bluuebunny/crossref_metadata_2025 huggingface dataset:
1371 Iatrogenic Lingual Hematoma Resulted in Impending Airway Compromise
Authors: Alnabulsi Rawaa , Ahmad Dina , Wong Richard C. , Smith Zachary L.
Published: October 2019

INTRODUCTION:

Rapidly expanding lingual hematoma can result in life-threatening airway compromise. We describe a rare case of iatrogenic large tongue hematoma in a patient on Rivaroxaban after securing the endotracheal tube tightly with a thread for an ERCP.

CASE DESCRIPTION/METHODS:

An 82-year-old male with history of atrial fibrillation on rivaroxaban, and newly-diagnosed adenocarcinoma of the pancreatic head. He had recently undergone endoscopic placement of an uncovered self-expanding metal metal stent (SEMS), and after deployment, a very tight waist was noted. He presented to the emergency department 5 days after ERCP with vomiting and fever. Laboratory data were significant for AST 3075 IU/L, ALT 1311 IU/L, ALP 1432 IU/L, and total bilirubin of 10.4 mg/dL. CT abdomen and pelvis showed evidence of possible biliary stent occlusion versus incomplete expansion. An ERCP was performed during which a plastic stent was inserted through the SEMS. The day after the procedure, the patient developed tongue swelling and speech difficulty. IV diphenhydramine was administered with no improvement. An emergent flexible nasolaryngoscopy was performed demonstrating tongue edema with dark red/black discoloration extending to the floor of the mouth and swelling of the aryepiglottic folds (Figure 1a). He was treated with IV dexamethasone, famotidine, and diphenhydramine, and was transferred to the ICU for closer observation. The hematoma was thought to have resulted from tightly securing the endotracheal tube with a thread during the ERCP (Figure 2b). The patient was observed for 24 hours in the ICU after which he improved clinically and tongue swelling subsided without need for further intervention.

DISCUSSION:

This case illustrates a rare and a serious iatrogenic injury to the tongue as a result of securing the endotracheal tube too tightly with a thread. Lingual hematoma should be identified early to avoid impending airway compromise. Recognition of this potential complication by anesthesiologists and interventional endoscopists is necessary to prevent it.
1378 Diagnostic Dilemma: Evaluation of an Exophytic Paragastric Mass
Authors: Dalal Ishita , Andalib Iman , Cristelli Ryan , Barnard Nicola , Shahid Haroon , Patel Anish V.
Published: October 2019

INTRODUCTION:

Ectopic pancreas is rare congenital entity that is usually asymptomatic, appearing as an upper gastrointestinal (UGI) mass and difficult to diagnose. Our case describes a presentation of ectopic pancreas with atypical imaging and endoscopic findings.

CASE DESCRIPTION/METHODS:

A 28 year old male with asthma presented with hematemesis and epigastric pain. Laboratory studies included normal lipase level. Computerized Tomography (CT) of the abdomen revealed a hypervascular soft tissue mass between the pylorus and gallbladder, possibly arising from the pylorus (Figure 1). The mass was noted on prior imaging but had increased in size with a new surrounding complex fluid collection. Magnetic Resonance Angiogram (MRA) showed the mass to be contiguous with the gastric antrum and more suggestive of a vascular mass. Upper endoscopy showed esophagitis but no gastric or duodenal lesions. Hypervascularity and increase in size raised concern for malignancy. A subsequent endoscopic ultrasound (EUS) revealed abnormal tissue between the gallbladder and stomach (Figure 2). Fine need aspirate (FNA) demonstrated pancreatic acini consistent with pancreatic tissue (Figure 3). This established the diagnosis of ectopic pancreas. Patient was discharged with plans for surveillance imaging in three months.

DISCUSSION:

We present a case of an exophytic paragastric ectopic pancreas. Ectopic pancreas is a rare anatomical abnormality where pancreatic tissue originates outside its typical location with no anatomical or vascular connection to the pancreas. It has been reported most commonly as a submucosal lesion in the gastric antrum, duodenum or proximal jejunum. It is difficult to identify because patients are usually asymptomatic. For our patient, location near the gastric antrum was typical of ectopic pancreas. However, the exophytic appearance, lack of submucosal gastric lesion on endoscopy, paragastric location between the gallbladder and stomach, and lack of gastric invasion was atypical which made the diagnosis challenging. There are limited reports of ectopic pancreas, and it can be difficult to differentiate from malignancy. Our case highlights an atypical presentation of ectopic pancreas and the diagnostic challenges in its identification. A combination of imaging with contrast CT or MRI, and EUS with FNA will help differentiate from other lesions such as GIST. Though a rare entity, clinicians and gastroenterologists should consider ectopic pancreas in the differential diagnosis of extra-luminal UGI lesions.
1397 Intrahepatic Bile Duct Adenoma: A Diagnostic Dilemma
Authors: Park Ji Seok , Ayyagari Sravanthi , Tismenetsky Mikhail , Brower Steven , Jhawer Minaxi
Published: October 2019

INTRODUCTION:

Intrahepatic bile duct adenoma (BDA) is a rare tumor arising from the epithelial cells of the bile ducts. BDA has been usually found incidentally by intra-abdominal surgery and autopsy. BDA is clinically significant because of its benign prognosis but also its difficulty differentiating from malignant neoplasms of the liver by imaging studies.

