bluuebunny/crossref_metadata_2025 huggingface dataset:
3180 Previously Undiagnosed Hepatocellular Carcinoma Presenting as Cardiac Mass Causing Decompensated Right Heart Failure and Subsequent Multi-Organ Failure
Authors: Higley Cory , Nadella Sandeep , Badoghaish Waleed , Lalos Alexander
Published: October 2019

INTRODUCTION:

Hepatocellular carcinoma (HCC) is the most common primary malignancy of the liver. Some patients may present with early stage disease due to HCC surveillance however widespread adoption of screening recommendations in this country is lacking. Therefore, many cases present with locally advanced or metastatic disease. We present the case of a patient whose initial manifestation of HCC was an unusual presentation of respiratory failure and an intracardiac mass. This case should emphasize the protean manifestations of metastatic HCC.

CASE DESCRIPTION/METHODS:

The patient was a 65-year-old male with past medical history significant for hepatitis C who had achieved a sustained virologic response (SVR) three years prior to presentation. He had not been previously diagnosed with cirrhosis according to family members and was not undergoing HCC surveillance. He presented to our hospital with a complaint of shortness of breath for one week and was noted to have significant dyspnea necessitating intubation. Laboratory results of significance are summarized in Table 1. An echocardiogram noted a large echodensity spanning both the right atrium and right ventricle, measuring 8 cm × 4 cm (Figure 1) and a CT angiography of the chest, abdomen and pelvis revealed a large heterogeneous, multiseptated right lobe liver mass measuring 11.5 cm by 8.6 cm by 12.2 cm in the setting of a cirrhotic liver (Figure 2). Due to extent of disease, there were no meaningful treatment options available and the patient expired 48 hours later following a family meeting and compassionate extubation.

DISCUSSION:

Cardiac metastases of HCC are rare, with rates estimated between 1.2% and 6%, and signify a late manifestation of HCC. As such, it often has a poor prognosis with median and mean survival times of 102 and 161 days, respectively, after diagnosis. A literature review did yield some cases of patients with HCC who eventually developed metastases to the heart, however none have described the presence of cardiac metastases at time of diagnosis of HCC which we believe makes our case particularly unusual. This is in part explained by underutilization of HCC surveillance in this country. This case highlights the associated morbidity of hepatocellular carcinoma and necessitates ongoing adherence to surveillance recommendations to reduce advanced stages of HCC.
3183 Explanted Liver Confirming Hereditary Hemochromatosis in an African American Male
Authors: Abraham Fiyinfoluwa , Subramanian Sruthi K. , Singh Khushboo , Younes Mamoun , Machicao Victor
Published: October 2019

INTRODUCTION:

Hereditary hemochromatosis (HH) is a disorder in which intestinal iron absorption leads to iron overload. It is associated with mutations in the HFE gene. Most commonly seen in Caucasian individuals; however, it is infrequent to see it present in those of African descent.

CASE DESCRIPTION/METHODS:

A 52-year-old African American male with a history of decompensated alcoholic cirrhosis with ascites, portosystemic encephalopathy (PSE), and non-bleeding esophageal varices presented to hepatology clinic with a MELD score of 16. He quit drinking ten years before the presentation. He was evaluated for a liver transplant, was subsequently deemed a candidate, and placed on the list. As a part of transplant evaluation, an MRI of the abdomen was obtained approximately which showed cirrhotic liver morphology with no hypervascular liver lesions, but the presence of diffuse T2 hypointensity suggestive of iron overload and fibrosis, located in the liver, pancreas and myocardial tissue (Figure 1). A dedicated cardiac MRI with iron protocol was done to confirm findings and give quantification, which showed iron overload with an iron concentration of 1.8 mg/g of dry weight. Serology showed serum iron 125 ug/dL (normal), ferritin 1281 ng/mL (very high), 95% transferrin saturation (very high), and total iron binding capacity of 132 ug/dL (very low). Hereditary hemochromatosis (HH) was suspected, and genetic testing was conducted. The patient was found to be negative for HFE mutations C282Y, H63D, and S65C. Two months following the serological workup, he underwent a liver transplant with an ABO identical allograft liver. The explanted liver (Figure 2) showed severe iron overload in the hepatocytes confirmed by iron stain with pericanalicular accentuation (Figure 3). The diagnosis was confirmed to be HH.

DISCUSSION:

HH was confirmed when the presence of multi-organ iron overload was seen in imaging, serology showed significant ferritinemia with 95% transferrin saturation, and biopsy showed the presence of severe iron overload in the hepatocytes. While genetic testing for C282Y, H63D, and S65C was negative, this does not mean HH can be ruled out. Identifying these mutations is not necessary for the diagnosis of HH, but the mutations are predominantly positive in Caucasians. For other ethnicities, including Africans, there are rare HH mutations that can return positive but were not tested. This case describes a rare phenomenon of biopsy proven HH found in an African American male.
3185 An Unusual Cause of Abdominal Pain and Elevated Liver Chemistries
Authors: Dave Isha , Dailey Francis , Turse Erica , Tahan Veysel
Published: October 2019

INTRODUCTION:

Nonalcoholic fatty liver disease (NAFLD) is a spectrum ranging from simple steatosis to cirrhosis. It is present in 33% of the general adult population and is more prevalent in overweight and diabetic patients. This can be explained by abnormal lipid metabolism with stressed conditions such as Cushing's disease (CD). In CD, glucocorticoids act synergistically with insulin to increase lipid accumulation. The incidence of NAFLD in CD is not well described but is thought to be greater than the general population. CD is less commonly labelled as a culprit of elevated liver chemistries. Here, we present a case of a young woman with uncharacteristically elevated liver tests found to be due to CD.

