory changes surrounding the pancreas and an ovoid hyperdense object adjacent to the junction between the duodenum and jejunum. The patient was then admitted under the impression of acute pancreatitis. Given the findings of the CT scan a repeat scan was done with oral and intravenous contrast. This showed the same ovoid soft tissue abnormality with findings suggestive of mildly complex enteric duplication cyst (Figures 1 and 2). During his hospital stay the patient was managed with morphine for pain control, intravenous fluids and was discharged two days later with follow up appointments scheduled.

DISCUSSION:

Several mechanisms have been proposed to explain the pathogenesis of enteric duplication cysts but no clear cause has been elucidated. The cystic structure is composed of a smooth muscle outer wall and internal epithelium that may be stratified, ciliated, or columnar. The majority of cases are diagnosed during the perinatal period and early childhood with rare cases being diagnosed during adulthood. It can be discovered either as an incidental finding during routine imaging such as CT scan, endoscopy, or laparotomy. When symptoms are present, they widely vary depending on the size and the location. Symptomatic disease can present in the form of gastrointestinal bleeding, gastric outlet obstruction, pancreatitis, dysphagia, intussusception, volvulus or obstruction of the biliary tree. Duodenal localization of duplication cysts is rare but may have significant clinical and therapeutic importance due to the nearby anatomic structures that can be disrupted by the abnormality.
2560 Small Bowel Carcinoid Causing Chronic Anemia
Authors: Kaushik Chandni , Clark August , Merwat Shehzad N.
Published: October 2019

INTRODUCTION:

Carcinoids are a relatively rare tumor that are often discovered incidentally. If symptoms are present, they may include abdominal pain, carcinoid syndrome, and occasionally bleeding.

CASE DESCRIPTION/METHODS:

A 59-year-old woman was admitted for bloody bowel movements. Past medical history includes hypertension and morbid obesity. She had chronic microcytic iron deficiency anemia and was evaluated in 2015 with EGD, colonoscopy, and capsule endoscopy. EGD was normal with no bleeding source, colonoscopy showed blood throughout colon without diverticulosis or AVMs, and capsule endoscopy revealed a jejunal ulcer. At presentation, vital signs were stable. Laboratory profile revealed iron deficiency anemia with hemoglobin 7.3 g/dL. Colonoscopy revealed a medium-sized mass in terminal ileum with oozing present and appearance concerning for carcinoid tumor. The mass was tattooed and a clip was placed. CT showed 2.1 cm mass in ileum as well as 1.9 cm enhancing lymph node concerning for metastasis. She underwent laparoscopic small bowel resection with removal of ileal mass and was noted to have multiple lesions along small bowel concerning for metastasis and grossly enlarged mesenteric lymph nodes, which were also removed. Pathology showed well-differentiated grade 1 neuroendocrine tumor with a lymph node positive for metastasis. Patient is scheduled to follow-up with oncology to determine treatment plan.

DISCUSSION:

Carcinoids are relatively rare with an incidence of 4.7 per 100,000 with rising incidence due to increased detection on endoscopy and imaging as well as increased provider awareness. They can arise in the gastrointestinal tract, lung, and genitourinary tract and are relatively slow growing and less aggressive than other cancers. Within the gastrointestinal tract, most carcinoids are found in the small intestine, rectum, and stomach, while small bowel carcinoids are commonly located in the ileum. Small intestine carcinoid tumors have been characterized as more aggressive in nature and commonly metastasize to lymph nodes or the liver. They require multidisciplinary evaluation with gastroenterologists, oncologists, and surgeons. In our case, the patient had chronic anemia many years prior and had undergone work-up prior to presenting with hematochezia. Previous evaluation showed a jejunal ulcer thought to be due to NSAID use. However, she continued to have iron deficiency anemia. This case illustrates the importance of repeat endoscopic evaluation in cases of persistent iron deficiency anemia.
2562 Duodenal Perforation From an Inferior Vena Cava Filter as a Rare Cause of Persistent Abdominal Pain
Authors: Khan Walid , Zhang Wei , Weiner Brian , Clark Virginia
Published: October 2019

INTRODUCTION:

Deep vein thrombosis (DVT) continues to be a significant source of morbidity for surgical patients. Inferior vena cava (IVC) filter placement is indicated for DVT in patients who have contraindications to anticoagulation or failure of anticoagulation. Over the last decade, there is exponential increase of IVC filter placement with increased complications reported. These include IVC penetration, IVC occlusion, insertion complication and filter migration. We report a rare case of symptomatic duodenal perforation by an IVC filter migration.