CASE DESCRIPTION/METHODS:

A 52-year-old male presented with hematuria. A CT abdomen and pelvis showed an incidental, 1.5 cm lesion in the right hepatic lobe. Following fine needle aspiration biopsy of the lesion, the tissue demonstrated a slightly irregular hepatic duct proliferation, for which a differential diagnosis of bile duct adenoma and well-differentiated cholangiocarcinoma was considered. Alpha-fetoprotein, carbohydrate antigen 19-9, and carcinoembryonic antigen were normal. An MRI was obtained to better ascertain the lesion, which demonstrated a 1.1 × 1.1 cm lesion within the right hepatic lobe, segment 6. The decision was made to pursue a hepatic resection. On gross examination, the specimen revealed an ovoid, well-circumscribed, white-tan, firm lesion measuring 1.4 cm in greatest dimension, and located 0.5 cm from the hepatic capsule. Microscopically, there was a well-circumscribed lesion composed of small biliary-type glands in tubular and branching trabecular patterns with a mild nuclear enlargement and inconspicuous mitotic activity. The lesion was well-delineated and the interphase with hepatocytes was regular without infiltrative growth (Figure 2). Immunohistochemically, CD56 stain was focally positive in the tumor.

DISCUSSION:

The main characteristics of BDA are as follows: the lesion is small-sized, with a diameter ranges between 1 to 20 mm; the lesion is always detected under the hepatic capsule, with clear borders but without capsule; the majority of the proliferated bile ducts are observed in the lesion, accompanied by plenty of chronic inflammatory cell infiltration; immunohistochemical stain for CK7, CK19, and CD56 are positive, whereas Ki67 and p53 are negative. Gütgemann et al. suggested that CD56 expression can aid the differential diagnosis of cholangiocarcinoma and a benign lesion such as BDA. Since our case showed positive CD56 stain along with other aforementioned features, the appropriate diagnosis was BDA. Since there are no definite imaging characteristics or tumor markers that allow a preoperative diagnosis, surgical resection followed by microscopic and immunohistochemical findings is crucial for the diagnosis of BDA.
1400 Thrombotic Thrombocytopenic Purpura as an Unusual Complication of Alcoholic Pancreatitis
Authors: Ridout Nicholas , Rai Puja
Published: October 2019

INTRODUCTION:

Thrombotic thrombocytopenic purpura (TTP) is a non-immune-mediated thrombocytopenic disorder with a high mortality rate if mistreated and usually presents with microangiopathic hemolytic anemia and end-organ damage, commonly as kidney injury. There are only a handful of cases featuring TTP induced by acute pancreatitis in literature, some of them succeeding alcoholic pancreatitis. None of these patients had any initial clinical or laboratory signs of TTP on admission and the median time to developing TTP after admission was 3 days.

CASE DESCRIPTION/METHODS:

A 22-year-old male without significant medical history presented with epigastric abdominal pain two days after significant alcohol consumption. Serum lipase was elevated to 15,000 IU/liter. Given a strong family history of pancreatitis, computed tomography (CT) revealing borderline prominent pancreas, and recent alcohol binge, a diagnosis of alcoholic pancreatitis was made. Within the first 36 hours, he developed increased indirect bilirubin, marked thrombocytopenia to 34 K/uL, and an increase in creatinine from 1.29 on admission to 2.30. Peripheral blood smear was remarkable for many schistocytes (Figure 1). Normal coagulation studies excluded a diagnosis of disseminated intravascular coagulation. The presumed diagnosis of TTP was made, and the patient was treated with 9 cycles of plasma exchange, while his pancreatitis resolved with bowel rest and intravenous fluids. ADAMTS13 activity eventually returned at 61% (normal value >67%).

DISCUSSION:

Pancreatitis preceding a TTP picture has been scarcely described in the literature, but few reports have shown TTP to present itself at a median of 3 days after initial admission for pancreatitis. Our patient is unique in the sense that he presented with laboratory signs within the first 36 hours and was found to have schistocytes present on his blood smear within two days of his presentation, representing a rapid time-course compared to prior documented cases. Similar to prior reports, our patient was diagnosed based on his clinical presentation as his ADAMTS13 activity was only moderately reduced. Although exceptionally rare, it is crucial to consider imminent TTP in patients presenting with acute pancreatitis who are found to have acute hemolysis and significant kidney injury. If clinical suspicion is high, patients should receive prompt treatment with plasma exchange to ensure adequate platelet and end organ recovery.
1419 Extramedullary Plasmacytoma of the Pancreas
Authors: Fazeli Cameron , Hopp Grace , Rosenkranz Laura , Malik Mishel S.
Published: October 2019

INTRODUCTION:

Multiple Myeloma (MM) is a hematologic malignancy that most commonly presents with anemia and lytic bone lesions. MM is considered more aggressive if extramedullary involvement in either bone or solid organs is present. Review of literature reveals there are only a few documented extramedullary plasmacytomas that have occurred in the pancreas. We present a case of MM relapse manifested by a pancreatic plasmacytoma without recurrent bone marrow involvement.

CASE DESCRIPTION/METHODS:

A 66-year-old male was diagnosed with stage 1 MM in 2014 after a bone marrow biopsy demonstrated clonal plasma cells. He underwent radiation, chemotherapy and received an autologous stem cell transplant with high dose melphalan. His M spike has remained undetectable, and he has had stable lytic lesions seen on surveillance imaging. He was considered to be in remission. He presented for a surveillance PET/CT scan which demonstrated a hypermetabolic lesion in the head of the pancreas. A follow up MRI pancreas confirmed the presence of a well circumscribed 2.7 cm structure in the proximal pancreatic body. The differential diagnosis was fairly broad, based on imaging. He underwent an endoscopic ultrasound with fine needle aspiration. Flow cytometry demonstrated monoclonal plasma cells consistent with plasmacytoma, confirming relapse of his MM. The patient is now undergoing systemic chemotherapy and local radiation.