CASE DESCRIPTION/METHODS:

A 35-year-old woman was admitted for abdominal pain, nausea, and vomiting. Her medical history included a pituitary adenoma with subsequent CD status post three resections, diabetes insipidus, diabetes mellitus type 2, bipolar disorder, and symptomatic cholelithiasis status post cholecystectomy. Admission labs showed total bilirubin 3.70 mg/dL, ALP 480 U/L, AST 681 U/L, ALT 992 U/L, lipase 25 U/L. Workup was negative including viral hepatitis including hepatitis E, autoimmune hepatitis, hemochromatosis, alpha-1 anti-trypsin deficiency were negative. Abdominal ultrasound and MRCP showed hepatic steatosis. Liver biopsy revealed 70-80% macrovesicular hepatic steatosis and prominent cholestasis. Her liver function tests transitioned to a cholestatic pattern with total bilirubin 7.07 mg/dL, ALP 1019 U/L, AST 273 U/L, and ALT 519 U/L. She was started on ursodiol 15 mg/kg resulting in immediate symptomatic improvement. One month following hospitalization while on treatment, labs were AST 21 U/L and ALT 30 U/L.

DISCUSSION:

NAFLD is diagnosed by adiposity within the liver on imaging or histopathology and remains the most common cause of abnormal liver chemistries. Patients with CD have been shown to have a higher incidence of NAFLD, as much as 20%. This is thought due to an increase in visceral fat rather than a direct effect of cortisol, as often the BMI is not particularly elevated. While a majority of patients with NALFD may have normal transaminases, a study by Shirin et al found that patients with higher elevations in cholestatic enzymes were more likely to have advanced liver disease. Thus, clinicians should have a high suspicion when a patient has comorbidities predisposing them to hepatic steatosis, including metabolic syndromes such as CD.
3187 Rare Presentation of Hereditary Hemochromatosis Brought to Light by Disseminated Mycoplasmosis
Authors: Khorasani-Zadeh Arshia , Shahi Diwas , Joshi Sumendra
Published: October 2019

INTRODUCTION:

Hereditary hemochromatosis is commonly caused by mutation of the HFE protein (C282Y/H63D), leading to iron overload and deposition in the liver, heart, pancreas, and pituitary. Manifestations of Hereditary hemochromatosis differ based on the primary site of iron deposition, ranging from cirrhosis, cardiomyopathy, to diabetes and immunosuppression. which increases susceptibility to opportunistic infections including disseminated mycoplasma. Even with its estimated prevalence of 15% of all community acquired pneumonias, mycoplasma pneumonia is not well recognized for its multitude of rare extrapulmonary manifestations (Figure 1).

CASE DESCRIPTION/METHODS:

43 year old male was found unresponsive at home. On admission, diffuse mucosal sloughing and bleeding with numerous small, flat, erythematous lesions on the trunk and extremities. Throat swab Polymerase Chain Reaction: positive for mycoplasma pneumonia, with IgM serum confirmatory test. These skin lesions would blister and ulcerate on following days. Skin biopsy revealed Steven Johnson Syndrome. On hospital day 6 patient was noted to have left hemiplegia, Head imaging, Right Middle Cerebral Artery ischemic stroke and hemorrhagic conversion. Cardiac Imaging showed No patent Foramen Ovale, no atrial thrombi or valvular pathology, leading to a diagnosis of cryptogenic stroke. In the presence of elevated liver function testing and diffuse hyperattenuation of the liver on non-contrast CT, Iron studies were obtained. Ferritin of 10,086 ng/ml, % Iron saturation of 78.7. Genetic testing returned homozygous for C282Y gene. Liver biopsy confirmed hemochromatosis. Appropriate antibiotics and serial phlebotomies started, after which he clinically improved.

DISCUSSION:

The liver plays a central role in the clearance of bacteria from the bloodstream as hepatic phagocytosis accounts for more than 80% of all reticuloendothelial system function. In hemochromatosis, patients have increased portocaval shunting from liver injury. Therefore, bypassing the liver, and reducing clearance of mycoplasma, predisposing patients to a more virulent clinical course. Mycoplasma's activity in an Iron rich environment is poorly understood. It is known that mycoplasma binds to lactoferrin, a protein largely responsible for iron sequestration in the body for bacteriostasis. This leaves room for further research regarding its evolutionary pathogenicity. Therefore, patients with unexplained opportunistic infections and elevated transaminases should be investigated for hemochromatosis.
3188 Alcoholic Hepatitis and the Need to Focus on Abstinence From Alcohol
Authors: Lewis Justin , Collins Judy
Published: October 2019

INTRODUCTION:

Alcoholic hepatitis (AH) results from long-term alcohol abuse that leads to liver inflammation and impaired hepatic function. Abstinence from drinking is of utmost significance for these patients.

CASE DESCRIPTION/METHODS:

A 56 year-old man with a history of severe alcohol use disorder presented with subacute vomiting, abdominal pain, dark stools, and fatigue. He drank 10 beers/day for 15 years. HR was 110 and BP 105/75. He was jaundiced, tremulous, and had moderate tenderness in his right upper quadrant. Labs showed WBC 12.7, Hgb 6.6 (baseline 8 - 9), AST 230/ALT 61, total bilirubin (TB) 8.1, ALP 295, INR 1.3, and EtOH level 156. CT demonstrated low liver attention consistent with hepatic steatosis. He was started on IV PPI, CIWA protocol, and given 1u pRBCs. EGD and colonoscopy revealed no source of GI bleed. His hemoglobin and transaminitis improved, TB peaked at 8.8 and declined, and he was discharged with outpatient alcohol counseling and PPI BID. He presented four weeks later in alcohol relapse and is now admitted for detoxification.