CASE DESCRIPTION/METHODS:

A 33-year-old female with a history of paraplegia secondary to motor vehicle accident, recurrent DVTs, and placement of IVC filter 10 years ago presented to the hospital for persistent epigastric pain for the past 5 years. Patient denied any nausea, vomiting, diarrhea, or hematochezia. Physical exam showed epigastric tenderness. Labs including complete blood count were unremarkable. CT scan showed a longstanding IVC occlusion with collaterals and displaced IVC filter into the duodenum and into the L3 vertebral body (Figure 1). An EGD confirmed prong migration to the second portion of the duodenum (Figure 2). This was distal to the ampulla and penetrating the duodenal wall with the tip embedding the opposite wall. Due to multiple workups being otherwise negative and symptomatic duodenal perforation of the IVC filter, she has been scheduled for an open IVC filter extraction with duodenal and caval repair.

DISCUSSION:

Duodenal and aortic perforations by IVC filters have been increasingly reported in the past 10 years although still rare. Penetration of the filter struts through the wall of the IVC can be asymptomatic. However symptomatic patients may present with epigastric pain, gastrointestinal bleeding and small bowel obstruction. Currently, there are no guidelines for the management of such patients. Most cases have been repaired using an open repair with excellent outcomes; however, endovascular retrieval and repair is being recognized as an alternative option especially in high risk patients. This case illustrates that even though IVC migration and perforation is a rare complication, it needs to be recognized as a potential cause for gastrointestinal symptoms in these patients. Retrievable IVC filters should always be removed if possible when deemed unnecessary to prevent complications such as migration from developing.
2570 Capecitabine-Induced Ileitis: A Case Report
Authors: Tageldin Omar , Kalakota Neeharika , Bartholomew Catherine
Published: October 2019

INTRODUCTION:

Capecitabine is a fluoropyrimidine chemotherapy agent used in the treatment of colorectal cancer. Gastrointestinal side effects are common, including diarrhea, nausea, vomiting, abdominal pain, severe hepatic impairment, and decreased appetite. Here we report a case of Capecitabine-induced ileitis with severe diarrhea leading to hypovolemic shock and acute kidney injury. The patient was admitted to the intensive care unit (ICU) twice during hospitalization and required cessation of capecitabine.

CASE DESCRIPTION/METHODS:

Our patient is an 82-year-old male with a history of prostate cancer now with stage IIA rectal adenocarcinoma who was started on Capecitabine neoadjuvant chemotherapy without radiation due to previous pelvic radiotherapy for the prostate cancer. He tolerated the first treatment cycle without any side effects. At the beginning of the 2nd cycle, he reported eight watery non-bloody bowel movements a day. CT abdomen showed wall thickening of multiple loops of the distal small bowel. He was admitted to the ICU, started on vasopressor therapy and broad-spectrum antibiotics, but diarrhea persisted. Physical exam showed mild diffuse abdominal tenderness. Laboratory studies were notable for elevated creatinine but stool culture, ova and parasites, and Clostridium difficile PCR were negative. Antibiotics were stopped and loperamide was started without significant improvement. Gastroenterology was consulted and colonoscopy showed linear ulcers at terminal ileum and ulceration at ileocecal valve - pathology showed active ileitis with ulceration. Diarrhea improved with supportive management and cessation of Capecitabine.

DISCUSSION:

Although Capecitabine's side effects are mostly well tolerated, they can occasionally lead to prolonged hospitalization and even ICU admission. Capecitabine is not a cytotoxic drug in itself, it is absorbed from the intestine and metabolized in the liver then in the tumor cells by three-step enzymatic cascade to be converted to 5-FU. Capecitabine-induced ileitis has been reported in the literature and was diagnosed by a combination of symptoms, CT scan, colonoscopy, and/or histopathology. The mechanism is reported to be due to the susceptibility of the intestinal vascular endothelium to 5-FU by the generation of free radicals which may lead to a hypercoagulable state. In summary, treating physicians should be aware of this critical side effect and intervene early when diarrhea is reported.
2572 Metastatic Renal Cell Carcinoma to the Small Bowel: A Rare Cause of Gastrointestinal Hemorrhage
Authors: Buckshaw Ricky , Malik Anam , Vaze Reema , Kloska Michal , Andrews Robert , Shah Hiral
Published: October 2019

INTRODUCTION:

We present a case of overt gastrointestinal blood loss which after thorough investigation, was found to be a manifestation of metastatic renal cell carcinoma (RCC).

CASE DESCRIPTION/METHODS:

A 55 year-old female with a history of clear cell RCC removed with nephrectomy and breast cancer on chemotherapy presented with melena and abdominal pain. The patient was assessed in the ED and was hemodynamically stable. On exam she had tenderness in her left lower quadrant. She was found to have a hemoglobin of 8.2 g/dL. CT revealed active diverticulitis, but no obvious masses were noted. Gastroenterology evaluated the patient and recommended admission and EGD for further evaluation. The EGD was obtained which did not reveal any source of bleeding, which prompted colonoscopy. The colonoscopy demonstrated sigmoid diverticulosis, patchy segmental inflammation of the sigmoid colon, but no active bleeding. Approximately one week later, the patient was readmitted for worsening fatigue and continued melena. A capsule endoscopy was done which revealed a bleeding mass in the proximal and distal small bowel. A push enteroscopy was advanced to the jejunum but no bleeding was found. MRE was completed, which revealed a 1.9 × 1.6 cm nodule in the left pelvic small bowel, diverticulitis as well as a 3.2 × 2.2 cm left lower pole renal mass. The patient later went for an exploratory laparotomy with resection of two segments of small bowel. Pathology showed a diagnosis of metastatic renal cell carcinoma.