DISCUSSION:

MM presents with diffuse myelomatosis and can have associated solitary myeloma of the bone or involve other organs as extramedullary plasmacytomas. Extramedullary plasmacytomas are extremely rare, occurring in 5% of cases of MM and indicate a more aggressive form of disease. Of these 5%, most extramedullary plasmacytomas involve the submucosal lymphoid tissue of the upper respiratory tract, spleen, lymph nodes and liver. There have been only 50 cases of pancreatic plasmacytomas documented in the literature, making this a rare occurrence. Most of these cases had active bone marrow disease. Of these 50, only 5 documented cases of MM relapse manifested as a solitary pancreatic plasmacytoma. Similarly, our patient had no active bone marrow involvement at the time of diagnosis. Additionally, pancreatic plasmacytomas comprise less than 0.1% of all pancreatic masses. This case demonstrates that, although rare, an extramedullary plasmacytoma should be high on the differential if a pancreatic mass is visualized in the setting of previously treated MM.
1429 Choledocholithiasis in Primary Hepatic Lymphoma (PHL): An Additional Hurdle to PHL Diagnosis?
Authors: Kumar Kishore , Essrani Rajesh Kumar , Sun Haozhe , Chime Chukwunonso U. , Tariq Hassan , Patel Harish , Nayudu Suresh
Published: October 2019

INTRODUCTION:

Primary hepatic lymphoma (PHL) is a rare disorder involving solely liver at the time of initial presentation. Diffuse large B-cell lymphoma (DLBCL) variant in PHL is scarce. Patients with Immune suppression and HIV infection are at increased risk for the PHL-DLBCL variant. We present an individual, whose initial clinical presentation is masked my choledocholithiasis, subsequently diagnosed with PHL-DLBCL by histopathology.

CASE DESCRIPTION/METHODS:

A 59-year-old-man with prostate cancer (Gleason score of 7) managed conservatively for the last two years presented to the ED with intermittent epigastric pain of one-week duration associated with subjective fever and night sweats. On examination, he was afebrile and hemodynamically stable. The liver was palpable below the right costal margin and found to have inguinal lymphadenopathy. The laboratory data revealed obstructive jaundice with a cholestatic pattern (Table 1). Abdominal U/S and MRCP revealed cholelithiasis with normal biliary anatomy. Viral hepatitis, autoimmune and metabolic markers of liver disease were normal. Given the worsening of the obstructive pattern of liver tests, the patient underwent ERCP which showed two small stones in the distal CBD. Cholestasis improved, and the patient was discharged home in stable condition. Three weeks later he was readmitted with significant weight loss, malaise and night sweats. The laboratory investigation showed worsening of cholestasis with no imaging evidence of biliary stent obstruction. Hence, liver biopsy was performed to evaluate infiltrative liver disease. His hospital course was complicated by multiple organ failure requiring mechanical ventilator support and renal replacement therapy. Despite all resuscitative efforts, patient's general condition deteriorated and expired. His liver biopsy was reported with findings suggestive of DLBCL. Extrahepatic involvement was ruled out by negative lymph node biopsy.

DISCUSSION:

PHL is very rare primary hepatic malignancy and, DLBCL variant is extremely rare. As laboratory and imaging findings in PHL are non-specific, it is difficult to distinguish from infiltrative, granulomatous and other malignant liver diseases. Liver biopsy is essential for diagnosis and identifying the immunophenotype. It is vital to consider this condition as outcomes in PHL vary from other liver diseases. Our patient is a unique example where coexistent choledocholithiasis posed a diagnostic challenge like prior reported cases in literature.
1441 Beyond Pseudocysts: When Acute Pancreatitis Involves the Colon
Authors: Hashmi Irma , Shor Julia , Mahmoud Mohamed , Singh Anupam
Published: October 2019

INTRODUCTION:

While common complications of acute pancreatitis can include pseudocysts, necrosis and infection, colonic involvement, leading to stenosis and necrosis, is a rare sequela of severe acute pancreatitis. We present the case of an unfortunate gentleman with severe pancreatitis complicated by sigmoid stricture and large bowel obstruction requiring hemicolectomy.

CASE DESCRIPTION/METHODS:

The patient is a 46-year-old man with history of necrotizing pancreatitis secondary to familial hypertriglyceridemia, complicated by pseudocyst formation, requiring cyst gastrostomy and stent placement, who presented with subacute nausea, vomiting and diffuse abdominal pain. Laboratory findings, including complete metabolic panel, complete blood cell count and lipase were unremarkable. Computed tomography, however, revealed interval development of large bowel obstruction, with transition point within the proximal descending colon. The patient was managed conservatively initially but required colonic decompression with colonic stent placement of the descending colon. Colonoscopy did not reveal any mucosal lesion and biopsy confirmed the absence of malignant cells. Due to persistent large bowel obstruction, the patient underwent an exploratory laparotomy and removal of fibrosis bowel with left hemicolectomy. His course was complicated by post-operative hypotension and an increase in peripancreatic fluid collection requiring endoscopic retrograde cholangiopancreatography with sphincterotomy and pancreatic duct stent placement. A drain was subsequently placed for infected intrabdominal fluid collection and the patient was discharged on a 10-day course of antibiotics.