DISCUSSION:

This patient presented with classic findings of AH, but his case represents how alcohol abstinence is paramount for these patients. The recent literature for AH centers upon the mortality benefit (or lack thereof) of steroids. Had our patient's Maddrey score been ≥32 (his was 24), this would have been considered, but this misses the larger issue of alcohol in AH. Abstinence is the only independent predictor of long-term survival in AH, with one study demonstrating 5-year survival of 75% in abstainers vs 26% in relapsed drinkers.
1
While most of our patient's care focused on his anemia workup, the highest mortality benefit gained is through resources to maintain sobriety, likely needing more than just outpatient counseling (as is demonstrated by his relapse). To this end, integrated psychotherapy is effective for achieving abstinence in AH patients. A systematic review found that 45% of patients in a psychosocial intervention group achieved abstinence vs 36% in the control group, with one study showing 74% vs 45% abstinence.
2
Getting AH patients to stop drinking is the most beneficial treatment for their health, and a deliberate effort utilizing integrated, multidisciplinary care can achieve this.
3199 Acute Decompensation of Cirrhosis Complicated by Simultaneous Portal Vein Thrombosis and Hepatocellular Carcinoma
Authors: Paz Sandra Gomez , Jiyani Rucha , Kumar Swati , Jacob Bobby , Rizvon Kaleem , Mustacchia Paul
Published: October 2019

INTRODUCTION:

Prognostic factors differ significantly between those with compensated and decompensated cirrhosis. We present the case of a patient with decompensated cirrhosis who was found to have portal vein thrombosis and hepatocellular carcinoma simultaneously.

CASE DESCRIPTION/METHODS:

68 year old Indian male with history of alcohol abuse, liver cirrhosis and gastroesophageal varices (GOV) type 2, presents with 4 days of diffuse abdominal pain, abdominal distension, fatigue and mild shortness of breath. Collateral information included recent episodes of confusion. Physical exam showed moderate abdominal distension with shifting dullness and diffuse tenderness. Patient was oriented only to person and space. Laboratory examination showed AST 166 U/L, ALT 58 U/L, total bilirubin 20 mg/dL, Ammonia 43 ummol/L and AFP 6.8 ng/mL. CT scan of the abdomen revealed heterogeneous nodular liver with enhancing nodule in the right hepatic lobe measuring 1.8 cm; portal hypertension, paraesophageal varices, and moderate intrabdominal ascites. Portal vein thrombosis (PVT) of intrahepatic portion was noted. Abdominal ultrasound was consistent with advanced cirrhosis and common bile duct (CBD) dilatation of 1.2 cm. Abdominal MRI and MRCP were performed, confirming liver lesion. Ascitic fluid analysis ruled out spontaneous bacterial peritonitis. CT- guided biopsy of hepatic lesion confirmed Hepatocellular Carcinoma (HCC). Patient underwent successful Transarterial Chemoembolization (TACE) of right hepatic tumor and was eventually discharged and followed by Gastroenterology as outpatient.

DISCUSSION:

Literature review stipulate that in the compensated patients, factors related to the tumor in HCC would be more important, whereas in the decompensated patient, both liver and tumor related factors would be important. However, the number of studies is too small to be conclusive, particularly regarding patients with mostly decompensated cirrhosis and those with non-advanced tumor stage. When it comes to PVT as a predictor of prognosis and mortality in patients with decompensated cirrhosis, recent studies strengthen the idea that PVT simply arises in the context of severe liver failure, and does not significantly worsen hepatic function. In our case, the simultaneous finding of PVT and HCC in setting of decompensation may be indicative of dismal outcome. The significance of HCC and PVT as predictors of prognosis and mortality, should be better evaluated in cirrhotic patients in compensated versus decompensated states independently.
3201 Acute Portal Vein Thrombosis Presenting With Atypical Abdominal Pain: A Rare Presentation
Authors: Randhawa Tejinder , Vohra Ishaan , Omar Yazan Abu , Patel Ricky , Flores Estefania
Published: October 2019

INTRODUCTION:

Portal vein thrombosis (PVT) is an uncommon etiology of transient abdominal pain that left undiagnosed can present with severe complications including variceal hemorrhage, intestinal ischemia, and portal biliopathy. The clinical presentation of PVT is highly variable and depends on the speed of development and extent of occlusion. Rarely do partial acute PVTs present with symptoms. As a result, many PVTs are found incidentally on CT scanning performed for other indications. Management of acute PVT relies on anticoagulation over a three- to six-month period, however this practice has not been evaluated in randomized trials. Current practices rely on the principal that spontaneous recanalization of PVT is rare compared to rates of recanalization as high as 40% in anticoagulated patients. We present a rare case of partial PVT presenting with localized abdominal pain and fever.

CASE DESCRIPTION/METHODS:

A 63-year-old male was admitted from the Emergency Department with right upper quadrant pain and subjective fever. Past histories remarkable for hypertension and alcohol use disorder. Patients examination revealed a soft abdomen with severe right upper quadrant tenderness. On initial presentation the patient had a fever of 100.5 degrees Fahrenheit sustained for 1 hour that self-resolved within 4 hours of admission. CT scan of the abdomen and pelvis revealed linear hypodensities in portal vein branches to the right anterior hepatic lobe and lateral segment of the left hepatic lobe and was otherwise unremarkable. Follow-up duplex ultrasound of the hepatic portal veins corroborated the CT findings. Anticoagulation was started initially with heparin and then subsequently transitioned to rivaroxaban with plans to continue anticoagulation for six months. Patient had complete resolution of abdominal pain within 24 hours of initial presentation. The patient was evaluated for underlying prothrombotic disorders and investigations revealed positive lupus anticoagulant. Patient currently awaits repeat imaging to document resolution of the PVT.

