bluuebunny/crossref_metadata_2025 huggingface dataset:
3091 Squamous Papilloma of the Esophagus
Authors: Olson Kristin , Sunkara Tagore , Becker Bradley , Gaduputi Vinaya , Andres Matthew
Published: October 2019

INTRODUCTION:

Squamous esophageal papillomas are rare epithelial lesions typically discovered incidentally during esophagoduodenoscopy (EGD). The occurrence in patients undergoing EGD is less than 0.45 percent and the prevalence in the general population inferred from autopsy is less than 0.04 percent. Most patients are asymptomatic unless the lesion is large. The most common symptom is dysphagia. A majority of these lesions are found in the distal one third of the esophagus. They have not been demonstrated to progress to esophageal carcinoma.

CASE DESCRIPTION/METHODS:

Our patient was a 53 year old male with history of alcohol abuse who presented with new-onset seizure/syncope, six painless maroon stools, and coffee-ground emesis. The patient admitted to frequent diclofenac use. He was found to be anemic with a hemoglobin of 7.9 G/dL and had an elevated INR of 1.2. He was transfused two units of packed red blood cells and was started on a pantoprazole drip. Initial endoscopy revealed an island of tissue growth in the mid-esophagus and a bleeding duodenal ulcer that was injected with epinephrine, cauterized with gold probe, and clipped. Biopsy of the esophageal lesion was deferred to outpatient follow-up given the severity of the patient's presenting condition. Following the procedure, he was continued on the pantoprazole drip with transition to oral pantoprazole 40 mg daily. He had no further signs of gastrointestinal bleeding. Two weeks later, an EGD was performed. Biopsies were taken of the stomach mucosa and mid-esophageal mass. Gastric biopsy demonstrated mild chronic gastritis without dysplastic changes or helicobacter pylori. Esophageal biopsy demonstrated findings consistent with squamous papilloma.

DISCUSSION:

Squamous papilloma of the esophagus is a rare but benign lesion. Its macroscopic appearance is similar to other, less benign growths (verrucous squamous cell carcinoma, granulation tissue, or papillary leukoplakia). The etiology is unclear. Chronic mucosal irritation from GERD or esophagitis is the prevailing theory of pathogenesis, but HPV – strongly associated with cervical, anal, and oropharyngeal cancers (depending on viral serotype) – has been detected in some lesions. Thus, the gold standard for evaluation is biopsy. There are various proposed therapies for squamous papillomas including resection, cautery and radiofrequency ablation. Future research is needed in regard to treatment and surveillance for these lesions.
3100 Acute Esophageal Necrosis (Gurvits Syndrome) in a 78-Year-Old Male Filipino Patient
Authors: Menchavez Ma Charisse P. , Batoctoy Karen S.
Published: October 2019

INTRODUCTION:

Acute Esophageal Necrosis (AEN), also known as Gurvits Syndrome and commonly referred to as Black Esophagus, is a rare life-threatening clinical entity with an estimated prevalence of 1 to 200 in 100,000 and a mortality rate of approximately 30%. Only 88 patients over a span of 40 years have been reported. It is associated with geriatric males, diabetes mellitus, GERD, CKD, hypertension, vascular disease, alcohol abuse, malnourishment, ingestion of caustic agents and some medications. These factors predispose a patient to AEN through hemodynamic compromise, low-flow states, tissue hypoperfusion, corrosive injury and diminished mucosal defenses. Upper GI bleeding is the presenting complaint in around 90% of cases. It is diagnosed on endoscopy where characteristically, a diffuse, circumferential, necrotic esophageal mucosa is seen. The treatment for AEN aims to address the underlying medical illness, maintain and restore hemodynamic stability with intravenous fluid resuscitation and blood transfusions, attain complete esophageal rest, gastric acid suppression and antimicrobials.

CASE DESCRIPTION/METHODS:

A 78-year-old Filipino man developed hematemesis on a background of T2DM, hypertension, NSAID use and excessive alcohol use. He had no GI signs or symptoms prior to this episode. Four hours later he became drowsy and confused and was noted to be in hyperosmolar hyperglycemic state. An endoscopy revealed a distinctly diffuse circumferential necrosis of the esophagus with abrupt demarcation at the gastroesophageal junction. The gastric mucosa and biopsies were unremarkable. CT showed a distended aperistaltic esophagus with circumferential thickening with no evidence of perforation. Post endoscopy he was treated in ICU where he was maintained on parenteral nutrition, meropenem, nystatin, pantoprazole and insulin. Repeat endoscopy 7 days later showed pink mucosa after appropriate glycemic control, bowel rest and hemodynamic stabilization. He was discharged 3 days later.

DISCUSSION:

This is the first known report of a Filipino diagnosed with AEN. He presented with hematemesis, many of the risk factors associated with AEN, and his endoscopic findings were classic for AEN. However, he was only diagnosed sometime after endoscopy. This case highlights that AEN may be underdiagnosed and that clinicians should be mindful of it as populations develop more co-morbidities and risk factors that predispose them to developing it. This case also highlights the reversibility of this life-threatening condition.
3101 Barrett's Esophagus With Metastatic Neuroendocrine Tumor
Authors: Burgos Melanie , Sotiriadis John
Published: October 2019

INTRODUCTION:

Neuroendocrine tumors are a rare group of cancers that can occur in many different organs. Due to their rarity and variable presentation, they are not well understood. In contrast, Barrett's esophagus is a well-known condition frequently associated with the development of esophageal adenocarcinoma. A review of literature has shown only 8 cases demonstrating an association between neuroendocrine tumors and Barrett's esophagus.