DISCUSSION:

Cited only a few times in the literature, colonic involvement as a complication of acute pancreatitis is a rare and interesting finding. Inflammatory pancreatic enzymes precipitate necrosis, leading to fibrosis with stricture formation, perforation or peritonitis. The colon is affected due to its anatomic proximity with the pancreas. The splenic flexure, which abuts the pancreatic tail, is most commonly involved. While aggressive debridement of necrotic pancreatic tissue and drainage of retroperitoneal collections can help prevent colonic pathology, once involved, large bowel necrosis carries a mortality rate as high as 50% and 95%. Management is with early colon resection. Interestingly, compression by a pancreatic pseudocyst can cause colon involvement and may have been the etiology for our patient's sigmoid stricture.
1449 The “Runaway” Gallstone: Cholecystoduodenal Fistula Presenting as Gallstone Ileus
Authors: Ramrakhiani Hannah , Simpson Nicole , Strichartz Seth , Shetler Katerina , Triadafilopoulos George
Published: October 2019

INTRODUCTION:

Gallstone ileus is a rare condition caused by impaction of a gallstone in the ileum after its passage through a biliary-enteric fistula. Diagnosis can often be delayed since symptoms may be intermittent. We present a case of gallstone ileus diagnosed with endoscopic ultrasound and computed tomography.

CASE DESCRIPTION/METHODS:

A 91-year-old female presented to the Emergency Department with symptoms of left flank pain, nausea, and vomiting. Laboratory studies including liver panel and complete blood count were unremarkable. Initial CT scan of the abdomen showed pericholecystic edema and possible gallstones with pneumobilia. Upper endoscopy revealed an ulcerated area with a fistulous opening containing pigment stone in the first portion of the duodenum. Endoscopic ultrasound findings included thickened gallbladder wall with a fistulous opening in the duodenum consistent with cholecystoduodenal fistula. Over the course of the next couple of days, the patient's symptoms of nausea and vomiting worsened. A repeat CT scan demonstrated signs of small bowel obstruction, pneumobilia, and an impacted stone in the jejunum - findings consistent with Rigler's triad. Patient underwent a laparoscopic-assisted enterotomy with removal of the obstructing intraluminal gallstone. She did well and was discharged home five days later. We postulate that the patient's intermittent obstruction was a result of the stone “tumbling” through the bowel lumen.

DISCUSSION:

Cholecystoduodenal fistula can be associated with obstruction either in the duodenum (Bouveret's syndrome), or more distally (gallstone ileus). Gallstone ileus can present with vague, intermittent symptoms that evolve over several days. A high index of suspicion is necessary for timely diagnosis. Our case highlights the role of upper endoscopy and endoscopic ultrasound in making an early diagnosis that may allow for expeditious treatment. If initial imaging is not diagnostic, repeat imaging may be helpful in confirming gallstone ileus.
1453 Cholecystocolic Fistula: An Unusual Cause of Abdominal Pain
Authors: Hamed Amira , Lambert Karissa , Hamed Ahmed Said , Ali Eslam
Published: October 2019

INTRODUCTION:

Biliary-enteric fistula is a rare but a pertinent complication of gallbladder disease. It is usually a complication of acute cholecystitis. It occurs in 0.06%-0.14% of patients with biliary disease. Cholecystoduodenal (70%) is the most common site of communication of the fistula, followed by cholecystocolic (10-20%), and then cholecystogastric fistula (10-20%). Failure to identify these fistulas during cholecystectomy can have catastrophic complications as it may result in division of the fistula, perforation of the colon that can result in fecal peritonitis which ultimately can lead to sepsis and death. We are reporting a 57-year-old female presenting with diffuse sharp abdominal pain, nausea, vomiting who was found to have a cholecystocolic fistula and a 1.7 cm gallstone in the proximal sigmoid colon.

CASE DESCRIPTION/METHODS:

A 57-year-old Caucasian Female with a history of diverticulosis presented with diffuse sharp worsening abdominal pain, nausea, vomiting and diarrhea. Her physical exam was normal except for diffuse abdominal tenderness. Her Laboratory findings were unremarkable including her liver function tests. An abdominal CT scan showed a non obstructing 1.7 cm gallstone in the proximal sigmoid colon and a fistula between the hepatic flexure and the gallbladder (Figures 1 and 2). It also showed evidence of colitis in in the distal left colon and proximal sigmoid colon. Patient was scheduled for a cholecystectomy with fistula repair.

DISCUSSION:

Cholecystocolic fistula is a rare but a pertinent complication of gallbladder disease. Although a diagnosis of cholecystocolic fistula is rarely suspected clinically, Clinicians should be aware of it given that it can have catastrophic complications.
1454 Recurrent Isolated Colon Ischemia Secondary to Kayexlate. Kayexelate Helps History to Repeat Itself
Authors: Florian Rosemarie , Jackson Christian
Published: October 2019

INTRODUCTION:

Kayexalate, sodium polystyrene sulfonate, is often used for treatment of hyperkalemia. This resin based medication has been associated with colon ischemia.

CASE DESCRIPTION/METHODS:

69 y/o male with extensive past medical history of end stage renal disease (ESRD) on hemodialysis (HD), atrial fibrillation not on anticoagulation, stroke with right hemiparesis s/p trach and PEG dependent, and left colostomy for diversion. He was transferred from the HD clinic to the ED for acute anemia, hypotension and hematochezia from ostomy. He was admitted for hemorrhagic shock, received intravenous fluid resuscitation, blood transfusions and was started on inotropic support. Infectious workup was negative. Computed tomography angiography was negative for acute bleed. EGD was unremarkable. Colonoscopy revealed extensive circumferential ulceration and pseudomembrane in the cecum and proximal ascending colon. Biopsies were consistent with colon ischemia. He improved clinically with supportive care and discharged. Three months later he was admitted for parotitis and hyperkalemia. He was started on Kayexalate and then developed hematochezia from ostomy with hemodynamic stability a few days later. He underwent repeat colonoscopy revealing persistent ulcerations with erythematous friability in the same area previously seen in prior colonoscopy. Biopsies this time revealed acute reactive epithelial atypia with embedded polystyrene sulfonate crystals.

