bluuebunny/crossref_metadata_2025 huggingface dataset:
2001 Mastocytosis Complicated by Upper and Lower GI Bleeding
Authors: Khamis Alia , Richards David , Chen Ellie
Published: October 2019

INTRODUCTION:

Mastocytosis is a rare disease caused by the abnormal proliferation and accumulation of mast cells in 1 or more organs of the body and is divided into cutaneous and systemic disease. Patients have increased susceptibility to urticaria, pruritis and anaphylactic shock. GI manifestations are thought to be related to direct mast cell infiltration and release of mast cell mediators.

CASE DESCRIPTION/METHODS:

A 39-year-old woman with a history of cutaneous mastocytosis intolerant to cromolyn sodium, Roux-en-Y gastric bypass, gastritis, celiac disease and hemorrhoids presented with melena and hematemesis following a mastocytosis flare and concurrent pneumonia. She had no prior history of GI bleeding, PUD, H. Pylori infection, NSAID or anticoagulation use, liver disease, or family history of GI malignancies. Prior EGDs and colonoscopies were unremarkable. She was on a chronic high-dose of famotidine and prednisolone taken as needed. Physical exam showed mild epigastric and left upper quadrant tenderness, bilateral rhonchi, and hemodynamic stability. Initial laboratory findings were insignificant. She was given IV pantoprazole BID and continued to have melena while remaining stable; with Hb down-trending to 11.6 gm/dL. EGD revealed a large gastric pouch with Roux-en-Y anatomy and 2 non-bleeding cratered ulcers near the congested, erythematous gastrojejunal anastomosis. The larger ulcer (9 mm) had a visible vessel and was clipped. Pathology revealed reactive gastropathy, mild chronic inflammation without H. pylori. Jejunal biopsies showed congestive mucosa and mild acute on chronic inflammation. The patient resumed IV continuous infusion of pantoprazole for 48 hours then transitioned to oral PPI with her usual famotidine.

DISCUSSION:

Up to 80% of patients with systemic mastocytosis can present with a variety of GI symptoms, with the most common being diarrhea and abdominal pain. Though the etiology of diarrhea is not well understood, abdominal pain is largely attributed to dyspepsia and gastroduodenal ulcers resulting from acid hypersecretion. Symptomatic treatment for GI symptoms largely depends on anti-mediator therapy where H1 and H2 receptors are typically combined. PPIs are added to treat gastric involvement. Cromolyn sodium is a highly effective treatment for GI manifestations (100-200 mg PO up to 4 times/day). Oral corticosteroids may relieve malabsorption and ascites in the rare cases of liver involvement. Lifestyle modifications include avoidance of triggers and stress management if possible.
2002 Oh My Lipoma: An Unexpected Cause of a Gastrointestinal Hemorrhage
Authors: Rao Shanti , Basilio Carlo , Baddour Nabil , Nakanishi Yukihiro , Gaspard Gregory
Published: October 2019

INTRODUCTION:

Gastrointestinal (GI) lipomas are benign tumors made of adipose tissue that are usually asymptomatic and slow-growing. Lipomas of the GI tract are uncommon, and even less common to find in the gastric region. Around 220 cases of gastric lipomas are reported in the literature. Of these cases, very few have shown a gastric lipoma that leads to symptomatic anemia and hemorrhage.

CASE DESCRIPTION/METHODS:

A 48-year-old man with a history of hypertension presented to the emergency room with shortness of breath and was found to have a hemoglobin of 6.0 g/dl, with a baseline of 15 g/dl. Gastroenterology was consulted, and the patient had an esophagogastroduodenoscopy (EGD) performed. The EGD showed a large, 4 cm, polypoid, submucosal, ulcerated mass with active oozing of blood on the lesser curvature of the gastric body. Biopsies were taken, and computed tomography (CT) imaging was performed as there was concern this was a malignant mass. Pathology showed the mass to be a gastric lipoma, and the patient was taken for a partial gastrectomy to remove the lipoma due to risk for bleeding. The surgery was performed without complications.

DISCUSSION:

Interestingly, gastric lipomas account for less than 1% of tumors in the stomach. This case displays a rare finding of a large gastric lipoma that led to symptomatic anemia and gastrointestinal hemorrhage. Most gastric lipomas are asymptomatic, but can ulcerate depending on the size and location. Ulceration can occur as a result of pressure necrosis of overlying mucosa, causing large volume bleeding. Lipomas can be diagnosed with endoscopic ultrasound, EGD, and CT scan. Treatment modalities include aspiration lumpectomy, strip biopsy, endoscopic unroofing technique, or surgical removal with partial gastrectomy. Rarely are gastric lipomas removed surgically, but in the case of large volume blood loss or active bleeding, they are removed surgically rather than endoscopically. Of note, it is important to rule out any evidence of malignancy or metastatic disease with imaging prior to surgical removal of a lipoma. If malignancy is ruled out, oftentimes endoscopic removal of the lipoma can be performed rather than undergoing a large surgical resection.
2008 Fundic Gland Polyps: Not Always an Innocent Bystander
Authors: Mosier Evan , Imbertson Erick
Published: October 2019

INTRODUCTION:

Fundic gland polyps (FGP) are often found incidentally on endoscopy in 1.9% of patients, with most being asymptomatic. However, as in this case, FGP have been a source of upper gastrointestinal bleeding (UGB) leading to hospitalization.