DISCUSSION:

Renal cell carcinoma is a common urological malignancy that can have many systemic complications. RCC presents with metastasis in as many as 30% of cases, however some signs may not lead physicians to timely diagnosis. RCC metastasizes to the small bowel in less than 0.5% of cases. Of these cases, gastrointestinal bleeding occurs in 1% of cases with <1% of cases coming from the small bowel. Small bowel involvement is rare and there are only a few case reports reporting this presentation. GI bleeding from metastatic RCC is an underdiagnosed disease and can cause increased morbidity and mortality. Being able to diagnose metastatic cancer and small bowel bleeding can be difficult. When it causes potentially life threatening symptoms, it becomes a priority to diagnose it. Prompt treatment requires knowledge of complications of RCC. Being able to identify these complications will not only allow us to improve outcomes in patients, but to better understand and anticipate future complications for our future patients.
2577 Dysdiadochokinesia, Ataxia, and Anemia: A Sign of Intraluminal Malignant Mesothelioma in the Small Bowel?
Authors: Rozner Raquel N. , Shah Shawn L. , Crawford Carl V.
Published: October 2019

INTRODUCTION:

Malignant mesothelioma (MM) is a rare cancer of the serosal membranes, the pleura and peritoneum, and causes significant morbidity and mortality. While implants of the bowel wall are common, only two case reports on intraluminal involvement exist. We present a case of an elderly male with dysdiadochokinesia found to have abdominal lymphadenopathy, and a jejunal mass from peritoneal mesothelioma (PM).

CASE DESCRIPTION/METHODS:

An 87 year-old male with a family history (FH) of colon cancer in one first-degree relative presented with one month of unintentional weight loss, gait instability, and trouble performing alternating movements. Two months prior to admission, evaluation included a negative MRI of the brain but positive CSF analysis for neuron-restricted autoantibody treated empirically with five days of intravenous immunoglobulin (IVIG) and three days of pulse dose steroids. Physical examination was notable for ataxia and dysdiadochokinesia and a benign abdominal exam. He had normal electrolytes and liver chemistries, but was anemic. PET/CT revealed intensely FDG-avid abdominal and mesenteric lymph nodes, one inseparable from the small bowel (Figures 1 and 2). Lymph nodes were not accessible by IR-guided biopsy, so he underwent push enteroscopy and colonoscopy, in light of his FH, to evaluate for anemia. A large, oozing ulcerated mass was found in the jejunum and biopsied (Figure 3). Immunostaining was positive for cytokeratin, CK7, WT1, and calretinin consistent with PM. His neurologic decline was then linked to PNS secondary to PM. He was discharged with plans for carboplatin therapy.

DISCUSSION:

MM is strongly associated with asbestos exposure, and is four to five times more prevalent in men than women. PM limited to the small bowel is exceedingly rare. Only one previous case report describes a mass spanning the entire small bowel, identified as mucin-positive epithelial mesothelioma. PNS affects 1 in 10,000 patients with cancer; more than 85% of cases are linked to gynecologic and breast cancers causing cerebellar dysfunction via purkinje cell destruction by anti-Yo antibody (Ab). Two cases of PM associated PNS with anti-Yo Ab in the CSF have been reported; one was treated with IVIG and high dose steroids. The treatment of PM is key to stabilizing neurologic symptoms, such as dysdiadochokinesia. The prognosis of PM and associated PNS remains poor. Anemia with cerebellar symptoms should trigger a search for malignancy and rarer causes such as PM.
2584 Running Into a Stone Wall: A Rare Case of Gastric Outlet Obstruction
Authors: Shah Ruchit N. , West Sara , Shafqet Muhammad A. , Foernges Luiz , Diehl David L. , Khara Harshit S.
Published: October 2019

INTRODUCTION:

Bouveret syndrome is an extremely rare and serious form of gallstone ileus with an incidence of 1-3% and a surgical mortality rate approaching 15-33 percent. Treatment often involves a combination of endoscopic and surgical interventions. We present a case of gastric outlet obstruction and duodenal ulceration caused by 3 impacted gallstones, treated ultimately with surgery.