DISCUSSION:

PVT can present a diagnostic challenge as presentation, though typically asymptomatic, can also be highly variable. Review of the literature demonstrates atypical presentations including nonspecific dyspepsia, epigastric pain mimicking pancreatitis, and colicky abdominal pain and diarrhea. Recognition and early treatment of PVT is important to prevent portal hypertension and its associated long-term complications.
3202 Where Is the Coin?
Authors: Widner Justin , Jain Rekha , Malkani Anjali
Published: October 2019

INTRODUCTION:

Foreign body ingestions are a common presenting complaint in the emergency department. Nearly 80 percent of the greater than 100,000 cases annually are in children. Coins are the most frequently ingested item in children. Most coins pass uneventfully, however they may get lodged at the level of the thoracic inlet, at the level of the arch of the aorta or at the gastroesophageal junction. Urgent evaluation involves obtaining a chest radiograph. Ingested coins found in the esophagus are oriented coronally on a posteroanterior (PA) radiograph. However, coins lodged in the trachea are oriented sagitally (due to the longitudinal orientation of the larynx and the incomplete C rings of the trachea, allowing a longer antero-posterior diameter of the trachea). We present a child with esophageal coin oriented sagitally on PA chest X-ray.

CASE DESCRIPTION/METHODS:

A healthy six year old boy presented to the Emergency Room with severe chest pain an hour after swallowing a nickel. There were no respiratory symptoms. On chest X-ray the coin was seen “on edge” on the PA view and “en-face” on the lateral view, below the level of carina. CT scan revealed the coin sagitally oriented in the esophagus at the level of the gastroesophageal junction. Due to persistence of chest pain he underwent endoscopy immediately after CT scan. At endoscopy under general anesthesia the coin- a nickel, was seen in the stomach and retrieved. The esophagus appeared normal.

DISCUSSION:

Even though most ingested coins are oriented coronally in the esophagus, our case demonstrates that coins in the esophagus may be oriented sagitally as well. Review of the literature revealed a study with 8 cases of sagittally oriented esophageal coins. In these children, 7 of the 8 were at the level of the aortic arch, while the other was at the distal esophagus, as was seen in our patient. The cause of the sagittal orientation is speculative; and may be related to peristalsis and a smaller sized coin.
3205 A Rare Case of Salmonella Gastroenteritis Presenting as Aspiration Pneumonia With Pleural Empyema in Immunocompetent Patient
Authors: Mehmood Asif , Ullah Waqas , Ashraf Aniza , Essrani Rajesh
Published: October 2019

INTRODUCTION:

Salmonellae are gram negative rods belongs to Enterobacteriaceae. They commonly cause enterocolitis, enteric fever, endovascular infection and bacteremia with localized infection which can occur at any site. Pulmonary involvement especially empyema is very rare and usually reported in immunosuppressed patients secondary to co-morbidities such as HIV,malignancy,diabetes and iatrogenic (steroids/chemotherapy).

CASE DESCRIPTION/METHODS:

76-year-old male with past medical history of Ischemic cardiomyopathy with 35% EF status post AICD, CKD stage 3, dementia and stroke presented to ER for generalized weakness, fever, coughing, right sided lower chest pain, abdominal pain, non-bloody watery diarrhea and vomiting for 3 days. Physical examination revealed new oxygen requirement with respiratory rate 24/min, blood pressure 110/75 mmgh, heart rate 70/min and temperature 100.9 F. He was ill appearing, lethargic with +1 pedal edema. Abdomen was soft but with epigastric/right upper quadrant tenderness. Decreased breath sounds were present at bases. Initial laboratory results showed leukocytosis of 12000 K/ul, normal AST/ALT, elevated bilirubin 2.1 mg/dl, Alkaline phosphatase 324 u/l, BUN 37 mg/dl and Creatinine of 1.8 (at baseline). Chest x-ray showed right greater than left small bilateral pleural effusions and bibasilar atelectasis/infiltrates. Ultrasound RUQ negative for acute cholecystitis. Patient was started on intravenous lasix was started given concern for volume overload and IV antibiotics for possible aspiration pneumonia. Low grade fevers persisted for next 24-36 hrs along with worsening breathing. Repeat chest x-ray showed worsening right pleural effusion. CT chest revealed large loculated left pleural effusion with infiltrates, small right effusion with nearby atelectasis and distended esophagus. Chest tube was placed along with injecting tPA/DNase to help break up loculations. Patient passed swallow evaluation and further testing was negative like blood/sputum cultures and stool studies. Pleural fluid was exudative and grew few non-typhoid salmonella species without reporting of exact identification by laboratory. Patient was discharged in stable condition on 4 weeks of Amoxicillin/clavulanic acid after consultation with Infectious disease specialist.