CASE DESCRIPTION/METHODS:

An 81-year-old male with GERD and non-dysplastic Barrett’s Esophagus, presented to the emergency department with coffee ground emesis for 2 weeks. He denied NSAID, steroid, or alcohol use. GERD is well controlled on Omeprazole 40 mg daily which he has taken for the past 10 years. He denies dysphagia, abdominal pain or weight loss. No family history of gastric or colon cancer or familial polyposis syndromes. Patient with normal heart rate and blood pressure however with orthostatic hypotension. Physical exam without abdominal tenderness and rectal vault without stool on exam. Hemoglobin 11.1 on presentation with last hemoglobin 13.3 four months ago. Last EGD 2 years ago revealed non-dysplastic Barrett’s Esophagus, along with a few sub centimeter non-bleeding FGP, confirmed with biopsy. A colonoscopy 4 years prior had one tubular adenoma. Patient underwent EGD and was found to have multiple gastric body polyps; several of the largest polyps had active oozing blood. The bleeding polyps measured 12 mm in size and were removed via hot snare polypectomy. Normal remainder of exam. Afterward he remained clinically stable with no further bleeding and was discharged with Omeprazole daily. Histology revealed FGP with low grade dysplasia. H.pylori was negative on biopsies. Repeat EGD 8 weeks later removed the remaining polyps and gastric mapping was performed. Histology revealed FGP without dysplasia and no gastric intestinal metaplasia was noted. Patient has done well since with no further bleeding.

DISCUSSION:

Bleeding gastric FGP are rarely considered in the differential of UGB, however in this case, led to the patient’s hospitalization. Long-term (>5 years) proton-pump inhibitors (PPI) have been associated with fourfold increased risk of FGP, with regression often seen upon withdrawal of PPI. This patient brings a unique case in which guidelines recommend long-term daily PPI for his Barrett’s Esophagus, however has already had complications from his growing FGP on Omeprazole. FGP can also be associated with polyposis syndromes. Malignancy is rare in sporadic and PPI induced FDG but can be seen in up to 4.2% of patients with familial adenomatous polyposis. The removal of FGP can potentially limit the risk of future bleeding as seen in this case.
2009 Bleeding Intestinal Lymphangiectasia Diagnosed and Treated by Using Double Balloon Enteroscopy in a 41-Year-Old Female: Case Report and Review of Literature
Authors: Gopalakrishnan Ravikumar Naveen Prasad , Shahab Danish , Bain Andrew
Published: October 2019

INTRODUCTION:

Intestinal lymphangiectasia (IL) is a rare disease characterized by dilated lymphatic vessels in the intestinal wall and small bowel mesentery, which induce loss of protein and lymphocytes into the bowel lumen. Gastrointestinal bleeding (GIB) rarely has been described as the only symptom of IL. We describe a case of obscure GIB in a young female caused by lymphangiectasia localized to the distal jejunum by antegrade double balloon enteroscopy.

CASE DESCRIPTION/METHODS:

A 41-year-old African American female who initially presented to her PCP with chronic fatigue and intermittent episodes of melena. The patient was subsequently placed on iron supplementation and referred to gastroenterology for further work up. Physical examination finding were largely unremarkable. On laboratory tests, her hemoglobin declined to 5.8 g/dL (from a baseline of 10 g/dL). Initial Esophagogastroduodenoscopy (EGD) showed 2 cm hiatal hernia but was otherwise unremarkable. A subsequent colonoscopy showed mild internal hemorrhoids and a 3 mm solitary ulcer in the distal rectum but no other obvious sources of GI bleeding. Magnetic resonance enterography (MRE) was unremarkable. Next, a video capsule endoscopy was done which showed a site of active bleeding from the mid-small bowel and was associated with nodular mucosa and prominent lacteals. A subsequent double balloon enteroscopy (DBE) showed an oozing fold in the distal jejunum with white speckled appearance consistent with a bleeding lymphangiectasia. A total of seven clips were placed on the lesion and during application of clips, a white milky substance was noted coming from the lesion suggesting the diagnosis of lymphangiectasia.

DISCUSSION:

IL is most commonly found in the small bowel, making its diagnosis difficult by EGD or colonoscopy. DBE and video capsule endoscopy (VCE) are the two most important diagnostic modalities available to evaluate the entire small intestine.The noninvasive nature of VCE and its capability to visualize the entire small bowel has made it a first-line tool in many centers. However, DBE is preferred over video capsule endoscopy because of higher sensitivity from better endoscopic visualization and ability to perform biopsies for pathologic diagnosis. In this report, we present an extremely rare case of primary intestinal lymphangiectasia in causing obscure GIB and successful intervention using DBE. We believe this is the second case to report small bowel bleeding from jejunal lymphangiectasia, which was successfully treated using DBE.
2012 Metastatic Merkel Cell Carcinoma Presenting With Upper GI Bleeding and Obstructive Jaundice
Authors: Elkafrawy Ahmed A. , Numan Laith , Zafar Yousaf , Elkhouly Mohamed A. , Bahaj Waled , Liu Cynthia , Hamid Fadi
Published: October 2019

INTRODUCTION:

Merkel Cell Carcinoma (MCC) is a rare and aggressive skin cancer that was first described in 1972. Lymph node metastases are common in MCC and distant metastases occur in 8.4% of cases. We present a case of MCC complicated by melena and obstructive jaundice from GI metastases. To the best of our knowledge, less than 20 cases were reported with a similar presentation.