CASE DESCRIPTION/METHODS:

A 73-year-old male presented to the hospital status post fall due to altered mental status. Relevant past medical history included GERD, Barrett's esophagus, and gastric adenocarcinoma which was treated with surgery and chemoradiation 6 years prior. Imaging of the head revealed metastatic lesions. Further investigation with a CT chest, abdomen, and pelvis showed metastatic lesions in the bilateral lung lobes and the left trochanter. Biopsies of the esophagus and stomach on esophagogastroduodenoscopy (EGD) showed Barrett's esophagus with no presence of gastric metaplasia. A biopsy of the trochanter was also performed. Pathology results were positive for synaptophysin, chromogranin, CK7, and CK20, at both sites of biopsy for the esophagus and trochanter. Ultimately, the patient was placed on hospice.

DISCUSSION:

Neuroendocrine carcinomas of the esophagus are rare, accounting for 0.4-5.9% of all esophageal carcinomas. The rarity of neuroendocrine tumors and their ability to manifest in many different organs often makes diagnosis difficult. As with this patient, the origin of metastatic disease was initially unclear due to the multiple sites involved. Synaptophysin and chromogranin are specific to neuroendocrine tumors which were found in both the esophagus and trochanter. CK7 and CK20 are markers usually found in gastrointestinal mucosa, suggesting that the esophagus was the primary site of cancer. Furthermore, biopsies of the esophagus and stomach were positive for Barrett's esophagus and negative for metaplasia of the stomach, indicating that these metastatic lesions were not from a recurrence of the patient's prior gastric cancer. Further research is needed to determine if these findings are coincidental or if there is a true association between Barrett's esophagus and neuroendocrine tumors.
3113 The Hidden Culprit: A Case of an Accidental Foreign Body Ingestion
Authors: Wankhade Charudatta , Jacob Bobby , Karim Syed , Jiyani Rucha , Rizvon Kaleem
Published: October 2019

INTRODUCTION:

Foreign body in the esophagus is a common emergency faced by a gastroenterologist. A thorough history and clinical examination followed by appropriate investigations and interventions is very essential. We present a case of a 41 year old male who accidentally swallowed a bottle cap and was symptomatic in spite of negative imaging studies.

CASE DESCRIPTION/METHODS:

41 year old African American male presented with epigastric pain after he accidentally ingested a plastic cap of a small water bottle 3 days ago. Pain was non radiating, intermittent, associated with an episode of non-bloody vomiting. He was unable to eat solid food after the ingestion of the bottle cap. He visited the two different hospital prior to this visit and was discharged after negative imaging studies. Review of systems was negative for any other systemic symptoms. Medical history was significant for asthma but he did not have any significant surgical, family or social history. On physical exam, he was afebrile, blood pressure and heart rate were 128/80 and 86 per minute respectively. He was speaking in full sentences but was irritable. Rest of the physical exam was unremarkable. After initial x ray's and CT scan were negative for foreign body ingestion, the patient was scheduled for upper endoscopy. Endoscopic intervention revealed a plastic bottle cap at 35-38 cm from incisors. It was successfully removed with a raptor forcep. A cratered linear esophageal ulcer was noted at 35-38 cm from esophagus. Patient tolerated the procedure well without any complications. He was able to consume mechanical soft diet a day after the procedure.

DISCUSSION:

The initial approach towards patients presenting with esophageal foreign body demands urgent clinical assessment and appropriate radiological investigation. Asymptomatic patients with an acute presentation and lack of respiratory impairment can be seen on an outpatient or inpatient basis, depending on the clinical scenario. Most foreign bodies in the esophagus pass spontaneously but about 3-10% may require some type of intervention. In the event of non-resolution of symptoms and negative radiography, intervention should be sought without delay. Our patient could have benefited from endoscopic intervention on his initial visit to the emergency room. Food, plastic, and wood are not radio-opaque and as a result are not seen on routine x-rays or can be missed on CT scan. If suspicion of a foreign body remains high after negative imaging studies, then diagnostic endoscopy may be indicated.
3117 “A Gut Feeling”: Autonomic Instability and Dysbiosis in Connective Tissue Disease
Authors: Steimle Cassandra , Ali Farhan , Kelts Andrew , Jeng Jennifer , Golikov Edwin , Kochik Michael , Raborn Eric
Published: October 2019

INTRODUCTION:

Ehlers-Danlos Syndrome (EDS) is a connective tissue disease in which mutations in certain genes result in a disruption of normal collagen. There are several subtypes of the disease. Among the various subtypes which exist, hypermobility is the most common. Many of these patients can have co-existing gastrointestinal symptoms, which are often times overlooked by practitioners.

CASE DESCRIPTION/METHODS:

A 23 year old female presented with chest tightness, daily palpitations, and diarrhea which had been persistent for three days. Her past medical history was notable for spinal stenosis and lactose intolerance. She denied any associated abdominal pain, fever, or chills. Her family history was non contributory. One month later, she continued to have diarrhea and heartburn. She endorsed symptoms of mucorrhea with associated bright red blood per rectum, lower abdominal pain, and fecal urgency. A thorough physical examination revealed hyper flexible joints and greater than normal mobility of her fingers. After genetic testing, she was later diagnosed with Ehlers-Danlos Type 3.