DISCUSSION:

Non-typhi salmonella causing pneumonia and empyema is very rare. Most common presentation is gastroenteritis. Patients presenting with gastroenteritis and pulmonary involvement, clinicians should keep salmonella as a differential diagnosis.
3216 SMA Syndrome and Small Bowel Obstruction
Authors: Kapadia Deena , Pham Michael
Published: October 2019

INTRODUCTION:

Superior mesenteric artery (SMA) syndrome is a condition in which the third portion of the duodenum, between the abdominal aorta and SMA, is compressed. The disease is rare, as incidence rates range from 0.1% to 0.3%. It is more prevalent in females aged 10 to 39 years old. Symptoms include severe weight loss, epigastric pain, nausea, and vomiting. SMA syndrome is an uncommon cause of small bowel obstruction (SBO). This case describes a patient with known SMA syndrome who presented with acute symptoms of SBO.

CASE DESCRIPTION/METHODS:

A 36-year-old male with past medical history of polysubstance abuse, hypertension, GERD, psychiatric disorders (bipolar, anxiety, depression), GI bleeds, and SMA syndrome presented with worsening abdominal pain for two weeks. Pain was described as dull and constant with radiation to his lower back. Associated symptoms included worsening nausea and coffee ground hematemesis, as well as dark stools and decreased appetite. The patient was hemodynamically stable. NG tube was placed to help with decompression. He was given IV fluids and started on pantoprazole 40 mg BID IV. CT abdomen with contrast showed a 4 mm obstruction at the third portion of the duodenum consistent with SMA syndrome and a second jejunal area of transition. General surgery deemed him to not be an appropriate surgical candidate, and medical management was recommended. EGD demonstrated a collapse of the duodenal mucosa at the third to fourth portion of the duodenum with moderate chronic appearing dilation of the duodenum proximal to this area. A small sliding hiatal hernia and LA class D esophagitis were also seen. He was started on sucralfate 1 gm QID PO and switched to pantoprazole 40 mg daily PO upon discharge. Liquid diet was advanced as tolerated. Once his symptoms improved, he was discharged and instructed to follow up with a GI physician.

DISCUSSION:

SMA syndrome should be considered in the differential for young adults presenting with symptoms of SBO due to the morbidity and mortality associated with malnutrition, dehydration, and other complications, such as gastric perforation and hemorrhage. Diagnosis is made based on clinical symptoms and radiologic imaging. Initial treatment is non-operative medical management with fluid resuscitation, TPN, NG tube, and electrolyte correction. Laparoscopic duodenojejunostomy is the most common surgical intervention used when medical management fails. In this case, the patient was able to have improvement in symptoms with medical management alone.
3221 A Rare Case of Collagenous Sprue
Authors: Gade Ajay , Rubery Bradley
Published: October 2019

INTRODUCTION:

Collagenous Sprue (CS) is a rare clinicopathological malabsorptive disorder characterized by mucosal villi atrophy and sub-epithelial collagen deposition. It is very important to consider the possibility of CS in patients diagnosed with celiac disease not improving on the gluten-free diet.

CASE DESCRIPTION/METHODS:

We present an elderly caucasian male with clinicopathological manifestations of Collagenous Sprue, as well as the successful treatment course that he underwent.

DISCUSSION:

Collagenous Sprue (CS) is a rare clinicopathological malabsorptive disorder characterized by mucosal villi atrophy which was first described in 1947. Approximately 60 cases have been reported so far in the medical literature. Replacement of the crypts with subepithelial collagen deposition in the small intestine made some experts believe CS to be a histopathologic variant of celiac disease with a poorer outcome. Although it's not true in all patients, diagnosis of CS should be considered in a patient whose symptoms are not getting better despite a gluten-free diet. Unlike in celiac disease, the collagenous deposits in CS doesn't regress with a gluten-free diet. Thus far, the etiology of CS is not clearly understood and it is very essential to initiate treatment at an early stage of the sprue to prevent fibrotic progression. Multiple treatment strategies were advised in the past but there is no standard therapy.
3223 Knot in the Stomach: Metastatic DLBCL Disguised as an Ulcer
Authors: Prakash Sameer , Banwait Amrit , Khandheria Bharat , Banwait Kuldip
Published: October 2019

INTRODUCTION:

Early primary gastrointestinal non-Hodgkin's lymphomas can be difficult to diagnose and can be mistaken for diseases such as Crohn's disease or intestinal tuberculosis. We present a 73-year-old patient who had large duodenal bulb ulcer on endoscopy that resulted in metastatic DLBCL.

CASE DESCRIPTION/METHODS:

A 73-year-old female with history of osteoporosis, Vitamin B12 deficiency, and leukopenia presented to her primary care physician complaining of feeling knot in upper abdomen for 1 month. She felt the knot was getting progressively bigger with mild abdominal discomfort. She had also complained of early satiety, abdominal bloating, and weight loss of 3-4 pounds in past few months. She denied diarrhea or blood in the stools. Physical exam was significant for minimal distension with prominent palpable pass in right upper abdomen with tenderness to palpation and no lymphadenopathy. Labs showed WBC 4.0, Hb 11.6, Plt 417, Alkaline Phosphatase 235, Alb 3.3. CT scan of abdomen pelvis showed circumferential mass like thickening along gastric antrum, mesenteric implants, and periaortic lymphadenopathy concerning for gastric carcinoma or lymphoma. She was referred to oncologist and gastroenterologist for evaluation with upper endoscopy. EGD showed large duodenal bulb ulcer with necrotic base and small ulcer in antrum. Duodenal biopsy showed newly diagnosed stage IV Diffuse Large B-Cell Lymphoma that also involved gastric, gallbladder, and pancreas. She completed 3 cycles of R-CHOP chemotherapy and was started on high-dose methotrexate for CNS prophylaxis. She had Whipple procedure done after leak of gastrografin and noted to have perforated duodenum.