CASE DESCRIPTION/METHODS:

The patient is a 67-year-old male with a history of CAD, COPD and metastatic MCC who was admitted with melena and severe blood loss anemia. He was diagnosed with MCC of the right eyebrow 2 years ago and had a recurrence in the parotid gland that was treated with resection, radiotherapy (RT) and chemotherapy. PET CT scan 3 months prior to admission showed no evidence of distant metastases. After resuscitation and initiation of appropriate medical therapy, the patient underwent an EGD that showed multiple (1 cm) lesions scattered in the stomach and a large (4 cm) ulcerated mass in the lesser curvature with stigmata of recent hemorrhage. Hemospray was applied successfully for hemostasis. Biopsies of the gastric lesions confirmed metastatic MCC. The patient was discharged home and was started on palliative immunotherapy (Atezolizumab) and RT. Repeated PET CT scan showed the progression of the disease with widespread lymphatic, pancreatic, right perinephric, diffuse gastric and bony metastases. Four weeks later he was admitted with jaundice. Bilirubin was 2.5 gm/dl, ALP 458, ALT 457 and AST 441. Abdominal ultrasound showed dilated intra and extrahepatic ducts. An ERCP was performed and it showed a distal CBD stricture. An uncovered metal stent was successfully placed. The patient continued to have recurrent melena and a repeated EGD showed a new friable 4 cm ulcerated periampullary duodenal mass that was not amenable to endoscopic intervention. Mesenteric arteriogram was performed and active bleeding from the duodenal mass with tumor blush in the third part of duodenum was seen. Coil embolization of the GDA and PDA was successfully performed with the cessation of the bleeding. The patient was discharged home to resume palliative RT and immunotherapy.

DISCUSSION:

Merkel cell carcinoma is rare and aggressive skin cancer. GI metastases are very uncommon. Close surveillance with PET CT scan is important and high suspicion of GI metastases should be exercised when clinically appropriate.
2018 Occam’s Diverticula: Multiple Causes of Significant Lower GI Bleeding in a Young Man
Authors: Powell Charleston , Lindholm Phillip C.
Published: October 2019

INTRODUCTION:

Meckel’s Diverticulum (MD) is the most common congenital malformation of the gastrointestinal tract. MD is difficult to diagnose as it presents with intermittent symptoms or none at all. Lower gastrointestinal bleeding (LGIB) is the most common presentation. The diagnosis is made even more difficult when there are other plausible causes of bleeding on endoscopy. We present a case of severe LGIB in a young man with right sided diverticulosis found to have symptomatic MD after a prolonged work-up.

CASE DESCRIPTION/METHODS:

A healthy 23-year-old male presented with several episodes of bright red blood per rectum and crampy abdominal pain relieved by defecation. He denied taking any NSAIDs. He was hemodynamically stable with mild, lower abdominal tenderness. During admission, his hemoglobin decreased from 14.4 to 8.6 and he became hypotensive, pale and diaphoretic requiring two units of packed red blood cells. CT of abdomen and pelvis was unremarkable. EGD did not reveal a cause of bleeding. Colonoscopy showed scattered, small-mouthed diverticula in the ascending colon with no active bleeding and he was discharged with a presumptive diagnosis of diverticular bleeding. Video capsule endoscopy (VCE) performed for a second admission for hematochezia found blood clots throughout the distal small bowel without active bleeding. After much delay, a 99mTc pertechnate scan showed MD. He underwent surgery and had an ectopic gastric mucosa-containing diverticulum resected. He sustained no additional bleeding following surgery.

DISCUSSION:

Gastrointestinal bleeding is a major cause for hospitalization in adults. Less than 5% of cases are attributed to small-bowel sources. Diagnosis is more difficult when there are more common explanations for bleeding available. Diverticula located in the right colon are more likely to bleed despite being less common than left-sided ones, making them a plausible explanation for our patient’s symptoms. Even with the advent of non-invasive techniques to visualize the small bowel, diagnosing a small bowel bleed can prove to be a challenging feat. Diagnosis is affected by the features associated with a MD to include active bleeding, inversion or presence of heterotopic mucosa. Sensitivities for 99mTc pertechnate scan, CT and VCE are low at approximately 60, 48 and 8%, respectively, leaving much room for undiagnosed MD. High index of suspicion and multiple imaging modalities are required for diagnosis of MD, especially when more common explanations are present.
2023 A Unique Presentation of GI Bleeding as First Presentation of AML
Authors: Raborn Erik , Kelts Andrew , Stiemle Cassandra , Ali Farhan , Valvano Gary , Jeng Jennifer , Mazza Bruno
Published: October 2019

INTRODUCTION:

Acute Myelogenous Leukemia (AML) is a heterogenous group of cancers of blood cells associated with many dysfunctions due to monoclonal expansion of blood marrow. AML typically presents with symptoms of pancytopenia, including general fatigue, weakness, infections, ecchymoses, epistaxis, or menorrhagia. Overt GI bleeding is not a common initial presentation for AML.

CASE DESCRIPTION/METHODS:

Our patient was an 85-year-old female with a past medical history of gastrointestinal bleed while taking DOAC for pulmonary embolism, gastroesophageal reflux disease, hypertension, and uterine adenoma with subsequent hysterectomy and bilateral oophorectomy. She presented with complaint of “jet black” stools for 12 hours and accompanying weakness. She had no other alarm symptoms including pallor, bruising, neurological complaints, weight loss, hematochezia, or night sweats. She was known to have a hiatal hernia on previous EGDs and a bleeding distal rectal mucosal lesion concerning for a Dieulafoy lesion, both of which were two years prior to admission. Her initial labs were significant for hemoglobin 8.4, platelets 24, INR 1.0, and white blood cell count 5.1 with normal differential. Upper GI bleed was suspected, despite her previous lower GI bleeding, and the first upper endoscopy was performed; this revealed a possible Dieulafoy lesion that was hemoclipped. Her anemia and melena continued to worsen and Hematology performed a bone marrow biopsy. In the intervening time, two more upper endoscopies were performed yielding no further evidence of bleeding. Given her continued symptoms, colonoscopy was performed showing blood in the terminal ileum and right colon with no obvious lesion; there was, however, discrete mucosal bleeding sites in the rectum with no lesions noted after extensive cleaning. Multiple hemoclips were placed in the rectum but,ultimately, none of the endoscopic interventions proved durative. Shortly after colonoscopy, bone marrow biopsy revealed AML.