DISCUSSION:

Up to 57% of patients with EDS have coexisting functional bowel disorders.1 Chronic gastrointestinal discomfort was reported in 86% of patients with Ehlers-Danlos – hyper mobile subtype.2 Gastrointestinal complications can include gastro esophageal reflux disease, hiatal hernia, gastritis, gastric emptying, irritable bowel syndrome (found in 62% of patients), rectal evacuatory dysfunction, and delayed colonic transit.1,2,4 Symptoms are thought to occur as a result of bidirectional signaling between gut bacteria and the brain. Enterochromaffin cells are not only accessible by enteric microbiota but also have contact with afferent and efferent nerve terminals acting as “transducers” between the gut and brain,8 able to secrete various compounds, including serotonin. One study showed that pretreatment of animals with probiotic formulation consisting of Lactobacillus helveticus R0052 and Bifidobacterium longum R0175 attenuated hypothalamic pituitary axis and autonomic nervous system activities, which were assessed through the measurement of plasma cortisol and catecholamines.10 In our patient, she was treated with a course of Rifaximin for IBS-D and was placed on a bowel regimen including a probiotic. At a four-week follow up, her symptoms had improved.
3119 Pseudomelanosis of Stomach and Duodenum
Authors: Pasha Syed Bilal , Yezaz Ghouri , Tahan Veysel , Samiullah Sami
Published: October 2019

INTRODUCTION:

Pigmentation of the lower gastrointestinal tract called melanosis coli is a commonly encountered endoscopic finding. A similar pattern of pigmentation called pseudomelanosis is sometimes encountered during upper GI endoscopies. Duodenum is the most commonly reported site for pseudomelanosis, but there have been limited number of reported cases of gastric pseudomelanosis.

CASE DESCRIPTION/METHODS:

We present a case of 71 year old male with history of iron deficiency anemia, coronary artery disease, congestive heart failure, chronic kidney disease, hypertension, gout and hyperlipidemia who presented for GI endoscopy to evaluate his anemia. His medications included torsemide, hydralazine, ferrous sulfate, clopidogrel, pantoprazole, febuxostat, atorvastatin, amlodipine, isosorbide mononitrate, bisoprolol, irbesartan, citalopram, doxazosin and oxybutynin. Esophagogastroduodenoscopy (EGD) revealed a 3 mm dark spot in the antrum which was biopsied (Figure 1). Similar pigmentation was seen in the duodenum as well (Figure 2). Pathology revealed benign gastric mucosa with histological pattern of pseudomelanosis. Rest of the gastric mucosa was benign with non-specific chronic inflammation. Additional endoscopic findings observed were a linear pattern of mild erythema in the gastric antrum which was consistent with endoscopic appearance of gastric antral vascular ectasia. No active bleeding or oozing was observed. Rest of the EGD, as well as colonoscopy was unremarkable except for multiple small colon polyps.

DISCUSSION:

The exact etiopathogenesis of this rare entity remains unclear and various mechanisms have been proposed for this pigmentation pattern. Iron supplementation or upper GI bleeding leading to abnormal iron accumulation in macrophages of lamina propria has been proposed as a possible mechanism. Results of electron probe X-ray identified the role of sulfur containing compounds in causing accumulation of this pigment. Conditions associated with pseudomelanosis are CKD, hypertension, gastric hemorrhage and diabetes. Medications such hydralazine, thiazide, furosemide, Iron sulfate, methyldopa and propranolol have been shown to be associated with it. Sulfur containing drugs (such as hydralazine, furosemide and hydrochlorothiazide) are worth mentioning, since sulfur is shown to promote pigment deposition. The clinical significance, treatment and follow up of this rare condition is still unknown. Furthermore, no malignant transformation or long term complications have been reported so far.
3131 Rectal Dieulafoy's Lesion: A Rare Cause of Massive Lower GI Bleed
Authors: Singh Vikram , Mehra Shilpa
Published: October 2019

INTRODUCTION:

Dieulafoy's lesions can be a life-threatening source of gastrointestinal bleeding. While most commonly seen in the stomach, they have been described throughout the GI tract, including the rectum. These lesions consist of a persistent caliber, submucosal artery that can be difficult to identify on endoscopic evaluation. Rectal Dieulafoy's lesions are a rare source of lower GI bleeding that can present with large volume hematochezia requiring prompt management. Two cases of bleeding secondary to a rectal Dieulafoy's lesion are reviewed.

CASE DESCRIPTION/METHODS:

Case 1: A 94-year-old man with multiple cardiompulmonary comorbidities presented initially for sepsis secondary to osteomyelitis and developed hematochezia during admission. Hgb went from 10.0 g/dL to 7.1 g/dL, but he remained hemodynamically stable and bleeding self-resolved. Colonoscopy was deferred due to patient preference. The patient was readmitted to the hospital 8 days later with continued hematochezia and found to have Hgb 6.3 g/dL. Colonoscopy showed a visible Dieulafoy's lesion that was injected with 2 mL 1:10,000 epinephrine and then treated with 2 hemostatic clips. After intervention, bleeding resolved. Case 2: A 91-year-old man with a history of dementia and COPD was admitted for two days of hematochezia. On admission, he was transiently hypotensive with a SBP in the 50s and a Hgb of 9.4 g/dL with a baseline of 13-14 g/dL. Hgb eventually reached a nadir of 7.4 g/dL. Flexible sigmoidoscopy showed a visible Dieulafoy's lesion. Three hemostatic clips were placed in setting of active oozing with control of bleeding.