DISCUSSION:

Diagnosis of primary GI lymphoma is difficult as it can be nonspecific and often benign gross appearance on endoscopy or colonoscopy. The duodenum represents roughly 6-8% of sites involving small intestine lymphoma. DLBCL of the intestine treated with surgery plus CHOP or R-CHOP chemotherapy has very good prognosis. Early diagnosis and treatment is crucial due to the aggressive nature of this malignancy.
3224 A Rare Case of Duodenal Adenocarcinoma in Situ Arising in the Background of Villous Adenoma
Authors: Rana Navpreet , Minhas Umair , Mahl Thomas
Published: October 2019

INTRODUCTION:

Villous adenomas (VA) of the small bowel are the most common benign periampullary neoplasms with the highest potential for malignant transformation to adenocarcinoma. Adenocarcinoma of the small bowel accounts for only 1% of all gastrointestinal malignancies and duodenal adenocarcinoma (DA) constitutes approximately half of these cases. Although a rare and aggressive cancer, DA has the more favorable outcomes than other periampullary malignancies. Hence, it is important to understand the pathogenesis of DA as well as pre-malignant lesions such as VA. We present a male with long standing history of iron deficiency anemia found to have a duodenal mass identified as adenocarcinoma in situ arising in the background of VA.

CASE DESCRIPTION/METHODS:

A 73-year-old male, with a medical history of hypertension, Hepatitis C status post treatment and iron-deficiency anemia was referred for anemia with a hemoglobin of 6.2. He reported recent fatigue with no dyspnea, chest pain, melena, hematochezia or hematemesis. Colonoscopy 1-year ago was significant for a tubular adenoma with recommendation to repeat procedure in 5 years. Patient was transfused 1 unit of red blood cells on admission and started on oral iron supplement. He remained hemodynamically stable. Push enteroscopy showed a circumferential mass in the 3rd portion of the duodenum without obstruction. Biopsy noted adenocarcinoma in situ arising in the background of villous adenoma. Patient was evaluated by the surgical team with a plan for resection and subsequent follow-up with an Oncologist.

DISCUSSION:

VA accounts for only 1% of all duodenal tumors. Given their rarity, pathogenesis and rate of transformation to adenocarcinoma is unclear. Symptoms associated with VA depends on their location in the duodenum and can range from vague abdominal complains to biliary or small bowel obstruction, pancreatitis or iron deficiency anemia. Iron deficiency anemia in our patient was likely secondary to impaired absorption of iron in the duodenum due to the mass. Duodenal adenomas are associated with an increased risk of colonic adenomas, similar to our patient given his history of tubular adenoma in the colon. Hence, concomitant colonoscopy is warranted for early diagnosis of potentially pre-malignant colonic lesions in patients with duodenal adenomas. With regards to treatment, complete resection of VA is recommended given their high risk of malignant transformation.
3226 Complications of Meckel's Diverticulum from Helicobacter pylori
Authors: Behzadpour Jabiz , Mehdi Shaun , Villa Eduardo
Published: October 2019

INTRODUCTION:

Meckel's diverticulum is a disease most prevalent in children. It is rare for it to present in adulthood, especially with complications. Below is a unique case of Helicobacter Pylori (H. Pylori) causing an abdominal abscess which led to the discovery of an adult male's Meckel's diverticulum.

CASE DESCRIPTION/METHODS:

A 26-year-old male with no past medical history presented to the emergency room complaining of intermittent midline abdominal pain in the lower quadrant for the past two weeks, with associated decrease in appetite, fever, nausea, and vomiting that started two days prior to arrival. The pain was worsened with eating and ambulation, and improved when lying down. One week ago he was in the emergency room for similar symptoms and was discharged home with given intravenous fluids, omeprazole, ranitidine, calcium carbonate and then subsequently discharged home. His pain did not improve, so three days later he went to his primary care physician's office where outpatient CT was ordered and patient was prescribed azithromycin, ciprofloxacin, and tramadol. Primary care physician contacted patient after obtaining CT scan results, and instructed him to immediately go to the emergency room. In the emergency room physical exam was significant for periumbilical and suprapubic tenderness with palpation and mild guarding. The CT scan showed a complex multiloculated 5 cm abscess in the mesentery of the midline lower abdomen. Patient was admitted and started on ceftriaxone and metronidazole. Surgery evaluated the patient and recommended laparoscopic exploration. During the procedure the perforated small bowel was resected and mesenteric abscess was suctioned. While in the hospital patient complained of a history of dyspepsia for the past three years which worsened 1-2 hours postprandially. This prompted him to be tested for H. Pylori IgG antibody and stool antigen. Serum IgG antibody was positive and stool antigen was negative. Ciprofloxacin and flagyl were continued, and he was also treated for H. Pylori with metronidazole prior to being discharged home. Etiology of patient's abdominal pain was determined to be a complicated H. Pylori infection and transmural perforation followed by auto seclusion via the mesentery.

DISCUSSION:

This case presents with unusual etiology for a diagnosis that is uncommonly discovered in adults. It highlights the importance of getting a thorough history with supportive diagnostic labs and imaging while maintaining a wide differential diagnosis during the initial workup.
3229 Helicobacter pylori-Negative Gastric Mucosa-Associated Lymphoid Tissue Lymphomas: A Challenge in Treatment Options
Authors: Nahar Ritu , Elden Andrew C. , Moleski Stephanie
Published: October 2019

INTRODUCTION:

Primary gastric lymphoma is a rare entity of which the specific variant, mucosa-associated lymphoid tissue (MALT) lymphomas may be the best recognized given its association with Helicobacter pylori (H. pylori) infection. It has been thought that repetitive immune stimulation from underlying infection is influential in the pathogenesis of this tumor. However up to 10% of gastric MALT lymphomas are diagnosed without a concomitant H. pylori infection. The pathogenesis and management of H. pylori-negative gastric MALT lymphomas remains uncertain.