DISCUSSION:

Our case highlights a unique presentation of AML, where gastrointestinal bleeding is the first major presenting symptom. Bruising, epistaxis, and vaginal bleeding are the most typical types of bleeding in AML, none were found in this patient. AML is due to dysfunctions due to monoclonal expansion blood marrow that can lead to preferentially nonfunctional blood lines. This patient had significant thrombocytopenia with cells that were dysfunctional, leading to diffuse gastrointestinal hemorrhage without the presence of bleeding lesions.
2025 Rare Obscure Cause of Upper Gastrointestinal Bleeding: Bleeding Duodenal Lymphangiectasia
Authors: Sorathia Sufian , Cantave Rulz T. , Choksi Vivek , Dave Kairavee , Kaplan Steven R.
Published: October 2019

INTRODUCTION:

While ulcerative and erosive mucosal changes are more commonly the culprit lesion of upper gastrointestinal bleeding, bleeding can also occur from traumatic, malignant or vascular lesions. An unusual and infrequent vascular cause of bleeding is from a focal intestinal lymphangiectasia (IL). We describe a patient who presented with bleeding from a duodenal IL.

CASE DESCRIPTION/METHODS:

A 94-year-old female was sent by her nursing home for witnessed melena and new onset normocytic anemia with a hemoglobin of 7 g/dl. She was unable to provide a reliable history due to her advanced dementia. Her medical history was unknown. She was hypotensive on presentation which she responded to fluid resuscitation and one unit of blood transfusion. Her physical examination revealed conjunctival pallor, benign abdominal exam and melanotic stool on rectal exam. EGD was performed. The esophagus and stomach was normal. In the second portion of the duodenum, there was a five millimeter white plaque-like lesion, consistent with IL, and with a central red erythematous spot, appearing eroded [Figures 1 and 2]. In the view of bleeding and absence of other potential sources of bleeding, three hemostatic clips were placed to the lesion for hemostasis and prevent further bleeding [Figure 3]. Patient was followed clinically over the next several days and her bowel movements became brown in color. She required no further blood transfusions and hemoglobin levels stabilized. She was discharged with a hemoglobin of 8.7 and determined to have had bleeding from a duodenal IL.

DISCUSSION:

IL is characterized by dilated lymphatic vessels, which can be focal or diffuse. Generally asymptomatic, IL can be associated with malabsorption. Acute gastrointestinal bleeding is rare. An obstructed normal efferent lymphatic flow could subsequently open a latent lymphatic-venous/arterial connection, which could potentially explain its association with bleeding. Unless actively bleeding or with recent stigmata of bleed, definite diagnosis of bleeding from a focal IL is difficult. Endoscopic treatment is amendable to the same therapeutic interventions available of any bleeding gastrointestinal lesions, which includes injection of epinephrine, thermal therapy and/or placement of hemostatic clips. In conclusion, focal type of IL may rarely present with acute obscure gastrointestinal bleeding. Physicians should remain cognizant of this infrequently-described-in-literature etiology and should include it in their differential diagnosis.
2028 Here’s the GIST: Expand Your Differential of an Acute Upper GI Bleed
Authors: Bergagnini Isabella , Nguyen Andrew , Robbins David
Published: October 2019

INTRODUCTION:

While gastrointestinal stromal tumors (GIST) are among the most common mesenchymal malignancies affecting the gastrointestinal (GI) tract, they are considered rare entities comprising a mere 1-3% of all GI tumors. The vast majority are detected incidentally. We report a case of a small bowel GIST presenting as a severe acute upper GI bleed.

CASE DESCRIPTION/METHODS:

A 38-year-old female with a history of Henoch Schonlein Purpura presented with melena, lightheadedness, and dyspnea for one week. She was orthostatic on admission and her exam notable for conjunctival pallor and melena in the rectal vault. Her hemoglobin was 7.0 mg/dl on admission with labile measurements throughout her stay. An EGD revealed heme within the gastric body with active oozing in the proximal duodenum but with no identifiable source. Subsequent EGD revealed an actively spurting Dieulafoy lesion in the duodenum. Hemostasis was achieved with epinephrine and deployment of four hemoclips. Hemoglobin levels continued to fluctuate raising concern for re-bleeding. CT angiography of the abdomen was negative for an active bleed, but incidentally demonstrated a 5.8 × 4.7 × 3.7 cm enhancing mass adjacent to the proximal jejunum. She was taken to the OR for diagnostic laparoscopy and underwent en bloc resection of the 4th portion of the duodenum and proximal jejunum. The pathology revealed a low-grade GIST (positive for cKIT proto-oncogene, mitotic index < 5). The patient underwent a follow-up CT nine months after discharge which demonstrated no evidence of recurrent disease.