DISCUSSION:

It is well known patients with renal failure on dialysis have a higher risk of developing colon ischemia. Kayexalate has been seen to cause colitis, which can progress to necrosis in 1% and perforation. This is hypothesized to be due to the release of prostaglandins and mesenteric vasoconstriction, thus causing mucosal damage. This may explain why this patient with recent history of right colon ischemia had Kayexalate induced injury in the same area. Symptoms of this damage can be seen within days to weeks after administration of medication, as in this case. In conclusion, patients with ESRD presenting with hematochezia, careful review of medications should be done as Kayexalate may induce colon ischemia. ESRD patients with previous colon ischemia, urgent HD rather than Kayexalate may be preferred, as the latter may recur as colon ischemia in the setting of previously injured tissue.
1465 A Rare Cause of Infective Ileocolitis: Brucella Abortus
Authors: Abu-Rajab Tamimi Tarek I. , Allan Wasim , Almustafa Sahar
Published: October 2019

INTRODUCTION:

Brucellosis is the world's most widespread zoonotic disease. It is a systemic infection that can involve many organs. The gastrointestinal manifestations of human brucellosis are relatively uncommon and nonspecific such as diarrhea and abdominal pain. Reports of documented specific gastrointestinal lesions caused by Brucella species are rare.

CASE DESCRIPTION/METHODS:

A 31-year-old male presented with complaints of intermittent fever, chills, and night sweats of 11-month duration. His symptoms were associated with lower abdominal pain and intermittent bleeding per rectum. On physical examination, the patient had mild tenderness to palpation at the lower abdomen. Laboratory tests revealed normal liver enzymes and normal complete blood count. Stool testing for ova or parasites, Clostridium difficile toxins, and stool cultures for pathogenic microorganisms were all negative. Serology testing for Brucella agglutinin titer was positive for Brucella abortus at 1:160; blood culture for Brucella were negative. A pan CT scan revealed hepatomegaly and few sclerotic bony lesions involving thoracic vertebrae. A colonoscopy was performed which showed multiple aphthous ulcers at the terminal ileum (TI) with normal intervening mucosa. There were multiple aphthous ulcers in the cecum, ascending colon and transverse colon. The descending colon, sigmoid colon and rectum appeared normal. Microscopic examination of biopsies from the TI showed focal active ileitis with focal ulceration including infiltration of the lamina propria by mixed acute and chronic inflammatory cells including many eosinophils. Biopsies from the right colon showed focal active colitis with focal ulceration including focal cryptitis and preserved crypt architecture. The patient was diagnosed with brucellosis with ileocolonic involvement, and treated with trimethoprim/sulfamethoxazole and rifampicin given orally for 6 weeks. Four weeks after starting treatment, the patient reported resolution of his fever, abdominal pain and bleeding per rectum. The patient is scheduled to undergo a repeat colonoscopy to evaluate for resolution of ileocolitis endoscopically.

DISCUSSION:

We report an extremely rare cause of infective ileocolitis due to brucellosis. This appears to be only the fifth well-documented case of brucella colitis; and the first case describing ileocolitis due to brucellosis. Although rare, ileocolitis should be considered in the work-up of patients with brucellosis who have abdominal pain, diarrhea or bleeding per rectum.
1479 Luminal Colonic Metastases From Primary Urothelial Carcinoma
Authors: Gladys-Oryhon Jordan , Sial Moaz , Umar Shifa , Goswami Raktima
Published: October 2019

INTRODUCTION:

Urothelial carcinoma often manifests with painless gross or microscopic hematuria. Significant risk factors are mainly environmental including tobacco use, occupational exposures, and recurrent urinary tract infections. Metastatic disease often progresses via direct soft tissue invasion or lymphatic spread, with a paucity of reported cases of luminal colonic metastases. Here we describe a patient with concerning history for malignancy with multiple risk-factors, found to have luminal colonic metastases from primary urothelial carcinoma.

CASE DESCRIPTION/METHODS:

A 51 y/o African-American male with medical history significant for HFrEF 15%, HTN, tobacco and alcohol abuse presented for outpatient colonoscopy, referred by his primary care physician for 6-month history of diarrhea and 30 lb weight loss. No prior colonoscopy performed. Family history was significant only for lung cancer in his paternal uncle. Colonoscopy was initially attempted with adult colonoscope, but was exchanged for an adult endoscope following inability to traverse >20 cm, secondary to thickened rectal folds also appreciated on rectal exam (Figure 1). Findings were significant for one 4 mm sessile polyp of the transverse colon and segmental moderately congested, erythematous mucosa throughout the entire colon (Figures 1 and 2). Pathology revealed new urothelial cancer with diffuse luminal colonic metastases. He completed staging work-up, found to have diffuse blastic, osseous bony metastases and was initiated on chemotherapy with further progression of his disease.