DISCUSSION:

Dieulafoy's lesions were first described in 1884 and are now more commonly described given advances in endoscopy. These lesions account for only 1-2% of GI bleeds, however this number may be underrepresented due to the difficulty of diagnosis. The rectum is involved in only about 2% of cases of Dieulafoy's lesions. The etiology of these lesions is unclear, but likely have some relationship to age, co-morbidities, and NSAID use. Endoscopy is the main method of diagnosis, though EUS, VCE, or angiography are also useful. Hemostasis is usually achieved through thermal therapy, injection with epinephrine, or banding/hemoclip with dual modality being preferred. The cases above represent two examples of a rectal Dieulafoy's lesion, a rare etiology of lower GI bleeding. Management of these bleeds requires prompt evaluation with endoscopy and can be successfully treated via multiple modalities.
3141 Large Gastric Hyperplastic Polyp as a Rare Cause of Iron Deficiency Anemia
Authors: Hafiz Nazar , Pandit Sudha , Maruvada Smita , Rashid Shazia , Alexander Jonathan , Jordan Paul , Manas Kenneth J. , Morris James D.
Published: October 2019

INTRODUCTION:

Gastric polyps are encountered in approximately 6% of endoscopic procedures. Most of the patients are asymptomatic, some of them can present with complications. We present a rare case of a large hyperplastic polyp resulting in iron deficiency anemia.

CASE DESCRIPTION/METHODS:

A 57 year-old man with past medical history of diabetes mellitus came in with complaints of 1 week history of dizziness, dyspnea on exertion and fatigue. Associated symptoms included persistent nausea and few episodes of non-bilious, non-bloody emesis. Patient denied melena or hematochezia. He endorsed weight loss of 8 lbs in 4 months. Vitals were grossly stable. Labs significant for Hb 6.7, Hct 23.8, and MCV 62. Patient was subsequently transfused with blood. Iron panel revealed severe iron deficiency with serum Iron 10, TIBC 443, Ferritin 4.6, Transferrin saturation 10. Colonoscopy was unremarkable however EGD revealed a large ulcerated polypoid mass, measuring about 10 to 15 cm in antrum concerning for early carcinoma. Pathology returned positive for hyperplastic polyp with no signs of dysplasia. Based on the large size of polyp, partial gastrectomy was done. On follow up, Hb increased and pt reported clinical improvement.

DISCUSSION:

Hyperplastic polyps constitute 75% of all the gastric polyps encountered. Hyperplastic polyps result from hyperplasia of epithelium secondary to chronic gastritis. Usually they range from 0.5 to 2 cm. About 1.4% of these polyps can reach a size large enough to cause iron deficiency anemia secondary to chronic bleeding. The risk of malignancy increases with size >1 cm and require surgical resection. Yun et al reported a rare case of 1.5 cm hyperplastic polyp which was a cause of iron deficiency anemia. We describe a case of a large 10-15 cm hyperplastic polyp causing GI bleeding subsequently resulting in iron deficiency anemia. We recommend that physicians should be aware of this rare complication as polypectomy will benefit therapeutically in preventing future complications such as chronic bleeding.
3146 A Curious Case of Hematochezia in a Young Adult
Authors: Lim Chong Teik , Law Ngai Moh
Published: October 2019

INTRODUCTION:

Meckel's diverticulum is a common congenital abnormality of the small intestine secondary to the vitello-intestinal duct. It commonly presents as hematochezia and abdominal pain in young children particularly those less than 2 years old.

CASE DESCRIPTION/METHODS:

A 26 years old lady presented to Emergency Department with history of hematochezia and abdominal pain for 2 days. The abdominal pain was mainly paraumbilical and colicky in nature and it was present intermittently for the past 6 months. One day prior to this visit, she was treated for acute gastroenteritis by a General Practitioner in view of presence of vomiting and diarrhea. However, symptoms were not improving and she subsequently developed hematochezia. She denies any fever and family history of gastrointestinal disease such as inflammatory bowel disease or malignancy. She denies any recent travelling and there is no sick contact recently. Physical examination was unremarkable and per rectal examination reveals blood mixed with stool with no mass or hemorrhoids seen. She has leukocytosis on blood investigation and abdominal radiograph performed in emergency department was unremarkable. She was subsequently admitted for treatment of dysentery and was started on intravenous ceftriaxone and metronidazole. However, patient's abdominal pain became severe requiring opioid for analgesia and an inpatient Computer Topography scan of her abdomen was obtained. Figures 1 and 2 shows the appearance of bowel within bowel appearance in the right lower quadrant in keeping with ileocolic intussusception. An urgent surgical consult was done and patient was agreeable for operation for bowel resection. Intra-operatively, a Meckel's diverticulum was noted to be the cause of the intussusception. The segment of ileum in the intussusception was noted to be ischemia with gangrene but no perforation noted. The intussuscepted bowel was resected and an end to end ileocolic anastomosis was performed. Post operatively patient recovered well and tolerated orally without any complications. She was discharged subsequently.

DISCUSSION:

This case illustrated that Meckel's diverticulum could be a differential diagnosis for young adults presenting with hematochezia. It is commonly misdiagnosed preoperatively in view of the rarity of these cases in the adult population.
3148 CMV Colitis in a Patient With Diffuse Large B-Cell Lymphoma (DLBCL) and Crohn's Disease
Authors: Atteberry Preston , Buffie Charlie , Wan David
Published: October 2019

INTRODUCTION:

Cytomegalovirus (CMV) colitis, while uncommon in immunocompetent hosts, can occur relatively frequently in patients with IBD. Here we present the case of a woman with Crohn's disease and DLBCL with biopsy evidence suggesting CMV colitis.