DISCUSSION:

Though GISTs are most commonly found in the stomach as well as the small bowel, the duodenum is an uncommon site of proliferation, comprising approximately 3-5% of all cases. Presentation varies, dependent on tumor size, with overt GI bleeding (hematemesis or melena) as the leading complaint in approximately 40-65% of cases. The presence of bleeding is associated with a high probability of tumor necrosis and ulceration and portends a poor prognosis. CT angiography has proven to be an effective imaging modality for the detection of GI bleeds, with sensitivities ranging from 63-90%. Surgical resection is preferred with or without the presence of a bleed. For larger tumors and those with chronic bleeding, oral imatinib is recommended to decrease tumor size. While GISTs commonly present with acute GI bleeding, they are rarely found in the small bowel, making this an important consideration when evaluating acute GI bleeds.
2032 Push Enteroscopy in the Diagnosis of a Gastrointestinal Bleed Caused by Diffuse Large B-Cell Lymphoma
Authors: Amine Mukarram , Srivastava Amit
Published: October 2019

INTRODUCTION:

Only 5-10% of gastrointestinal bleeding is from the small intestine, and in these cases, video capsule endoscopy (VCE) is considered as a first line procedure for small bowel investigation. The most common causes of small intestinal bleeding in patients older than 40 years include angioectasias and NSAID-induced ulcers. In younger patients, its is more common to see bleeding events as a result of Crohn disease, Meckel diverticula, Dieulafoy lesions, and tumors. Celiac disease can cause bleeding in both age groups. Our case reports on an uncommon presentation of a rare gastrointestinal malignancy, and the utility of push enteroscopy in the diagnosis thereof.

CASE DESCRIPTION/METHODS:

A 77-year-old female with a past medical history of gastric carcinoid, iron deficiency anemia, and history of pulmonary embolism now on rivaroxaban had presented after a syncopal episode. Upon review of systems, the patient did report dark stools, which she attributed to her iron pills. On presentation, the patient was found to have severe iron deficiency anemia and heme-positive stools. EGD and colonoscopy were performed, which did not reveal an active source of bleeding. She was taken off of rivaroxaban and her hemoglobin subsequently stabilized and she had no further episodes of melena. She was discharged with instructions to follow up for an outpatient VCE. Ten days later, before the scheduled VCE, the patient returned to the hospital with another episode of melena, and was again found to have a substantial decline in her hemoglobin. The patient then underwent push enteroscopy, which revealed multiple actively bleeding, cratered ulcers ranging in size from 10 mm to 20 mm in the distal duodenum and proximal jejunum which were endoscopically ablated. Biopsy of these ulcers was positive for non-germinal center derived diffuse large B-cell lymphoma. The patient was subsequently transferred to a tertiary care center for further staging and possible treatment.

DISCUSSION:

This case demonstrates the utility of push enteroscopy for both diagnosis and treatment in clinically significant, obscure, occult gastrointestinal bleeds. In this patient in particular, it also enabled the early diagnosis of a rare and morbid malignancy for which survival without treatment is measured in months. While small bowel tumors are among the most common causes of obscure GI bleed in young patient, this is a rare finding in the elderly. As this case demonstrates though, the possibility of malignancy should not be overlooked.
2039 Invasive "Intracholecystic Papillary-Tubular Neoplasm" (ICPN) Presenting as Hemobilia in a Jehovah's Witness Patient
Authors: Iyer Divya G. , Siddappa Pradeep K. , Aujla Amreet K. , Selden Michael A.
Published: October 2019

INTRODUCTION:

Hemobilia is a rare cause of upper gastrointestinal bleeding, which requires high index of suspicion for diagnosis. In various case series, hemobilia due to neoplastic disease of the hepatobiliary system ranges from 6% - 15%. ICPNs are rare neoplasms of the gallbladder that are usually detected incidentally. This is a case of a Jehovah’s Witness patient with severe symptomatic anemia secondary to hemobilia due to invasive ICPN.

CASE DESCRIPTION/METHODS:

71-year-old Jehovah’s Witness patient with a 4 month history of anemia, suspected to be due to multiple small intestine angioectasias seen on prior enteroscopies, presented with a 3 day history of fatigue, dyspnea on exertion, and melena. Patient’s hemoglobin/hematocrit at presentation was 6.4/23.4. She underwent gastroduodenoscopy which showed blood in the second part of the duodenum which prompted a side viewing duodenoscopy examination which showed blood oozing from the ampulla (Figure 1). Abdominal MRI showed markedly distended gallbladder with polypoid appearing wall thickness and blood (Figure 2). Patient received iron infusions to improve hemoglobin and hematocrit. She then underwent open cholecystectomy, and intraoperatively the surgeons did not appreciate any mass lesion in the gallbladder. Surgical pathology found invasive mucinous adenocarcinoma (1.0 cm) arising from a large (14.5 cm) ICPN with high-grade dysplasia (Figures 3a,b). The tumor invaded the muscularis propria and had negative cystic duct margins for carcinoma or dysplasia. Two lymph nodes were positive for malignancy. It was staged as III-b and pT1b, pN1, pMx. After discussion in the tumor board, she was recommended to have surveillance imaging in 3 months because her comorbidities precluded chemotherapy.

DISCUSSION:

To the best of our knowledge this is the only reported case of ICPN presenting as hemobilia. Residual changes of ICPN are seen in only 6.4% of the patients with invasive GB carcinomas. The presence of angioectasias in the small intestine acted as a red herring in this patient. The fortuitous timing of endoscopy to visualize bleeding from the ampulla clinched the diagnosis of hemobilia. The presence of blood in the gallbladder made it difficult to identify the mass lesion which was eventually confirmed on surgical pathology. Hemobilia should always in the differential diagnosis for patients presenting with upper GI bleed and should be actively investigated when no obvious bleeding lesions are noted from the gastric or intestinal mucosa.
2040 Where Can the Lesion Be? A Pelvic GIST With Both a Normal Upper and Lower Endoscopy
Authors: Arroyo-Mercado Fray Martin M. , Likhtshteyn Michelle , Alshal Mohamed , Reka Safak
Published: October 2019

INTRODUCTION:

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumor of the GI tract; the age-adjusted incidence is 6.8 per million in the SEER data collected from 1992-2000 [1].