CASE DESCRIPTION/METHODS:

A 57-year-old male with no known medical conditions was admitted to the intensive care unit with a one-week history of epigastric pain, nausea, and dark emesis. He was tachycardic and hypotensive on arrival. On exam, the patient was diaphoretic with dark-bloody return from the nasogastric tube. Hemoglobin was 5.6 g/dL (ref: 14.0-16.8 g/dL) with a leukocytosis of 17.69 K/uL (ref: 4.0-10.8 K/uL). Liver enzymes were unremarkable. Given concerns for an upper gastrointestinal bleed, patient underwent an esophagogastroduodenoscopy showing a 3-cm non-bleeding ulcer in the duodenal bulb, a cholecystoduodenal fistula, and a large impacted gallstone in the first portion of the duodenum distal to the fistula (Figure 1). Subsequent contrast-enhanced computed tomography demonstrated significant pneumobilia and a perforated duodenal ulcer (Figure 2). Removal of the obstructing gallstone was unsuccessful despite using a Raptor grasping device, Roth net retriever, and snare. Patient subsequently underwent exploratory laparotomy with cholecystectomy, pyloric exclusion, Roux-en-Y gastrojejunostomy, and duodenal enterorrhaphy with Graham patch (Figure 3). He tolerated the procedure well and was discharged to a rehabilitation facility.

DISCUSSION:

Bouveret Syndrome is a rare form of gallstone ileus characterized by gastric outlet obstruction secondary to gallstone impaction within the duodenum or pylorus through a cholecystoduodenal or choledochoduodenal fistula. Prompt imaging is warranted and in patients with gallstone ileus, may reveal pneumobilia, bowel obstruction, and ectopic gallstone, also known as Rigler's triad. Enterolithotomy, gastrostomy with cholecystectomy, and fistula repair are considered the mainstay of management, but prompt gastroenterological evaluation is warranted to evaluate the possibility of mechanical extraction or stone fragmentation.
2589 Disseminated Salmonella Species-Induced Septic Shock: A Case Report
Authors: Singh Annapoorna , Zafar Yousaf , Makovec Anthony
Published: October 2019

INTRODUCTION:

Nontyphoidal Salmonellosis is the leading cause of foodborne illness in the U.S., causing approximately 1.4 million infections annually. Most cases of Salmonellosis are due to ingestion of contaminated food items such as eggs, dairy products, and meats. We present a case of septic arthritis presumably after an episode of gastroenteritis that disseminates into Salmonella bacteremia in a patient without any of the risk factors for Salmonella bacteremia. This case suggests that Salmonella bacteremia can occur not only in patients with common risk factors but also patients with no obvious risk factors.

CASE DESCRIPTION/METHODS:

81-year-old African American male with past medical history of end stage renal disease, congestive heart failure, hypertension, myocardial infarction, and cerebrovascular accident presents to the ED with new onset left lower extremity pain in the posterior aspect of the knee after completing dialysis earlier in the day. He was later admitted to the hospital for concern of a septic joint. On admission, his temperature was 97.4 degrees F, heart rate was 86 beats per minute, respiratory rate was 16 breaths per minute, and blood pressure was 130/70 mmHg. Basic metabolic panel showed electrolyte disturbances including hypochloremia of 94 mEq/L, creatinine of 7.2 mg/dL, and low GFR for an African American male of 9. Complete blood count showed a hemoglobin level of 16.1 g/dL and normal leukocyte count of 5.89 TH/uL. Arthrocentesis was done three days in a row, which all initially grew gram negative rods that were later determined to be Salmonella species. The patient was becoming hypotensive and was transferred to the critical care unit and was started on pressor support. Blood cultures were drawn on the second day of admission for concern of systemic infection, grew Salmonella species. Patient was weaned off pressor support and was discharged from the hospital in stable condition.

DISCUSSION:

Salmonella is typically a bacteria species that colonize the gastrointestinal tract, there is a chance of bacteremia if Salmonella spreads from the intestines to the mesenteric lymph nodes and then to nearby organs or the bloodstream directly. In our patient with septic arthritis of the knee joint due to Salmonella, the bacteria must have traveled from the gastrointestinal system through the mesenteric lymph nodes into the bloodstream and then reaching the knee joint, where it colonized and caused infection. Early intervention with broad-spectrum antibiotics is key in preventing mortality.
2592 When Is It More Than Hiccups? Understanding the Diagnosis and Treatment of Superior Mesenteric Artery Syndrome
Authors: Mbolu George U. , Mallipudi Rajiv , Miryala Rekha , Nathan Swami
Published: October 2019

INTRODUCTION:

Superior mesenteric artery (SMA) syndrome is defined as an upper gastrointestinal mechanical obstruction caused by compression of the 3rd part of the duodenum between the SMA anteriorly and the aorta posteriorly that has an incidence of 0.1-0.3%. This is due to loss of the intervening mesenteric fat pad and classically seen in young females in anorexic or hyper-emetic states with rapid weight loss and progressively worsening postprandial epigastric pain, hiccups, abdominal fullness and vomiting.