CASE DESCRIPTION/METHODS:

A 59 year-old woman with Crohn's disease and DLBCL (on 12 mg dexamethasone daily) presented with abdominal pain and gastrointestinal bleeding. The patient was having sharp, intermittent, left-sided epigastric pain, similar to her prior Crohn's flares, and 5-6 bloody bowel movements per day, requiring 6 units of packed red blood cell transfusions at an outside hospital. She initially received mesalamine, with some relief of symptoms. On exam, the patient was in mild discomfort and had a soft, non-tender, non-distended abdomen. Initial laboratory testing was notable for a normal WBC count, hemoglobin 9.3, ALP 721, ALT 157, AST 102, ESR 2, CRP 5.2, and CMV viral load of 6,806,760. Abdominal CT and CT angiography showed colonic musical enhancement and mural edema indicative of probable colitis, without evidence of active bleeding. Empiric treatment with ganciclovir was initiated for presumed CMV colitis while the medical team awaited receipt of reports from the outside hospital. The patient had intermittent bleeding for several days that eventually resolved spontaneously. A prior colonoscopy report from the outside hospital ultimately showed colonic ulceration and endoscopic features “highly suggestive of CMV infection.” The immunopathology report of colon tissue biopsies showed ulceration and numerous enlarged cells with intranuclear and intracytoplasmic eosinophilic inclusions, consistent with CMV infection.

DISCUSSION:

This patient's presentation demonstrates the diagnostic challenge that can occur with IBD patients. Typical presenting symptoms for CMV colitis, including abdominal pain, diarrhea, and intestinal bleeding, can overlap significantly with symptoms of a non-infectious IBD flare. A high degree of clinical suspicion and appropriate laboratory testing is therefore needed to distinguish these two disease processes. Diagnosis is typically established by a combination of CMV viral load and immunohistochemical testing of colonic biopsy specimens. CMV colitis can be treated with antiviral medications, as in this case, but is associated with poor overall clinical outcomes, possibly requiring colectomy. After completing treatment for CMV colitis, the decision to reintroduce immunomodulatory therapy is made on a case-by-case basis.
3167 Rare Case of UTI: Complicated by Pylephlebitis With Hepatic Abscesses
Authors: Yella Prashanth Reddy , Choksi Vivek , Dermendjian Daniel , Patel Nehal , Dave Kairavee , Surapaneni Balarama K. , Priyadarshni Shivani , Obrien Keith , Rivas John
Published: October 2019

INTRODUCTION:

Pylephlebitis, also known as infective suppurative thrombosis of the portal vein, requires imaging revealing portal vein thrombosis in a bacteremic patient. It has high mortality as the symptoms are nonspecific. We present a rare case of UTI complicated by PV thrombosis, further complicated by liver abscesses.

CASE DESCRIPTION/METHODS:

76 y/o female presented to ER with non-specific symptoms like fevers, chills, lethargy, decreased appetite, dark-foul smelling urine, for a week. Her vital were WNL. She had no abdominal pain, but had RUQ tenderness on exam. On labs, she had leukocytosis, elevated liver enzymes (cholestatic pattern), and abnormal UA. Hepatitis panel was negative. RUQ ultrasound showed gallstones, but no features of cholecystitis, which was confirmed by -ve HIDA scan. She was started on empiric antibiotics, for UTI. MRCP showed no choledocholithiasis and CT abdomen with IV contrast showed incidental hepatic-splenic cysts as well as a hepatic abscess. Meanwhile, urine culture was -ve and blood culture grew Proteus mirabilis. Antibiotic coverage was broadened to Merrem based on sensitivities. IR was consulted for possible drainage of liver abscess. A closer review of the imaging with IR showed suspicious small filling defects in the portal circulation. MRI abdomen showed thrombus within the branches of the right portal vein and 2 right hepatic abscesses. The diagnosis of pylephlebitis was made and the patient was continued on appropriate treatment with IV antibiotics. Her clinical condition improved and she was discharged on Day 10 with PO antibiotics for 4 more weeks. Repeat imaging in 4 weeks, showed resolution of the abscess.

DISCUSSION:

Pylephlebitis, a serious life-threatening condition is characterized by infected suppurative thrombosis of PV or its branches. It is often a delayed diagnosis, however outcome has improved with modern diagnostic & therapeutic modalities and with the use of broad-spectrum antibiotics. It occurs as a result of intraabdominal or intrapelvic infections draining into PV system, with the most common inciting infections being diverticulitis and appendicitis. The infection is frequently polymicrobial. Diagnosis requires demonstration of PV thrombosis on abdominal imaging in a bacteremic patient. Treatment includes antibiotics for at least 4-6 weeks. Role of anticoagulation in pylephlebitis is not well known. After our extensive literature search, we did not come across any reported case of UTI causing pylephlebitis, as in our patient.
3170 Autoimmune Hepatitis in an Elderly Patient
Authors: Madhani Kamraan , Leventhal Robert
Published: October 2019

INTRODUCTION:

Autoimmune hepatitis (AIH) is a chronic inflammatory disease associated with younger age and female predominance. While patients presenting ≥65 years has been described, these are based on small cohorts.
1,2
We present a case of an elderly man admitted with painless jaundice, found to have AIH. Given favorable prognosis if diagnosed and treated early, AIH is an important differential diagnosis regardless of age.