CASE DESCRIPTION/METHODS:

An 80-year-old female with history of CVA, hypertension, diabetes, hyperlipidemia, diverticulosis, and mild antral gastropathy with negative H.Pylori presented to the hospital with syncope and two episodes of dark stools mixed with bright red blood. Physical exam revealed normoactive bowel sounds and tenderness to palpation in the left lower quadrant without rebound tenderness. A rectal exam was positive for melena but negative for any palpable masses or hemorrhoids. Initial laboratory workup showed a hemoglobin of 4.8 and elevated BUN to 60 from a baseline of 40. Patient was fluid resuscitated and given packed red blood cells with appropriate response to transfusion; the patient remained hemodynamically stable and had no further episodes of hematochezia. On endoscopic investigation, both upper and lower endoscopy were unremarkable and did not reveal any lesions; colonoscopy showed old blood but no active bleeding. An Abdominopelvic CT scan was performed which showed a 9.5 × 9.8 cm soft tissue mass in the right abdomen inferior to the liver and a 12.5 × 12.4 cm conglomerate soft tissue mass in the right pelvis as well as a 1.3 cm left hepatic hypodensity concerning for liver metastasis (Figure 1). Core biopsy of the pelvic mass revealed spindle cells and positive KIT (CD 117) consistent with GIST (Figures 1 and 2).

DISCUSSION:

GISTs are commonly are found in the stomach and proximal small intestine, but they can be found in any part of the gastrointestinal tract. GISTs are composed of spindle (70%) or epithelioid (30%) cells, and 10%-30% are malignant showing intra-abdominal spread or liver metastases. Most GISTs will be positive for a KIT protooncogene mutations leading to uncontrolled activation of KIT (CD 117), a receptor tyrosine kinase (RTK) [2]. The likelihood of metastasis increases when the tumor reaches a size of 10 cm. Tumors located in the small intestines have more potential of metastasis than gastric tumors due to delay in onset of symptoms. While endoscopic investigation is a significant diagnostic method, some cases may yield unremarkable findings. Our case highlights the importance of obtaining further imaging studies when no source of gastrointestinal bleed or mass can be identified on initial endoscopy.
2042 A Therapeutic Misadventure With Helminth Therapy for IBD
Authors: Meluban Lee , Spinnell Mitchell K.
Published: October 2019

INTRODUCTION:

Intestinal colonization by helminths has decreased in the developing world coinciding with an increased prevalence of inflammatory bowel disease (IBD) in these regions. This has raised the question of the protective role these parasites play in attenuating intestinal inflammation. Trichuris suis ova (TSO), porcine whipworm, has been evaluated as a possible therapy for IBD, but the most recent meta-analysis of efficacy and safety of this treatment showed no clinically significant benefit in inducing remission. We describe a case of a patient with Crohn’s disease whose symptoms were exacerbated by self-administered helminth therapy.

CASE DESCRIPTION/METHODS:

A 24-year-old male with a longstanding Crohn's disease presented with active colonic inflammation. Patient learned of a clinical trial involving ingestion of TSO, and failing to qualify, independently obtained T. trichiura, human whipworm, and hookworm products from an online vendor marketing themselves as a safe alternative to standard IBD therapy. Following a protocol under advisement from the vendor, the patient ingested whipworm ova and applied hookworm ova to his arm regularly for six months, in the meantime refusing standard IBD therapy. Failing to improve, the patient was eventually started on infliximab infusions and obtained clinical remission. Stool studies for Ova and Parasites negative prior to starting biologic therapy. Five years later while still on biologic therapy, the patient presented with worsening abdominal pain and diarrhea. Colonoscopy was performed and showed quiescent Crohn's colitis with live helminth seen in the cecum. Stool studies confirmed Trichuris trichiura worm and eggs. Patient was treated with mebendazole 100 mg and clinical remission was restored. Patient has been asymptomatic since parasite treatment and continues to be maintained on infliximab.

DISCUSSION:

This case illustrates the risk associated with the vast naturopathic products marketed for the treatment of IBD. Patients have an arsenal of products at their disposal, many sold based on loose or inconclusive data, not overseen by federally guided regulatory supervision. Through an internet search, we identified several vendors marketing helminths for the treatment of IBD and other illnesses. The availability of these products needs to be recognized when treating patients with IBD, and the presence of parasites needs to be tested when diagnosing and treating such patients, even those from regions of the world where these infections are uncommon.
2045 Linear IgA Bullous Dermatosis Is an Unusual Skin Extra-Intestinal Manifestation in IBD
Authors: Williams Kathy N. , Nocerino Angelica , Rivas Shelly , Ivanina Elena , Swaminath Arun
Published: October 2019

INTRODUCTION:

Linear IgA bullous dermatosis (LABD) is a rare extraintestinal manifestation of inflammatory bowel disease (IBD). This autoimmune subepidermal disease presents with bullae, erosions and vesicles. LABD is characterized by the immunopathologic finding of linear IgA deposits in the basement membrane along the dermo epidermal junction. There is an uncommon association of LABD with IBD and PSC.