CASE DESCRIPTION/METHODS:

An 83-year-old male with a history of hypertension and coronary artery disease presented to the ED with complaints of persistent hiccups for 1-week duration associated with drooling, decreased appetite, inability to lie flat, and significant weight loss over several months. He was hemodynamically stable and afebrile but noted to have diffuse abdominal tenderness with distension, firmness on palpation and hypoactive bowel sounds. Significant lab values were Cr 3.5 mg/dL, BUN 63 mg/dL, lactate 9.2 U/L, 11,500 white blood cells/UL and abdominal X-ray revealed mildly dilated air-filled loop of bowel in the right side of the abdomen. He was started on IV fluids and nasogastric tube was placed for suction and decompression. Given lactic acidosis in the setting of bowel obstruction and acute kidney injury, a CT abdomen and pelvis without IV contrast was done which revealed significant gastroduodenal distention to the level of the SMA at the 3rd portion of the duodenum (Figures 1 and 2). An EGD was done to rule out endoluminal causes of duodenal obstruction. However, endoscopy showed gastroesophageal reflux disease with esophagitis and extrinsic compression of the 3rd part of the duodenum, thus confirming a diagnosis of SMA syndrome (Figure 3).

DISCUSSION:

While SMA syndrome is typically treated with adequate nutrition, nasogastric decompression, and proper positioning of the patient after eating, this was not an option for this patient. Given the severe gastroduodenal distension, progressive weight loss, poor gastric motility and extensive fluid collection in the stomach, the patient underwent a gastrojejunostomy for gastric fluid drainage. There were no complications and he has remained asymptomatic for the past year. This unique case stresses the importance of keeping a high clinical suspicion of SMA syndrome in the setting of severe weight loss with gastroduodenal distension and hiccups, as well as the prompt use of CT and endoscopy to diagnosis and assess the surgical approach.
2595 Metastatic Urothelial Carcinoma to the Duodenum: An Unusual Cause of Duodenal Stenosis
Authors: Kobeszko Matthew , Samra Mahmud , Blumenstein Brian , Elkhatib Imad
Published: October 2019

INTRODUCTION:

Bladder cancer typically presents within the confines of the bladder wall with less than 4% of cases spreading to distant lymph nodes and organs. We present a unique case of gastric outlet obstruction with early satiety and weight loss secondary to usual mass effect from metastatic bladder cancer in the duodenum.

CASE DESCRIPTION/METHODS:

An 81-year-old male presented with two weeks of bilious vomiting, early satiety, and 20 lb weight loss. Medical history significant for prostate cancer status post prostatectomy with biochemical recurrence and bladder cancer status post radical cystectomy. On physical exam, he had mild epigastric tenderness. Labs were significant for metabolic alkalosis, acute kidney injury, and normal liver function tests. MRI of the abdomen showed diffuse thickening of the duodenal wall. He subsequently underwent an esophagogastroduodenoscopy (EGD), which revealed gastric outlet obstruction at the second portion of the duodenum. An endoscopic ultrasound (EUS) was performed which revealed no pancreatic head mass. However, a two centimeter hypoechoic thickening of the second portion of the duodenum with resultant peri-duodenal biopsies via fine needle aspiration revealed metastatic urothelial carcinoma. Patient was managed conservatively with nasogastric tube placement. With gradual improvement to a soft diet, he was discharged home with plans for outpatient palliative chemotherapy. However, he was readmitted two weeks later with similar complaints and underwent an exploratory laparotomy and palliative gastrojejunostomy. The patient was discharged on a soft diet and plans for platinum chemotherapy.

DISCUSSION:

Bladder cancer ranks as the ninth most frequently-diagnosed cancer worldwide. It typically spreads via the lymphatic and hematogenous routes with the most common sites involving: regional lymph nodes, liver, lung, and bone. Metastasis to the duodenum is extremely rare and to the best of our knowledge is only reported in 4 cases in the literature to date. Three of these cases presented as duodenal obstruction and one case presented as a massive upper GI bleeding. We describe an uncommon presentation of gastric outlet obstruction from bladder metastasis to the duodenum in a patient whose cancer was in remission. Tumor metastasis should be considered in a patient with a history of cancer and presenting with gastric outlet obstruction despite a normal EGD. We also highlight the utility of EUS as a safe and minimally invasive procedure to establish the diagnosis.
2597 An Unusual Case of an Asymptomatic Intramural Duodenal Abscess
Authors: Prado Eric E. , Rodrigues Medora , Serrao Steve , Imbertson Erick
Published: October 2019

INTRODUCTION:

Duodenal abscesses are seldom reported in medical literature. Most recently, a case of an intramural duodenal abscess was reported in 1995 complicated by a perforated peptic ulcer without accompanying peritoneal signs. The lack of signs or symptoms raises for concern for missed intervention and a subsequent high mortality. These abscesses seem to have an association with perforated peptic ulcers. Here we discuss an unusual case of a duodenal abscess in a patient with melena.