CASE DESCRIPTION/METHODS:

An 85-year old man presented with 5-week history of weakness. Physical exam revealed jaundice of the eyes and skin. Laboratory data revealed alanine transaminase (ALT) 173 IU/L, aspartate aminotransferase (AST) 258 IU/L, alkaline phosphatase 306 IU/L, total bilirubin 9.9 mg/dL, and serum albumin 2.7 g/dL. Abdominal CT revealed normal liver size and contour without biliary ductal dilatation. MRCP showed filling defect within distal common bile duct to the ampulla however ERCP did not identify filling defect and sphincterectomy did not reveal stone or sludge (Figure 1). Liver biopsy revealed interface and lobular hepatitis with abundant plasma cells and minimal bile duct damage (Figures 2 and 3). Anti smooth muscle antibody and immunoglobulin G (IgG) were elevated to 76 U and 2,875 mg/dL, respectively. Anti liver-kidney microsomal antibody IgG, viral hepatitis, anti nuclear antibody, and anti mitochondrial antibody studies were negative. The patient began Azathioprine and Prednisone and within 9 weeks, ALT and AST normalized with improved sense of well being.

DISCUSSION:

AIH reported in the elderly has been described, however onset <40 years is more common.
1
Thus, this diagnosis is often delayed in elderly patients. It has been suggested that AIH in the elderly may represent a less severe, indolent process, which presents clinically at a later age. Unlike other autoimmune processes, few differences in disease course have been described between younger and older patients. Compared to other etiologies of chronic liver disease, AIH carries an excellent prognosis once therapy is initiated using prednisone ± Azathioprine. Untreated, AIH carries a dismal prognosis, with 5 and 10-year survival reported to be 50% and 10%, respectively.
3
3179 Case Report: Spontaneous Hemobilia After Liver Transplantation
Authors: Sobotka Lindsay , Wellner Michael , Black Sylvester , Michaels Anthony
Published: October 2019

INTRODUCTION:

Liver transplantation is a safe and effective intervention for cirrhosis and acute liver failure with a survival rate greater than 90% at five years. Despite medical and surgical advancements, biliary complications affect about 10 to 30% of patients after liver transplantation and typically include a biliary stricture or leak. Hemobilia affects 1% of patients after transplantation and can present with abdominal pain, elevated liver function tests or anemia. This case report highlights the presentation and management of hemobilia after liver transplantation.

CASE DESCRIPTION/METHODS:

A 61 year old female with a past medical history of cryptogenic cirrhosis complicated by hepatic hydrothorax underwent a orthotopic liver transplantation. There were no complications during surgery. She developed worsening abdominal pain and increasing liver function tests within a week after transplantation. Given concern for biliary pathology, she underwent an endoscopic retrograde cholangiopancreatography (ERCP) which revealed hemobilia with spontaneous blood flow from the major papilla prior to biliary cannulation. Cholangiogram was performed and did not reveal any evidence of bile leak, anastomotic stricture or vascular communication. Clots were swept from the biliary tree and a stent was placed for continued drainage. Liver function tests returned to normal and abdominal pain resolved. The stent was removed 6 weeks later.

DISCUSSION:

Spontaneous hemobilia is a rare complication after liver transplantation that presents with rising liver function tests, abdominal pain or upper gastrointestinal bleeding. Diagnosis and management are typically with ERCP.
3215 Duodenal Blackout: A Rare, Benign Endoscopic Finding
Authors: Aggarwal Pankaj , Garapati Karthik , Kim David
Published: October 2019

INTRODUCTION:

First described in 1976, psuedomelanosis is a rare, benign, incidental endoscopic finding most commonly seen in the duodenum. PD has been associated with chronic renal disease and the ingestion of various medications including hydralazine and iron supplements. Here we describe a classic presentation of an uncommon endoscopic abnormality.

CASE DESCRIPTION/METHODS:

A 66-year-old woman with decompensated cirrhosis, end stage renal disease, and hypertension presented to the hospital with hepatic encephalopathy and failure to thrive. Her medications included hydralazine and a history of iron supplementation. An esophagogastroduodenoscopy (EGD) performed for early satiety, weight loss and to initiate a liver transplant evaluation demonstrated diffuse mucosal hyperpigmentation in a striped pattern, predominantly in the second portion of the duodenum (Figure 1). Mucosal biopsy revealed an abundance of brown pigment deposition in the lamina propria (Figure 2) which was negative on Prussian blue stain and immunohistochemistry—consistent with a diagnosis of pseudomelanosis duodeni (PD).

DISCUSSION:

Despite its striking endoscopic appearance, there is no evidence that pseudomelanosis duodeni is associated with any progressive pathology. Though PD has been described anecdotally in case report and case series, little is known about the pathophysiology. Some have posited PD is related to iron or lipofuscin deposition in the lamina propria. PD has been associated with end-stage renal disease, hydralazine, thiazide diuretics, and iron supplementation. This case describes a classic presentation of PD with the archetypal imaging and histopathology to support the diagnosis of this uncommon condition.
3227 Can a Gluten-Free Diet Be an Option in Treating Collagenous Colitis in the Absence of Celiac Disease?
Authors: Florian Rosemarie , Jackson Christian
Published: October 2019

INTRODUCTION:

Collagenous colitis (CC), a subtype of Microscopic Colitis, is known to cause chronic diarrhea in the elderly. Steroid medication, particularly budesonide, has been rigorously studied and shown to be effective, leading to remission. Few studies have revealed the role diet has on decreasing these symptoms.