CASE DESCRIPTION/METHODS:

A 36-year-old male, with a history of Ulcerative Colitis (UC) presented for initial evaluation. For 6 years, the patient has been treated for UC with combinations of steroids and mesalamines. He always discontinued therapy due to what he perceived were adverse drug reactions: pruritic blisters affecting his chest, abdomen, back, and arms. He describes multiple bloody bowel movements, pain with defecation, and a 12-pound weight loss over 2 months. His most recent colonoscopy revealed pancolitis. He has never been in clinical remission. He was referred to a dermatologist for evaluation of his skin lesions, to determine if the dermatitis reaction was a true adverse drug reaction. Hyperpigmentation on his chest and back were noted and appeared to be due to a resolved bullous dermatosis (Figure 1). Skin biopsies identified Linear IgA bullous dermatosis. Dapsone 100 mg daily resulted in resolution of the rash. He was subsequently treated for UC with infliximab and achieved a deep remission. Persistently elevated alkaline phosphatase was investigated with MRI. This revealed intrahepatic duct dilation, and liver biopsy confirmed comorbid PSC.

DISCUSSION:

LABD is defined by three criteria: vesicles/bullae, subepidermal vesicles with a neutrophil predominance and the linear pattern of IgA basement membrane deposits. This case identifies a rare extra-intestinal skin manifestation of IBD. The exact pathophysiology of the association between these distinct, yet inter-related diseases, has yet to be elucidated.
2047 Insidious Onset of Crohn's Disease During Pregnancy
Authors: Prabakaran Sabrina , Patel Krishen
Published: October 2019

INTRODUCTION:

Inflammatory bowel disease (IBD) affects 1.3 million people in the United States. The typical age of onset is at 15-30 years, thus affecting women during their childbearing years. Symptoms can often be mistaken for other conditions, especially in pregnant individuals. This case shows an interesting presentation of IBD occurring immediately after childbirth.

CASE DESCRIPTION/METHODS:

A 21-year-old female with no significant past medical history presented to the ER with GI discomfort and diarrhea. Her symptoms began 1 month prior, immediately after an uneventful vaginal delivery of her first child. She developed abdominal pain and cramping, which she was initially told was normal after her delivery. However this persisted and she also developed diarrhea with 5-7 loose bowel movements per day, hematochezia, as well as inability to tolerate PO intake. She had presented to an outside hospital 5 times for further evaluation, and was diagnosed with endometritis, a UTI, and most recently infectious colitis for which she was on ciprofloxacin and flagyl with no improvement. On presentation to our hospital, she was tachycardic with abdominal distension and tenderness on exam. Labwork was notable for hemoglobin of 7.7 with MCV 80.3, ESR 79, and CRP 2.34. CT abdomen/pelvis was performed with concerning findings of mucosal hyperenhancement and bowel wall thickening throughout the colon. Infectious colitis work up was negative and the patient proceeded to undergo a colonoscopy, which revealed severe colitis with apthous ulcers within the ileum and throughout the colon, with sparing of the rectum. Biopsies confirmed a diagnosis of severe rectal sparing ileocolonic Crohn’s disease (CD). She was immediately started on steroids with the plan to transition to a biologic medication as an outpatient.

DISCUSSION:

Inflammatory bowel disease first manifesting in pregnancy is a unique presentation that is not well described or discussed in the literature. It has been estimated that approximately 4.1% of women diagnosed with CD are diagnosed while pregnant. This case is especially interesting as the patient’s symptoms were initially attributed to her recent pregnancy and delivery, despite her relatively classic IBD symptoms. Thus, CD and IBD should be considered in the differential diagnosis of abdominal pain in a pregnant patient, especially as early diagnosis and treatment may affect maternal and neonatal outcomes.
2050 NUDT 15 C415T Variant as a Cause of Azathioprine-Induced Pancytopenia With Severe Sepsis
Authors: Debnath Prasanta , Jain Shubham , Nair Sujit , Udgirkar Suhas , Rathi Pravin
Published: October 2019

INTRODUCTION:

Thiopurines (i.e. azathioprine [AZA] and mercaptopurine exert a glucocorticoid-sparing effect for patients with inflammatory bowel disease (IBD) who cannot maintain remission when glucocorticoids are tapered and withdrawn. However, side-effects like leucopenia, pancytopenia limit its use in several conditions where immune suppression is required.

CASE DESCRIPTION/METHODS:

17-year-old female presented with abdominal pain for 10 months with acute deterioration for 1 month with intermittent episodes of low-grade fever, loose stools on and off non-bloody, with nausea and multiple episodes of vomiting for last 5 days. She was diagnosed to have Crohn’s disease and was started on Azathioprine 50 mg OD which was increased to 100 mg within next 7 days, along with with with Prednisolone 30 mg and Mesalamine 1500 mg for last 3 weeks. Her baseline investigations showed normocytic normochromic anemia (Hb 9 g/dl) with thrombocytosis. When she presented to us she had pancytopenia Hb-6.6, TLC 900/µL (DLC- N20% L77% M3%), Platelet count of 1,64,000/µL, ESR 31, CRP 140 with normal liver chemistries, Normal Vitamin B12 & Folate level. Patient also started developing alopecia. Azathioprine and steroids were stopped. Initial blood and urine cultures were sterile. She was started on broad-spectrum antibiotics along with G-CSF. Despite antibiotics, patient went on having high fever with falling leucocytes (TLC 300) with Absolute Neutrophil Count of 120/µL. Bone marrow biopsy revealed hypoplastic marrow. Repeat blood culture grew ESBL Escherichia coli sensitive to Tigecycline. After change in antibiotics, there was resolution in her symptoms. Genetic analysis for TPMT mutation and NUDT 15 was considered, which revealed wild type TPMT genotype and homozygous NUDT 15 C415T variant. In the meantime, the patient developed symptoms of intestinal obstruction. CT enterography revealed stricturing Crohn’s disease and was posted for surgery.