CASE DESCRIPTION/METHODS:

A 83-year-old gentleman with a past medical history atrial fibrillation and cholecystectomy status post stent placement presented to Loma Linda Veterans Affairs Hospital with a new one month onset of generalized abdominal pain and melena following addition of edoxaban. Hemoglobin was noted at 12.9 g/dl down trending from 13.8 g/dl one month prior. The scheduled diagnostic EGD was then performed which showed bleeding gastropathy and two small 2 mm ulcers in the body of the stomach. In the duodenum, we noted mucosal irregularity in the bulb (Figure 1) with purulent drainage consistent with an abscess. This was probed with the biopsy forceps resulting in more purulent drainage continued (Figure 2). A biopsy was taken with mildly edematous duodenal mucosa showing reactive changes and expansion of lamina propria by inflammatory cells consistent with an inflammatory process.

DISCUSSION:

There is limited literature for the management of duodenal abscesses. The patient did not exhibit any warning signs such as; abdominal tenderness, guarding, fever, or leukocytosis. There is a potential association with chronic inflammation and duodenal abscesses and the previously stated association with peptic ulcers.
2599 Retained Video Capsule Due to Stricturing Crohn's Disease Safely Diagnosed With Use of Magnetic Resonance Imaging (MRI) in a Pregnant Patient
Authors: Brandt Daniel R. , Judge Thomas A. , Chaaya Adib
Published: October 2019

INTRODUCTION:

Videocapsule endoscopy (VCE) is a noninvasive technology that provides diagnostic imaging of the small intestine. We present a case where MRI was safely utilized to diagnose a retained VCE in a pregnant patient. There is a lack of literature on the use of VCE in pregnancy as well as the use of MRI to diagnose retained VCE. Our case highlights the use of MRI to diagnose a retained VCE during pregnancy without any harmful effects to the patient or fetus.

CASE DESCRIPTION/METHODS:

A 16-year-old woman with a 4-year history of Crohn's disease presented at 24 weeks gestation with six months of achy, left upper quadrant (LUQ) abdominal pain associated with a 20-pound weight loss. On presentation, the patient was depressed, withdrawn and provided limited history. Exam demonstrated a thin young female with gravid uterus and LUQ tenderness. Labs were notable for ESR >100 mm/h and CRP 4.1 mg/L. An MRI was performed to aid diagnosis and minimize risk of radiation to the fetus. This revealed artifact at the anterolateral aspect of the left mid-abdomen (Figure 1). CT enterography confirmed foreign body in the left mid small bowel, likely jejunum, compatible with retained videocapsule (Figure 2). There was an adjacent segment of small bowel with suspected stricture (Figure 3). Additional history was then revealed by the patient's mother. She had undergone VCE six months prior. Shortly after, pregnancy testing was positive and imaging to confirm passage of the VCE was deferred. Subsequently, her pain worsened. Antegrade double balloon enteroscopy was attempted but could not reach the videocapsule. She underwent exploratory laparotomy revealing an intra-abdominal phlegmon and a loop ileostomy was performed. Patient delivered a healthy infant at 34 weeks. Resection of phlegmon and retrieval of foreign body were performed post-partum.

DISCUSSION:

Capsule retention is a potential complication of VCE, with a rate of 2.6% in patients with known or suspected Crohn's disease compared to an overall retention rate of 1.4%. Pregnancy is a relative contraindication to VCE due to a lack of safety data on whether the electromagnetic field of the capsule-recorder-system could harm the fetus. There is also feared theoretical complication of performing MRI while a capsule is within the gastrointestinal tract due to migration of the capsule and the potential for bowel injury or perforation. Our case reinforces the theory that 1.5 Tesla MRI can be safely performed in pregnancy with retained VCE without harm to patient or fetus.
2600 A Typical Presentation of a Rare Disease: Clostridium difficile Enteritis After Total Abdominal Colectomy
Authors: Bundschuh Mark , Moleski Stephanie
Published: October 2019

INTRODUCTION:

Clostridium difficile enteritis (CDE) is rare, but is increasingly diagnosed among those who have undergone colectomy. After colectomy, colonic-type bacterial flora including Clostridium difficile are able to colonize, and under the right circumstances, infect the small bowel. The reported mortality of CDE is high, likely due in part to the emergence of a virulent strain of Clostridium difficile, NAP1/BI/027. Physicians should have a high index of suspicion for CDE, particularly among patients with antibiotic exposure after colectomy.

CASE DESCRIPTION/METHODS:

A 50-year-old-woman with a previous history of Clostridium difficile infection (CDI) and colonic inertia status post total abdominal colectomy with ileorectal anastomosis three months prior presented with waves of left lower quadrant abdominal pain, abdominal distention, nausea, and vomiting. In the three weeks prior to admission, she completed courses of Amoxicillin and Trimethoprim-sulfamethoxazole for UTI. CT abdomen/pelvis with contrast showed 20 cm of circumferential thickening of the distal small bowel with associated free fluid and mesenteric inflammation proximal to unaffected ileorectal anastomosis. Laboratory evaluation was notable only for mild leukocytosis (12,000 cells/µL) with no bands. On admission, the patient had a nasogastric (NG) tube placed for abdominal decompression. A Bisacodyl suppository was prescribed, and the patient had a bowel movement that resulted positive for Clostridium difficile toxin DNA PCR. The patient was diagnosed with CDE. She was initially started on NG Vancomycin 150 mg every 6 hours for a first recurrence of CDI, which was then escalated to 500 mg every 6 hours with the addition of IV Metronidazole. This resulted in resolution of symptoms and ileus.