DISCUSSION:

Urothelial cancer often spreads via direct soft tissue invasion or lymphatic spread. Interestingly, our patient presented with advanced disease with atypical luminal colonic metastases, in the absence of direct invasion or soft tissue mass. The pathogenesis of metastasis remains unclear, but is likely related to lymphatic spread. In a thorough review of the literature, no other case of luminal colonic metastases from urothelial primary has been described. Any new change in bowel habit, warrants further evaluation with colonoscopy to rule out carcinoma of colonic or metastatic origin.
1510 Positive Fecal Immunochemical Testing in Detection of Mantle Cell Lymphoma With Gastrointestinal Involvement
Authors: Khiew Yii Chun , Dhawan Ishita , Modi Mitul B. , Bhattacharyya Siddharth , Nunes Frederick A.
Published: October 2019

INTRODUCTION:

Current colorectal cancer (CRC) screening guidelines are directed at early detection of adenocarcinoma via stool testing or direct endoscopic or radiologic visualization. Compared to a colonoscopy, fecal immunochemical Testing (FIT), a non-invasive test that detects hemoglobin in stool by immunoassay, has similar CRC detection rates. We report a case of mantle cell lymphoma (MCL) involving the gastrointestinal tract (GIT) in a patient diagnosed through routine CRC screening.

CASE DESCRIPTION/METHODS:

A 70 year-old male with a history of diverticulitis was referred for urgent colonoscopy following a positive FIT. He reported a seven-month history of right upper quadrant abdominal pain, pruritus, and a 19 pound unintentional weight loss. He denied fever, night sweats, melena, hematochezia, and family history of malignancy. Physical exam did not reveal splenomegaly and lymphadenopathy. Notable labs included normocytic anemia and a normal LDH. Colonoscopy showed congested, nodular and thickened mucosal folds in the terminal ileum, ascending colon, and cecum. Random biopsies revealed diffuse atypical lymphoid infiltrates in a multiple lymphomatous polyposis pattern with cyclin D1, CD5 and CD20 immunohistochemical positivity consistent with MCL. PET-CT detected bone marrow and diffuse lymph node involvement. He tolerated six cycles of lymphoma-directed chemotherapy with complete metabolic response on imaging.

DISCUSSION:

Extranodal disease at primary presentation accounts for 25% of patients with MCL. Microscopic gastrointestinal involvement in MCL at presentation is widely underestimated and has been documented in up to 80% of cases at the time of diagnosis, suggesting that MCL has a propensity to home to the GIT. Clinically, most patients with MCL with GIT involvement are asymptomatic, but can also present with abdominal pain, altered bowel habits, and gastrointestinal bleeding. To date, annual FIT testing has been used solely as a screening test for CRC. The role of non-invasive stool testing such as FIT, and its detection of other primary malignancies involving the gastrointestinal tract besides CRC, has not been studied and requires further investigation.
1548 Double Intussusception Deception
Authors: Singh Kanwardeep , Gabriel Joseph G. , Bains Nimrat , Young Mark F.
Published: October 2019

INTRODUCTION:

We report a case of colo-colic intussusception caused by sigmoid adenocarcinoma with concomitant incidental entero-enteric intussusception in a middle aged female. Intussusception in adults is a known rarity, but it is important to note that more than 60% of large bowel intussusceptions are caused by a neoplasm.

CASE DESCRIPTION/METHODS:

A 50 year old female presented with intermittent abdominal pain for 2 months, worsening with oral intake and associated with abdominal distension and obstipation. Computed tomography of the abdomen & pelvis showed two areas of intussuscepted bowel in the left upper quadrant. One was thought to be an incidental loop of the jejunum. The other representing the splenic flexure and was causing obstruction within the small and large bowel proximal to this lesion. With the diagnosis of intussusception, exploratory laparotomy was performed. A mass was palpated at the splenic flexure, and this was found to originate at the sigmoid colon, leading to left hemicolectomy and transverse colostomy. The histological diagnosis of the mass was well-differentiated adenocarcinoma stage IIIb. The patient later underwent adjuvant chemotherapy with Capecitabine plus Oxaliplatin.

DISCUSSION:

Large bowel intussusception can be due to benign, malignant, or idiopathic etiologies. As the incidence of intussusception in adults is low, surgical exploration is imperative.
1551 The Vasculitic Mimic: Polyarteritis Nodosa Initially Presenting With Colonic Involvement
Authors: Lorio Eric , Vizuete John A.
Published: October 2019

INTRODUCTION:

Polyarteritis nodosa (PAN) is a necrotizing vasculitis of the medium and small vessels which presents with gastrointestinal symptoms in up to 24.1% of patients, most commonly in the small bowel. Here we present a case of isolated colonic involvement in a patient without prior systemic immune illness or HBV.

CASE DESCRIPTION/METHODS:

A 62 year old man with no significant past medical history was admitted with 10 days of worsening abdominal pain and constipation. At the time of admit, labs were notable for CRP 178, leukocytosis, and creatinine 1.13. He began to pass multiple bloody, mucoid bowel movements and hemoglobin fell to as low as 6.9 g/dL, requiring transfusion. CT noted segmental colitis in the distal and sigmoid colon with proctitis. Stool pathogen panel was negative and ensuing colonoscopy showed circumferential edematous, erythematous, slightly granular mucosa from splenic flexure to rectum with areas of friability. Rectosigmoid biopsy demonstrated focal architectural distortion with a mild increase in lymphoplasmocytic inflammation and basal plasmocytosis. The patient was administered IV methylprednisolone with a prednisone taper for the presumed diagnosis of indeterminate inflammatory bowel disease (IBD). He returned 3 days later with increasing pain, tenesmus, and new findings of fever and multiple mucoid, bloody bowel movements per day. Increased stool burden proximal to the same area of colitis was seen on MRE, and colorectal surgery was consulted. Full thickness rectal biopsy revealed mucosal erosion to the muscularis layer and reactive changes thought to be due to rectal prolapse. Despite conservative therapy, he presented again 2 weeks later endorsing continued periumbilical abdominal pain, now with hgb 8.2 and WBC 18. Repeat CT showed evidence of acute appendicitis and persistent colitis, prompting emergent appendectomy with descending colostomy. Surgical pathology revealed diffuse ischemic colitis due to polyarteritis nodosa with areas of ischemic necrosis and focal bowel wall rupture in the sigmoid colon. Acute periappendicitis was also found in the appendiceal tissue, but PAN was notably absent.