CASE DESCRIPTION/METHODS:

69 y/o male with past medical history of chronic intermittent diarrhea for the past thirteen years. He initially presented with recurrence of non-bloody watery diarrhea, alternating with constipation and fecal incontinence for 2 weeks. Previous colonoscopy performed thirteen years ago revealed normal mucosa with diverticulosis. Further workup revealed a negative tTG- IgA, polypharmacy, or an infectious etiology. Labs were unremarkable. He underwent repeat colonoscopy, which demonstrated a fractured and nodular appearance of the cecum and ascending colon with small tears. Biopsies showed a focal increase in intraepithelial lymphocytes with a positive trichrome stain consistent with the diagnosis of CC. He was started on a GFD trial and had complete remission of his symptoms for three years.

DISCUSSION:

Chronic diarrhea affects approximately 5% of the population and at times can be challenging for gastroenterologists. When working up chronic diarrhea, microscopic colitis and celiac disease often play a large role. In this case, the patient was diagnosed with CC, however symptoms resolved on a GFD alone despite having multiple negative TTG levels. We believe that the multiple negative TTG levels were indicative of negative celiac disease. However, there is evidence showing that gluten can induce microscopic colitis. However, in women dietary gluten intake may not be a risk factor for the development of microscopic colitis in the absence of celiac disease. Nevertheless, the effects of gluten may be different in male veterans. CC is usually treated with a steroid based regimen, budesonide, to obtain remission. There are limited studies that have evaluated the impact that a GFD has upon the symptoms and histological findings in CC. Use of these medications can be associated with hyperglycemia, hypertension and metabolic bone disease which may be detrimental to the patient's health and prognosis. In conclusion, in patients diagnosed with CC consider starting a trial of GFD. Further studies are needed to evaluate the response of how a GFD affects the spectrum of severity in symptoms and histologic findings in patients diagnosed with CC, specifically in male veterans.
Role of apolipoprotein A-I in the anabolic effect of steroid hormones
Authors: Panin L. Ye. , Khoshchenko O. M. , Usynin I. F.
Published: October 2019

As early shown, a portion of steroid hormones binds to blood lipoproteins, primarily to high-density lipoproteins (HDL) [Panin et al. 1988]. Steroid hormones together with HDL are captured by resident macrophages of the liver where in secondary lysosomes HDL are degraded to form apoA-I and steroid hormones restore a ∆4, 3-keto group with the participation of 5-α and 5β- reductases to give rise to tetrahydro compounds. In this study, an attempt was undertaken to show a role of a complex of some steroid hormones with apo A-I in realization of the anabolic action of these steroid hormones by using the cultured hepatocytes and concurrently cultured hepatocytes and Kupffer’s cells isolated from the liver of male Wistar rats weighing 180-200 g.

Steroid hormones having an anabolic action, such as androsterone, dehydroepiandrosterone, dehydroepiandrosterone sulfate and tetrahydrocortisol as ingredients of a complex with apolipoprotein A-I (apoA-I), increased the rate of protein biosynthesis and dehydroepiandrosterone sulfate and tetrahydrocortisol also did the rate of DNA synthesis in the cultured hepatocytes. All the hormones had a restored ∆4,3-keto group in the A ring structure. Restoration of this group of steroid hormones and formation of their complex with apoA-I are associated with the action of resident macrophages (Kupffer’s cells). That is the reason that addition of HDL (a source of apoA-I) and cortisol (a source of the restored form - tetrahydrocortisol) to the coculture of hepatocytes and macrophages, by concurrently stimulating the latter by lipopolysaccharide led to a significant increase in the rate of protein and DNA biosynthesis. The findings show an important role of a ∆4,3-keto group of the A ring of steroid hormones and their complex with apo A-I in realizing the anabolic action of steroids.
Platelet activity in patients with hyper- and hypoparathyroidism
Authors: Kirichuk V. F. , Arefyev F. G.
Published: October 2019

Platelet aggregatory activity was studied in a patient with hyperparathyroidism before and after parathyroid adenomectomy and in 3 patients with hypoparathyroidism. In these patients, changes in the aggregation activity of platelet were evaluated after their incubation with parathyroid hormone. The patient with hyperparathyroidism was found to have activated platelets, their high readiness for an aggregation response, increased and a highly effective aggregatory activity and insignificantly decreased stability of formed platelet aggregates. After parathyroid adenomectomy there was a partial recovery ofplatelet functional activity. The patients with hypoparathyroidism had a lower platelet functional activity as compared with the controls. Preincubation of platelet-rich plasma from the patients with hypoparathyroidism with parathyroid hormone caused a varying recovery of platelet functional activity.
Role of some types of serotonin receptors in murine hypophyseal-testicular complex activation induced by the presence of a female
Authors: Amstislavskaya T. G. , Popova N. K.
Published: October 2019