DISCUSSION:

Our patient had several CDE risk factors including a prior history of colectomy and recent antibiotic exposure. In addition to CDE risk factors, our patient also had two CDI risk factors - chronic acid suppression and previous history of CDI. Additional research is needed to determine if other typical CDI risk factors also play a role in the development of CDE. In patients with altered gastrointestinal anatomy or obstruction, it may be challenging to confirm the diagnosis using stool-based PCR toxin studies. Abdominal CT scan may be helpful in making the diagnosis. Much like our patient, previous studies have demonstrated circumferential edema and mesenteric stranding of the small bowel as common radiologic features of CDE.
2607 Small Intestinal Helminths on a Capsule Endoscopy Capture
Authors: Tsipotis Evangelos , Kolli Sindhura , Aamar Ali , Reddy Madhavi
Published: October 2019

INTRODUCTION:

Intestinal helminth infection is a well known cause of occult GI bleed and iron deficiency anemia, most commonly seen in developing countries. With the introduction of capsule endoscopy in the diagnostic algorithm of occult GI bleed, reports of intestinal helminths identified during capsule study have been published. [1] We present the case of a patient with iron deficiency anemia and occult GI bleed found to have helminth infection.

CASE DESCRIPTION/METHODS:

A 77-year-old Puerto Rican female patient was sent for evaluation of iron deficiency anemia. She was asymptomatic, denying any melena, hematochezia or hematemesis. Her Hb was 8.1 mg/dL, MCV of 83 fL with low iron levels. Fecal occult blood test was positive. EGD and colonoscopy were negative. Outpatient video capsule showed helminths in the ileum, but unable to identify speciation. Multiple stool workups were negative for ova and parasites. Strongyloides serology was negative. Patient empirically received 400 mg of albendazole daily for 3 days and iron tablets.

DISCUSSION:

Helminth infection is most commonly seen in developing countries. Intestinal helminths are transmitted from the soil to the human intestine leading to inflammation of the small intestine or colon, ulcers, anemia secondary to iron and B12 deficiency, eosinophilia, and obscure gastrointestinal bleed. Diagnosis begins with microscopic examination of feces, blood test (serology and blood smear) and imaging ( X-ray, magnetic resonance imaging, and computed tomography).[2]. If worm burden is minimal, then concentrated feces with formalin is recommended. PCR has a higher sensitivity and specificity. When stool studies are negative with high suspicion of helminth infection or the patients present for evaluation of obscure gastrointestinal bleed, conventional endoscopy is the next sequential diagnostic measure. [2] The introduction of capsule endoscopy has assisted the diagnosis of helminth infection in patients with persistent symptoms or anemia and negative esophagoduodenoscopy and colonoscopy. Helminths identified in capsule endoscopy should be categorized and treated based on their macroscopic characteristics if stool studies are falsely negative. If identification is not possible, empiric treatment with monitoring of the response to anemia and repeat capsule endoscopy might be indicated.
2610 Metastatic Melanoma Mimicking Enteritis
Authors: Alimirah Maryam , Bhatti Faiza
Published: October 2019

INTRODUCTION:

Metastasis of melanoma to the gastrointestinal tract is rarely identified in clinical practice. We relay the case of a patient presenting with abdominal pain and leukocytosis with CT imaging initially suspicious for infectious or inflammatory bowel disease, but later confirmed to be small bowel melanoma. This report highlights the unpredictable nature of melanoma and underscores the need to be cognizant of imaging and endoscopy limitations in identifying disseminated disease.

CASE DESCRIPTION/METHODS:

A 59-year-old man with no past medical history presented to the ED with a one-day history of nausea associated with severe right lower quadrant abdominal pain. Labs showed leukocytosis to 20 K/uL. CT of the abdomen and pelvis showed significant wall thickening of a long segment of distal small bowel loop with adjacent fat stranding. He was discharged with antibiotics for presumed infectious enteritis and with gastroenterology follow up. Patient underwent ileocolonoscopy one month later that was significant for multiple polyps but otherwise normal appearing ileum and biopsies were negative for colitis or ileitis. Two months later, during follow up, patient underwent MR enterography which showed large mass measuring 9.0 × 7.1 × 7.4 cm in size in the small bowel, correlating with area of thickened bowel noted on CT previously (Figure 1). Patient underwent exploratory laparotomy with resection of small bowel mass with pathology positive for melanoma (Figure 2). Primary site was identified shortly thereafter as a cutaneous lesion in area of right upper back.