DISCUSSION:

Delayed diagnosis of vasculitic colitis can lead to life-threatening complications. Here we present a case showing how PAN can mimic both IBD and ischemic colitis. Response to high dose steroids, the common initial treatment for both IBD flares and PAN, further confounded the diagnosis. This case highlights the need for consideration of PAN in unclear cases of colitis.
1580 Endometrioid Adenocarcinoma Presenting With Hematochezia and an Extraluminal Rectal Mass
Authors: Fiore Benjamin D. , Mellor Thomas E. , Fick Daryl B. , Fawley Ryan K.
Published: October 2019

INTRODUCTION:

We present a case of primary endometrioid adenocarcinoma with invasion of the rectosigmoid colon, highlighting the importance of colonoscopy, biopsy, cross-sectional imaging, and a multidisciplinary approach to the management of extraluminal lesions.

CASE DESCRIPTION/METHODS:

A 47-year-old female with a history of lymphangioleiomyomatosis (LAM) was admitted for abdominal pain, hematochezia, tenesmus, and proctalgia following 7 months of abnormal bowel habits and 20 pounds of unintentional weight loss. Review of symptoms was negative for abnormal uterine bleeding. Examination revealed tenderness on palpation of the lower abdominal quadrants, and grossly bloody stool with digital rectal exam. Computed tomography (CT) of the abdomen and pelvis with contrast demonstrated circumferential rectal wall thickening with enhancement. Colonoscopy revealed an ulcerated extraluminal rectosigmoid mass, and biopsies were obtained. Magnetic resonance imaging (MRI) demonstrated a large heterogeneous mass involving the uterus and rectum with no discernable fascial plane. Initial pathology reported invasive adenocarcinoma without a primary origin delineated. A multidisciplinary conference prompted additional immunostaining of the sample, confirming endometrioid adenocarcinoma. The patient was diagnosed with International Federation of Gynecology and Obstetrics (FIGO) stage IVa endometrioid adenocarcinoma and underwent surgical management with adjuvant chemoradiation. Genetic testing demonstrated heterozygosity with a pathologic variant in the MutL homolog 1 (MLH1) gene consistent with Lynch Syndrome. Surveillance positron emission tomography scanning 6 months later revealed no evidence of disease recurrence.

DISCUSSION:

Extraluminal lesions are notoriously difficult to diagnose with endoscopy alone. In this case, cross-sectional imaging with CT and MRI was unable to differentiate the origin of the lesion, and pathologic examination without the clinical context of the extraluminal nature of the tissue obtained on colonoscopy delayed the definitive diagnosis. This case highlights the importance of a multidisciplinary approach to cases of suspected extracolonic malignancies with colonic invasion in order to expedite definitive diagnosis and treatment. There are no reports of concomitant Lynch Syndrome and LAM in the literature and the clinical significance is unclear. Further study may be helpful in elucidating potential links between these two uncommon conditions.
1593 Skeletal Muscle (SM) Metastasis: A Rare Initial Presentation of Metastatic Colon Cancer
Authors: Tai Cheng-Hung , Park Connie , Bhardwaj Richa , Jean Ryan Des , Harshan Manju , Ilyas Nazish , Swaminath Arun
Published: October 2019

INTRODUCTION:

Colon cancer is the third most common type of cancer globally and approximately 20% patients diagnosed with colon cancer will already have metastatic disease at the time of diagnosis. The liver is the most common site of metastasis, followed by lung, nervous system and bones. Only 15% of patients with stage IV colon cancer will have metastases to locations outside these sites. Here we report a rare presentation of metastatic colon cancer with skeletal muscle (SM) metastases.

CASE DESCRIPTION/METHODS:

81-year-old male with peripheral artery disease and diabetes mellitus presented with severe right shoulder pain and shortness of breath. Lab work revealed iron deficiency anemia with a hemoglobin of 5.8 g/dl. CT of the chest revealed an 8.2 cm mass in the right lower lung lobe. Positron-emission tomography-CT (PET-CT) revealed increased activity in the right lung, right supraspinatus, gluteus maximus, and right adductor magnus muscles (Figure 1). He then underwent biopsy of the right supraspinatus muscle, which revealed a poorly differentiated metastatic adenocarcinoma with immunohistochemistry (IHC) positive for CK7, and negative for CK 20, CDX-2, TTF-1, NKX3.1 and Napsin A. Colonoscopy revealed a 5 cm friable ulcerated mass in the cecum (Figure 2) with biopsy showing poorly differentiated adenocarcinoma with morphology similar to the muscle mass. Patient subsequently received palliative chemotherapy and underwent a palliative right hemicolectomy. IHC staining of the resected mass was similar to that of the biopsied right supraspinatus muscle (Figure 3). Patient ultimately transitioned to hospice.