CASE DESCRIPTION/METHODS:

65 year old woman with Celiac disease and GERD presented with worsening severe reflux and epigastric pain. She underwent EGD which revealed multiple superficial ulcers in the cardia with notable nodularity, ulceration, and friability. Cold forceps biopsies of the abnormal mucosa demonstrated diffuse atypical small B-Cell lymphoid infiltrate with features compatible with low grade MALT lymphoma. Of note, immunostain for H. Pylori was negative. Subsequent H. pylori stool antigen assay as well H. pylori IgG, IgM, and IgA were all negative. Given her negative antibodies indicating she truly had no exposure to H. Pylori, the patient has been referred to oncology for multidisciplinary management.

DISCUSSION:

This case of early stage gastric MALT lymphoma without evidence of active H. pylori infection elucidates that there is limited literature for the management for these patients. Studies have suggested that H. pylori eradication therapy can be efficacious for a proportion of H. pylori-negative gastric MALT lymphomas, possibly due to a false negative detection by biopsy. Local radiation therapy with curative intent and single agent rituximab therapy rather than H. pylori eradication have also been explored as alternate options. The data stems from retrospective studies and single agent prospective trials. Thus, there may be a role for future research directly comparing treatment strategies for optimal management of this clinical entity.
3230 Metastatic Signet Ring Cell Carcinoma to the Pelvis in a Young Female
Authors: Likhtshteyn Michelle , Iqbal Sadat , Arroyo-Mercado Fray Martin M. , DeRoche Ketisha , Rao Prameela
Published: October 2019

INTRODUCTION:

Gastric Cancer is the fifth most frequently diagnosed cancer in the world. While the incidence of gastric cancer has been decreasing, the incidence of signet-ring cell carcinoma (SRCC) continues to increase; with data from 2014 SEER analysis showing incidence of 0.4 per 100,000 cases [1-3]. The incidence of SRCC has increased ten-fold between 1970 and 2000 [3]. SRCC tends to occur in younger patients with a mean age ranging from 55 to 61 years [4]. Here we present a case of SRCC in a 23-year-old female with metastasis to the pelvis.

CASE DESCRIPTION/METHODS:

23-year-old female w/medical history of iron deficiency anemia presents with 6 months of abdominal pain, nausea, vomiting and 20-pound weight loss. CT scan showed a 4 cm mass of the right pelvic side wall contiguous with the uterus and ascites. Recent endoscopy showed a 4 cm ulcerated mass in the body of the stomach, pathology was positive for poorly differentiated adenocarcinoma with signet ring cell features invading the lamina propria positive for CK20, CK7, AE1/3, EMA. Patient underwent laparoscopy, pelvic washing and peritoneal biopsy, which was positive for malignant cells. The immunostains were positive for CK7, Ber-EP4, MOC31; consistent with gastric adenocarcinoma. Further imaging did not show any distant metastasis and she was referred to oncology after discharge for further treatment.

DISCUSSION:

SRCC carries a poor prognosis and therapeutic strategy remains unclear; overall prognosis depends on the stage of the cancer [3]. Some studies have shown that prognosis of early stage SRCC cancer might be equivalent to other gastric adenocarcinomas. On the other hand, prognosis of advanced SRCC is very poor with a 5-year survival rate as low as 9% [3]. SRCC differs significantly from non-SRCC oncogenic pathway, as it involves loss of cell-cell adhesion and collection of mucin in large vacuoles. It has been shown that e-cadherin deficiency might initiate carcinogenesis in SRCC at an earlier stage than other cancers [3]. Furthermore, as compared to non-SRCC cancers, gastric SRC patients has reduced sensitivity to chemotherapy [5]. Young patients with SRCC tend to present with more advanced disease; however, they have improved survival as compared to older patients [6]. This is consistent with our young female patient, who presented with metastatic disease. Further studies need to be done concerning treatment strategies and prognostic factors in young patients who present with advanced SRCC.
3231 Gastric Outlet Obstruction in a Patient After Hip Surgery
Authors: Kraus Fabian B.T. , Mehta Amit , Wan David
Published: October 2019

INTRODUCTION:

Until the 1970s, peptic ulcer disease was the most prevalent cause for gastric outlet obstructions (GOO) and accounted for 90 percent of all cases. However, with the introduction of proton pump inhibitors (PPI) and the treatment of H. pylori infections, the etiology of GOO changed rapidly. Today, only around two percent of all peptic ulcers lead to GOO. Here we report the case of a woman with nausea, abdominal pain and coffee ground emesis, found to have a GOO, whose symptoms completely subsided under PPI treatment of a 12 mm large peptic ulcer (Forrest III) in the duodenal bulb.