DISCUSSION:

Delayed diagnosis in this case hinged on unrevealing colonoscopy and CT findings describing only distal small bowel wall thickening concerning for enteritis due to infection or inflammatory bowel disease. Bender et al reported a sensitivity of 66% for contrast-enhanced CT in demonstrating intestinal metastatic deposits. A less common radiographic manifestation of metastatic melanoma infiltrating the serosa described in the literature includes segmental circumferential bowel thickening that can mimic the appearance of Crohn’s disease or intestinal enteritis, a characteristic that might explain the CT findings described in our patient. Also of note is the inability of endoscopy to uncover serosal metastases which is especially concerning as it is common for intestinal melanoma metastases to grow extraluminally.
2611 An Unlikely New Home for Metastatic Melanoma
Authors: Tan Christopher , Yanchak Teresa , Ramirez Jonathan
Published: October 2019

INTRODUCTION:

Symptomatic gastrointestinal involvement from primary malignant cutaneous melanoma represents only 1–4% of melanoma cases but is found in 60% of autopsies in patients who have had a primary cutaneous melanoma. We present a case of metastatic melanoma with initial symptomatic cecal involvement as demonstrated by colonoscopy and subsequent jejunal involvement discovered using single balloon enteroscopy. Our case illustrates that presenting symptoms for metastatic lesions in the gastrointestinal tract are often nonspecific but despite this, metastatic melanoma with gastrointestinal involvement should be considered in any patient that’s been diagnosed with a primary cutaneous melanoma.

CASE DESCRIPTION/METHODS:

A 61-year-old male presented with one-week history of melena. An iron panel was obtained which revealed iron deficiency anemia. The patient’s past medical history was significant for previously excised cutaneous melanoma. Initial colonoscopy demonstrated a malignant appearing mass in the cecum with an immunoprofile consistent with metastatic melanoma on biopsy. Patient was unable to tolerate initial chemotherapy and continued to have chronic blood loss anemia. The patient had a follow up pill cam endoscopy which showed slow oozing lesion noted in the duodenum. Subsequent single balloon enteroscopy was performed showing a non-obstructive, polypoid and ulcerated appearing proximal jejunal mass which was found to be melanoma on biopsy.

DISCUSSION:

Malignant melanoma is the most common metastatic tumor to the gastrointestinal tract. The propensity of the primary tumor to metastasize is dependent on Clark staging. Detection of small bowel lesions is often difficult. Small bowel lesions may present diffusely, as mural nodules, or “target” lesions on radiograph. Endoscopically, lesions may appear as ulcerated melanotic nodules, submucosal masses with ulcerations, or mass lesions with necrosis and melanosis. However, if the lesions involve the serosa or mesentery they can be missed on endoscopy. Various treatment modalities exist for metastatic melanoma of the GI tract including but not limited to surgical resection, immunotherapy, and chemotherapy.
2613 A Rare Case of Undifferentiated Malignant Epithelioid Neoplasm
Authors: Prakash Sameer , Sindi Ghassan , Suliman Abdelrazig
Published: October 2019

INTRODUCTION:

The small bowel is rarely a site for development of tumor malignancy and accounts for less than 1% of all GI malignancies. We present a case of a 53-year-old male with recurrent episodes of gastrointestinal bleeding and negative upper and lower GI endoscopies found to have high-grade undifferentiated high-grade malignant epithelioid neoplasm.

CASE DESCRIPTION/METHODS:

A 53-year old male with history of peptic ulcer disease, duodenal ulcer perforation presented to the ED with right upper and lower extremity pain for last few weeks along with black stools. He had required several units of blood transfusion with recurrent admissions to hospital and had also lost about 20 lbs in last 2 months. EGD and colonoscopy 3 months before had shown duodenal angiectasia and colonic polyps which were removed. Outpatient capsule endoscopy was recommended but patient did not follow up. Bleeding scan was negative and CT abdomen pelvis with contrast showed thickening in distal jejunum concerning for mass-like lesion. Patient underwent laparoscopic small bowel resection of 18 cm and pathology showed high-grade undifferentiated malignant epithelioid neoplasm with macro-metastatic tumor. The tumor showed diffuse staining for vimentin,pancytokeratin, CK7 with subset moderate cytoplasmic staining for calretinin and CK8/18.Port-A-Cath was placed and patient was started on standard adjuvant chemotherapy including combination of 5-FU, leucovorin, and oxaliplatin.

DISCUSSION:

Small bowel tumors are very rare and aggressive and have poorer prognosis than colon cancer. They present a diagnostic challenge as access to small bowel is limited during conventional diagnostic procedures and symptoms present late. We present a patient who was having recurrent gastrointestinal bleeding requiring multiple blood transfusions and found to have high-grade undifferentiated high-grade malignant epithelioid neoplasm. The differential for this includes monophonic synovial sarcoma, malignant epithelioid mesothelioma, and large cell lung carcinoma vs others. Video capsule endoscopy has rapidly become the conventional standard for small bowel evaluation, followed by other methods such as magnetic resonance enteroclysis. Standard chemotherapy treatment closely resembles that of large bowel cancer, including combinations of 5-FU, leucovorin, and oxaliplatin/irinotecan/capecitabine.