DISCUSSION:

In this report, we present a case of Azathioprine toxicity with pancytopenia with severe sepsis in a young patient with homozygous NUDT 15 variant and wild type TPMT genotype. This case, along with recent researches, enlightens us to consider NUDT 15 variant analysis before starting thiopurines in any patient, particularly in Asian population.
2057 Refractory Fulminant Ulcerative Colitis With Concurrent Clostridioides difficile Colitis Challenging Modern Guideline-Directed Medical Therapy to Failure
Authors: Ghanim Marcel , Javaid Toseef , Ghazaleh Sami , Nehme Christian , Nawras Ali
Published: October 2019

INTRODUCTION:

Guidelines on treatment of ulcerative colitis (UC) follow a stepwise approach of escalating medical therapy. Similarly, treatment guidelines for Clostridioides difficile infection (CDI) are well-established based on severity. The combination of fulminant UC & CDI especially patients with treatment naïve pancolitis is challenging with concerns for safety & efficacy of various therapies in concurrent conditions.

CASE DESCRIPTION/METHODS:

A 21-year-old male presented with 3 weeks of diarrhea, hematochezia & abdominal pain. Stool cultures & CD were negative & antibiotics were started. Subsequent colonoscopy showed pancolitis & UC on biopsy. IV steroids & probiotics were initiated with modest improvement & he was discharged. However, he was readmitted with worsening symptoms, started on IV steroids. Repeated colonoscopy with biopsies confirmed moderate active chronic colitis with focal ulceration & no granulomas or dysplasia. CD testing was positive. Hence, PO vancomycin was started. He had IBD-related arthritis & was started on sulfasalazine then methotrexate (MTX). Response to IV steroids (10 days) & PO vancomycin (14 days) was limited, therefore with infliximab was started. Vancomycin was switched to fidaxomicin with IVIG (3 doses). Colonoscopy was repeated revealing ongoing severe pancolitis with pseudomembrane, Mayo grade 3. Fecal microbiota transplant (FMT) was done. Biopsies were negative for CMV. Follow up CD testing was negative, yet, he progressed to fulminant UC within 6 weeks of initial diagnosis despite 4 doses of infliximab & steroids. He remained hemodynamically stable with supportive care. He was reluctant to have colectomy & hence tofacitinib was started. Despite IV steroids, infliximab, & tofacitinib; sulfasalazine & MTX; parallel PO vancomycin, fidaxomicin, IVIG & FMT, along with lactobacillus acidophilus, bloody diarrhea continued; patient was dependent on fluid support & blood transfusions. Finally, total colectomy was done as a last resort.

DISCUSSION:

Guidelines are lacking on treatment of concurrent refractory fulminant UC with CDI especially in patients who do not want colectomy. Potential success of biologic therapy & risk of progression to fulminant CDI in this setting is unknown. Safety & efficacy of the various treatments including immunosuppressants & FMT in cases of concurrent UC & CDI is a grey zone. Further case-reports & studies are needed to establish the optimal stepwise approach & guide therapeutic choice & decision making.
2059 A Case of Hepatosplenic T-cell Lymphoma in a Patient on Vedolizumab for Crohn’s Disease
Authors: Fischer Monika , Walker Megan J.
Published: October 2019

INTRODUCTION:

Hepatosplenic T-cell lymphoma (HSTCL) is a rare malignancy, most commonly affecting young males with often fatal prognosis. In patients with inflammatory bowel disease (IBD), HSTCL has been associated with thiopurine analog and tumor necrosis factor (TNF)-α inhibitor therapy; particularly when used in combination, the risk increases up to 4 fold. Development of HSTCL has not been reported in association with vedolizumab.

CASE DESCRIPTION/METHODS:

A 22-year-old male with severe, stricturing colonic Crohn’s disease of 10 years duration, on vedolizumab monotherapy every 4 weeks for 15 months, was incidentally noted to be pancytopenic in October 2016 and subsequently diagnosed with HSTCL by bone marrow biopsy. Previous IBD therapies included mesalamine, azathioprine, infliximab, adalimumab, intravenous immunoglobulin (IVIG), budesonide, certolizumab pegol and most recently 6 mercaptopurine (6-MP). The 6-MP was discontinued 1 year prior to HSTCL diagnosis. He achieved remission with chemotherapy, followed by autologous stem-cell transplant in September 2017. Unfortunately his disease relapsed only a few months later. He achieved a second remission with salvage chemotherapy, and proceeded to allogeneic bone marrow transplant in April 2018. Since diagnosis of HSTCL, he did not receive any therapy for Crohn’s disease and has been asymptomatic from his IBD. Colonoscopy demonstrated complete endoscopic and histologic remission as well. On last bone marrow biopsy, over 200 days post-transplant, there was no evidence of HSTCL relapse 24 months following HSTCL diagnosis.

DISCUSSION:

Fortunately, our case had a favorable outcome compared to those reported in the literature with a median overall survival of 10 months, and up to 17 months in patients who receive stem cell transplant. In addition, following stem cell transplant, our patient achieved cure of his Crohn’s disease. A recent review of patients with immunoregulatory disorders who developed HSTCL noted that 56% of patients were treated with TNF-α inhibitors versus 89% with immunomodulators, indicating that the latter pose higher risk. To our knowledge, there have not been reports of HSTCL associated with vedolizumab use nor is there a known mechanism by which vedolizumab could cause HSTCL. In our case, TNF-α inhibitor was stopped 5 years prior and thiopurine analog 1 year prior to diagnosis, raising the question as to how long the risk of HSTCL remains elevated after cessation of such agents.