DISCUSSION:

Muscle metastasis from solid tumors is very rare, accounting for less than 1% of overall metastases. This is in part due to the fact that muscles produce antitumor factors and its sarcolemma or cell membrane acts as a physical barrier against tumor cells. Muscle metastases are more common in primary lung, stomach, or genitourinary tumors and portend poor outcomes due to advanced disease stage. This case appears to be one of the few reported cases of metastatic colon cancer presenting with SM metastases and emphasizes the importance of considering metastatic colon cancer in the differential of SM lesions. It also highlights the importance of PET-CT and IHC in establishing diagnosis and hence guiding appropriate therapy.
1597 An Unexpected Cause of Colonic Ulcers in a Young Chinese Male Resulting in a Total Colectomy—Intestinal Behcet's Disease
Authors: Kuang Jonathan , Lin Huiyu
Published: October 2019

INTRODUCTION:

Behçet's disease (BD) is an uncommon immune-mediated inflammatory disorder. Gastrointestinal (GI) BD may affect any part of the GI tract but most commonly manifests in the ileocecal region. The diagnosis of GIBD is challenging and complications can be severe.

CASE DESCRIPTION/METHODS:

A 32-year-old Chinese male with HLA-B27 positive spondyloarthropathy was undergoing treatment with golimumab and methotrexate. He had a history of retinal vasculitis, erythema nodosum and was taking isoniazid for latent tuberculosis (TB). He was admitted for 1 day of right iliac fossa pain with occasional tongue ulcers but no fever or bloody stools. Abdominal computed tomography scan (CTAP) showed inflammatory changes in the ileocecal region. Colonoscopy with biopsies revealed an inflamed terminal ileum but no other colonic abnormalities; TB and cytomegalovirus biopsies were negative. He was discharged with antibiotics. He re-presented 4 weeks later with recurrent abdominal pain and 7-kg weight loss. CTAP showed worsening ileocecal thickening. The patient declined a colonoscopy only to be readmitted 5 days later for similar symptoms. Repeat colonoscopy showed large discrete round punched-out ulcers with overlying slough in the cecum, transverse, and left colon, with intervening normal mucosa. Biopsies showed extensive ulceration, acute inflammatory infiltrate with 1 non-caseating granuloma and intraluminal thrombi in submucosal arterioles/venules, raising the suspicion of gut vasculitis. Intravenous hydrocortisone and heparin were started. He developed worsening abdominal pain and a repeat CTAP showed pneumoperitoneum. Emergency surgery revealed multiple colonic perforations with feculent peritonitis necessitating total colectomy with end ileostomy. Histology revealed acute mucosal ulceration, areas of transmural necrosis, inflammation at perforation sites and luminal thrombi in the blood vessels around inflamed areas. A diagnosis of GIBD was made based on his constellation of symptoms. Treatment included prednisolone, cyclophosphamide, and he was later transitioned to azathioprine.

DISCUSSION:

In this immunosuppressed host with arthropathy presenting with abdominal pain, the key differentials of TB, Crohn's disease and GIBD are challenging to distinguish as there is significant clinical overlap. Endoscopic features may be helpful but are not pathognomonic of GIBD. This case highlights the diagnostic and management difficulties in GIBD and need for heightened awareness as outcomes in GIBD are potentially catastrophic.
1600 Follicular Lymphoma Presenting as a Colon Polyp
Authors: Gajjar Bhavesh A. , Aasen Tyler , Goenka Puneet
Published: October 2019

INTRODUCTION:

Follicular lymphoma (FL) is the second most common type of Non-Hodgkin's lymphoma (NHL).  There are two types of follicular lymphoma, nodal and extranodal. The gastrointestinal (GI) tract is the most common site of extranodal NHL and accounting for 30%-40% of all extranodal NHL. GI-FL comprises of only 1 to 4% of GI-NHL with less than 400 reported cases.  GI-FL primarily involves the duodenum, distal ileum, and stomach. A colon is an uncommon place for GI-FL with less than 20 cases reported in the literature. We present a case of GI-FL identified on colonoscopy as a pedunculated polyp.

CASE DESCRIPTION/METHODS:

A 72-year-old female was seen for a positive stool occult test. She denied blood in the stool, abdominal pain, any weight loss, fatigue, night sweats, fevers, and diarrhea. She had occasional constipation which resolved with a stool softener. Physical examination was unremarkable without any palpable lymph nodes or organomegaly. During the colonoscopy, a 1.5 cm benign appearing pedunculated polyp in the mid-transverse colon was found (Figure 1).  Primary histology of the polyp revealed lymphoid aggregates compatible with a lymphoid polyp. Diagnosis of GI-FL was later confirmed by immunohistopathological staining. Positron emission tomography (PET) scan showed aortocaval lymphadenopathy. The diagnosis of follicular lymphoma grade 2 stage IV is made. The oncologist has scheduled a bone marrow biopsy with consideration to immunochemotherapy.

DISCUSSION:

Colonic GI-FL is quite a rare disease with increasing incidence. Most patients are asymptomatic and diagnosed during endoscopy. The most common endoscopic appearance is 1 to 2 mm whitish polypoid nodules scattered or confluent together forming large nodules. Other appearances of GI-FL may include mass lesions with or without ulcer, lymphomatous polyposis, or polyps. These endoscopic features are also seen in lymphoid hyperplasia, MALT, mantle cell lymphoma. Immunohistopathological testing is the only way to confirm the diagnosis. GI-FL stains positive for CD10, CD19, CD20, and CD22, and bcl-2. It stains negative for cyclin D1 and CD5. PET scan is used for initial staging and surveillance of disease. GI-FL is an indolent lymphoma with favorable survival outcomes. A “watch and wait” approach is typically adopted. GI-FL presenting as a pedunculated polyp is an extremely rare presentation. Clinicians should be cognizant of endoscopy and immunohistopathological features of GI-FL.