CASE DESCRIPTION/METHODS:

A 62-year-old female patient with a history of hypothyroidism, recent left hip fracture repair and subsequent pulmonary embolism, presented with nausea, hematemesis, melena, epigastric pain, decreased appetite and weight loss. She was treated with daily aspirin 325 mg and apixaban, and denied any drug abuse. PPI prophylaxis was not administered. Her physical examination was unremarkable. Initial blood tests included blood count, electrolytes and coagulation monitoring, and were unremarkable except for mild anemia (hemoglobin 9.9 g/dL). Contrast CTs of the abdomen and pelvis with PO/IV contrast showed marked gastric distension with luminal narrowing at the level of the duodenal bulb. Small and large bowel appeared normal in caliber and neither obstructions nor wall thickenings could be found. Accordingly, an esophagogastroduodenoscopy was performed showing a non-bleeding, cratered ulcer with a clean ulcer base (Forrest III) in the duodenal bulb. The lesion was 12 mm in largest dimension and surrounded by edema and erythema, resulting in a complete luminal obstruction. Upon gastric decompression with a nasogastric tube and PPI treatment, the patient recovered quickly and was discharged after four days.

DISCUSSION:

Due to an increase in PPI administration and H. pylori eradication in the last decades, peptic ulcers are nowadays treated early on, and gastric outlet obstruction has become a rare complication of peptic ulcer disease. In this case, we report on a 62-year-old patient who developed an obstructive peptic ulcer following extensive hip surgery and anticoagulation with aspirin and apixaban. We hereby want to highlight the importance of a timely PPI prophylaxis for peptic ulcer disease in severely ill patients with chronic NSAID intake. Conservative measures can moreover suffice to resolve the issue.
3232 Metastatic Adenocarcinoma of the Stomach With Elevated AFP but Normal CEA in a White American Patient
Authors: Ishtiaq Rizwan , Wilhelm Darlene M. , Ahmad Sumair
Published: October 2019

INTRODUCTION:

Globally, gastric cancers are the fourth most common cancer and second most common cause of cancer-related mortality. Alpha-fetoprotein (AFP) is a glycoprotein that is typically found during the process of fetal development. It has a very short half-life and is cleared from the body rapidly after birth. Increasing concentration of this glycoprotein in adult life is associated with malignancy of the liver, yolk sac tumor of testis, mediastinum and other conditions like hepatitis and cirrhosis of the liver. Alpha-fetoprotein (AFP) producing gastric adenocarcinoma is very rare. Its incidence is reported to be only 2.7 to 8% amongst all gastric cancers. Most of the cases of gastric adenocarcinoma producing AFP reported in the literature are from Asia. It is a very aggressive tumor with an estimated survival time of less than one year because of its rapid spread to lymph nodes and liver.

CASE DESCRIPTION/METHODS:

In this case report, we present a unique case of AFP producing gastric adenocarcinoma in a white American patient. AFP producing gastric adenocarcinoma have elevated levels of both AFP and carcinoembryonic antigen (CEA). Our case had closer to normal levels of CEA despite very high levels of AFP. The levels of AFP in our patient did not correlate with the size, stage or prognosis of the tumor. Despite the presence of liver metastasis, our case had a very good prognosis so far and had received up to six cycles of chemotherapy without any complications.

DISCUSSION:

In this case report, we have discussed the histological subtypes of AFP producing gastric adenocarcinomas. We have emphasized the use of immunohistochemical markers in the differentiation of primary hepatocellular carcinoma from AFP producing gastric adenocarcinoma. We have also discussed up to date treatment options, prerequisites for treatment, monitoring of treatment response and prognosis of AFP producing gastric adenocarcinomas in detail in this case report.
3236 This Can't Be GOO-D: Gastric Outlet Obstruction Cause by Bulky Lymphadenopathy
Authors: Likhtshteyn Michelle , Lewis Akeem , Gupta Nikita , Arroyo-Mercado Fray Martin M. , Iqbal Sadat , Al-Ani Firas , Cheung Derrick
Published: October 2019

INTRODUCTION:

Mechanical impediment to gastric emptying is the underlying pathology for GOO; the most common cause of GOO is due to pancreatic adenocarcinoma extension to the stomach. Here we present a patient with GOO due to underlying bulky lymphadenopathy (LAD) without obvious malignancy.

CASE DESCRIPTION/METHODS:

A 60-year-old male with hx of ulcerative colitis for 25+ years, HTN, CKD, presenting with progressively worsening lower abdominal pain for two weeks with constipation, nausea, vomiting and weight loss (8 lbs in 2 weeks). For his ulcerative colitis, patient has been taking sulfasalazine for 20+ years and 6-MP for 2.5 years; he has no family history of cancer. Physical exam was benign. Labs were normal except for a creatinine of 3.43. CT abdomen and pelvis with contrast showed extensive mesenteric, retroperitoneal and pelvic LAD and markedly distended stomach with likely gastric outlet obstruction at the level of the third portion of the duodenum due to the aforementioned LAD (Figures 1–3). LAD also caused obstructive uropathy eventually leading to hemodialysis. EGD showed extrinsic compression of the second portion of the duodenum from LAD. A nasal duodenal tube was first placed and then at a later time a PEJ tube. Biopsy of the lymph nodes with IR guidance showed poorly differentiated carcinoma of unknown primary. Plan was to start chemotherapy but hospital course was complicated due to sepsis, multiple DVTs, pulmonary embolism, NSTEMI and psoas/paraspinal abscesses. Patient eventually succumbed to his co-morbidities after 3+ month hospital stay.

DISCUSSION:

GOO can be due to metastatic or benign causes, but should always be considered malignant until ruled out otherwise.1 Patients usually present with nausea, vomiting, abdominal pain and weight loss. Also can have a succussion splash or in chronic cases of GOO could have a thickened stomach on physical exam.2 CT is the recommended imaging modality while EGD is often used to establish the diagnosis and cause. Initial management involves making patient NPO, IV fluids, daily PPI and decompression with a NG tube.2 Ultimately our patient may have benefited from chemotherapy if he was able to recover completely.