Placement of a sexually receptive female mouse behind a partition that prevents physical contacts, but permits it to see and smell caused an increase in the blood levels of testosterone in male mice. The selective 5-HTIA-serotonin receptor agonist 08-OH- DPAT (0.1 mg/kg) and the mixed 5-HTIA/IB agonist eltoprazine, 3.0 and 10.0 mg/kg, blocked the activating effect of female exposure on the male pituitary-testicular system. The 5-HT/-receptor agonist p-MPPI (0.2 mg/kg) prevented the inhibitory effects of 8-OH-DPATand eltoprazine. The 5-HT/B-receptor agonist CGS- 12066A (1.0 and 2.0 mg/kg) exerted no effect while the mixed 5-HTIB/2C-receptor agonist TFMPP (5.2 mg/kg) inhibited a female-induced increase in the levels of male blood testosterone. The 5-HT/-receptor agonist keranserin (1.0 and 2.0 mg/kg) prevented a female-induced increase in the levels of testosterone. The 5-HT3-receptor agonist ondansetron (0.05 and 0.1 mg/kg) elevated the baseline level of plasma testosterone, but blocked receptive female-induced activation of the male hypothalamic-pituitary-testicular system (HPTS). It is concluded that 5-HTIA-receptors are involved in the control of male sexual activation. At the same time different types and even subtypes of the same type of 5-HT-receptors produce varying inhibitory and activating effects on the receptive female-induced activation of HPTS. Blocking of the female-induced activation of HPTS seems to be realized by involving 5-HTu- and 5-HT2C-receptors and its activation occurs with the participation of 5-HT^- and 5- HT3-receptors.
Dialogismo e verbo-visualidade sobre o questionamento da arte no Brasil
Authors: Knoll Graziela Frainer
Published: October 2019

O objetivo deste artigo é analisar, por meio da teoria dialógica, três charges que materializam, na verbo-visualidade, reações ao questionamento do que é arte no Brasil. Foram sele-cionadas três charges que tiveram como tema o acontecimento no Museu de Arte Moderna (São Paulo) em setembro de 2017, analisadas de forma descritiva e interpretativa, com o suporte teórico da teoria dialógica do Círculo Bakhtiniano. A análise evidenciou as relações dialógicas e ideológicas, que são relações semânticas, estabelecidas entre as imagens e os recursos verbais nos textos, além de serem feitas relações possíveis entre as três charges.
Sarcoporosis Is a Part of Aging
Authors: Broulík Petr
Published: October 2019

Ageing is associated with the accumulation of damage to all the macromolecules within and outside cells leading to progressively more cellular and tissue defects and resulting in age-related frailty, disability and disease. As a result of the aging process the bone deteriorates in composition, structure and function. Age-related musculoskeletal losses are a major public health burden because they can cause physical disability and increased mortality. We tried to find out on a small set of old women, without risk factors for osteoporosis, what caused them the loss of bone minerals. All 492 women had just only one risk factor – the old age. Laboratory findings have shown a decreased serum C telopeptide and low serum alkaline phosphatase circulating markers, used to quantify bone resorption and formation, and very low level of vitamin D. Very low level of vitamin D that disrupted calcium absorption through the intestine, and decreased calcemia increased parathyroid hormone levels with resulting bone effect. The manifestation of physiological aging is worsening eyesight, peripheral neuropathy, depression, worsening of physical condition, skin aging, sarcopenia and bone mineral loss. Senile osteoporosis, which is not caused by known risk factors for osteoporosis, does not appear to be a separate disease, but is part of the physiological process of aging. Treatment of senile osteoporosis should be focused on the control of secondary hyperparathyroidism by administration of vitamin D and calcium. The risk of fractures in the advanced age is determined by a large number of factors ranging from hazards in the home environment to frailty and poor balance.
Winter wheat variability according to local conditions
Authors: NAZARENKO Mykola , SOLOHUB Irina , IZHBOLDIN Olexandr
Published: October 2019

The objectives of our experiments are the description of the phenotypic and genotypic variability by the main agriculture-value traits of the new winter wheat lines according to their interactions with different environmental conditions. Five new winter wheat lines were investigated at field experiment during three years by parameters of grain productivity and quality, uptaking of macro- and microelements and heavy metals from soil under different relief conditions.Our investigations confirmed statement about more perspective direction for exploiting local sources for winter wheat improvement and closely relation between concentration of nutrient substances in plants, their loss from soil and peculiarities of relief, genotype and limits of adaptation. We developed high-adaptive line 213 (‘Leana’), which provides us higher than standard grain yield under all conditions. All lines showed higher grain productivity under favorable conditions than control. Variability of traits was higher under south slope conditions (unfavorable conditions) rather than on other (proper conditions). Only line 156 was identified by good protein content and composition under every condition for gliadin and glutenin components. Influence of relief on microelements and heavy metals uptake to the winter wheat plants is not so important as for macroelements and, in consequence, for grain productivity and quality.
Field evaluation of the relative susceptibility of six pear varieties to the pear psylla (Cacopsylla pyricola (Foerster, 1848))
Authors: EMAMI Mohammad Saeed
Published: October 2019

The pear psylla, Cacopsylla pyricola (Foerster, 1848) (Hemiptera: Psyllidae), is one of the most detrimental pests in commercial pear orchards. Varieties with low infestation level to pear psylla would offer to integrated psyllid management. The natural infestation level of six pear varieties to pear psylla was studied under field conditions during three successive years. The pear varieties consisted of ‘Comice’, ‘Buerre Giffard’, ‘Bonne Louise’, ‘Felestini’, ‘Shahmiveh’, and ‘Sebri’. Psyllid population was sampled weekly by limb jarring method and selecting 10 leaves randomly per tree. The results indicated that the size of the psyllid population on the tested pear varieties was significantly different (F 5, 30 = 816.18, p < 0.0001). ‘Shahmiveh’ and ‘Sebri’ showed high and low susceptible, respectively, to pear psylla infestation. The natural infestation level of C. pyricola was 37.01 % and 35.8 % lower on ‘Bonne Louise’ and ‘Sebri’, respectively, than on ‘Shahmiveh’. These varieties may be used for crossing in breeding programs to develop plant resistance to C. pyricola and may be exploited in integrated psyllid management.