bluuebunny/crossref_metadata_2025 huggingface dataset:
1943 Gastrointestinal Plasmacytomas
Authors: Hasan Yazan , Gerke Henning , Abukhiran Ibrahim
Published: October 2019

INTRODUCTION:

Plasmacytomas are tumors consist of abnormal plasma cells.They are divided into solitary plasmacytomas of the bone and extramedullary plasmacytomas (EMP). GI tract involvement is seen in 7% of EMP cases. The small intestine is the most commonly involved GI site, followed by stomach, colon, and esophagus.

CASE DESCRIPTION/METHODS:

A 57-year-old African American female with a history of multiple myeloma treated with chemotherapy followed by autologous stem cell transplant with failure to achieve remission. She presented with a two day history of melena, hematochezia and fatigue. Vital signs: BP 85/45 mmHg, HR 98 bpm, T 98.6 F, RR 18, Oxygen sat 96% on RA. Labs showed a drop in hemoglobin from 8.4 g/dL to 4.9 g/dL. Upper endoscopy showed 1.5 cm polyp in the gastric body (Figure 1a) that was removed. Colonoscopy showed multiple colonic polyps with a 1.5 cm polyp (Figure 1b) in the ascending colon that was removed. Histopathologic examination of stomach polyp (Figure 2a,d) revealed a malignant neoplasm consisting of plasmacytoid cells with inconspicuous nucleoli and abundant mitotic activity. The neoplastic cells were directly infiltrating the residual gastric epithelium and extending beyond the muscularis mucosa. Immunohistochemical staining showed the cells to be strongly positive for CD138 and lambda light chain, while negative for CD20, CD3, and Kappa light chain. These findings were consistent with a diagnosis of plasmacytoma. Histopathologic examination of the colon polyp (Figure 2e,f) showed similar morphology to the gastric polyp.

DISCUSSION:

Gastrointestinal plasmacytomas are rare, accounting for approximately 7% of all EMPs. Endoscopically, GI plasmacytomas have variable morphological appearances including ulcers, polyposis, thickened folds, ulcerative masses, and constricting lesions. Differentiating GI plasmacytomas from other tumors require histopathological examination. GI plasmacytomas should be considered in the differential diagnosis of myeloma patients presenting with GI bleed.
1946 Recurrent Lower Gastrointestinal Bleeding Secondary to Hermansky-Pudlak Syndrome
Authors: Tambe Ajay , Sharma Anuj , Manocha Divey
Published: October 2019

INTRODUCTION:

Hermansky-Pudlak syndrome (HPS) is a rare autosomal recessive disorder with a prevalence of 1 in 1,800 in Puerto Rico. It is characterized by oculocutaneous albinism with nystagmus, variable skin hypopigmentation, loss of visual acuity, and platelet storage pool deficiency resulting in bleeding diathesis. Hematochezia in HPS primarily occurs due to inflammatory bowel disease (IBD) presenting in first to third decades. However, lower gastrointestinal bleeding can occur even without evidence of endoscopic or histological findings of colitis.

CASE DESCRIPTION/METHODS:

A 20-year-old Puerto Rican male with history of HPS presented with 3 to 5 episodes of bright red blood per rectum for the past one week. The patient has been experiencing intermittent hematochezia since the age of 7 years. Previous work-up with double balloon enteroscopy 4 years ago showed small bowel erosions. Colonoscopy performed during that time showed normal findings, however biopsy was not performed. Meckel’s scan did not show any evidence of Meckel’s diverticulum. He did not experience any bleeding for 2 years before this presentation. His vital signs on presentation were stable. Laboratory findings showed hemoglobin of 13 gm/dl, platelet count of 330,000/ul and white blood cell count of 8,900/µL. International normalized ratio (INR) was 1.1, prothrombin time (PT) 14.6 seconds and partial thromboplastin time (PTT) 32.3 seconds. The patient was started on intravenous fluids, pantoprazole infusion and was given one dose of aminocaproic acid. Following the dose of amino-caproic acid, the patient’s hematochezia resolved and he did not have any recurrent bleeding episodes. He was discharged after 3 days, and followed up one month later, when he did not report of recurrent bleeding episodes.

DISCUSSION:

Previous studies have shown that mucosal inflammation can occur in absence of endoscopic abnormalities in symptomatic patients. The likely cause of hematochezia in our patient was mucosal inflammation along with platelet dysfunction. Patients with mild intermittent episodes of hematochezia can be managed conservatively. For acute bleeding episodes, desmopressin acetate (DDAVP) or aminocaproic acid can be used and in case of severe bleeding, platelet transfusion should be performed.
1947 Unintentional Bread Bag Clip Ingestion Leading to High Risk Duodenal Ulcer
Authors: McEntire Dan , Bank Jeffrey S.
Published: October 2019

INTRODUCTION:

Ingestion of bread bag clips has been described as a surprisingly common cause of GI bleeding or bowel perforation.

CASE DESCRIPTION/METHODS:

A 21-year-old man with no previous medical history or known foreign body ingestion presented after several episodes of acute onset coffee-ground and bright red hematemesis and hematochezia. Vital signs were notable for hypotension (90/65 mmHg) and tachycardia (120 bpm). Hemoglobin decreased from 15.5 to 12.2 mg/dL over four hours, and he received two units of pRBCs without an appropriate response in his hemoglobin concentration. During his EGD, we identified a 14 mm cratered ulcer with a visible vessel and an adjacent foreign body in the duodenal sweep. The object was grasped by rat-tooth forceps, but each attempt to remove it was complicated by hypotension and tachycardia. He then underwent urgent duodenotomy, where a bread-bag clip was identified and removed. Post-operative recovery was uneventful.

DISCUSSION:

Ingestion of foreign bodies poses a significant risk of GI bleeding or perforation. Guidelines generally recommend timely endoscopic removal of disk batteries in the esophagus, sharp objects, objects >6 cm in length, or in patients with severe esophageal obstructive symptoms. Various retrieval devices are available, and an overtube may be used to protect the esophagus. Surprisingly, there are already several described cases of bread bag clip ingestion that describe esophageal, small bowel, or large bowel bleeding or perforation. The unique shape of these clips leads to snaring of mucosal tissue which may ultimately lead to progressive ulceration. Interestingly, described cases of bread bag clip ingestion occur after unknown or accidental ingestion and occurs most commonly in cognitively impaired patients. Identification of these objects is difficult due to radiolucency, and often goes unnoticed until symptoms begin. Some are amenable to endoscopic removal, while others require surgical resection.
1952 Safety of Capsule Endoscopy During Pregnancy
Authors: Siddiqui Mohammad A. , Haq Khwaja F. , Schairer Jason
Published: October 2019

INTRODUCTION:

Currently there is limited literature on the safety of Video Capsule Endoscopy (VCE) during pregnancy. There is a theoretical risk of the growing uterus compressing the GI tract. Moreover the gastrointestinal transit is prolonged in the second and third trimester which may jeopardize VCE procedure. We hereby report a case of a pregnant patient who safely underwent a VCE without retention.

CASE DESCRIPTION/METHODS:

A 30 years old female who was 18 weeks pregnant with a history of myeloproliferative disorder and splenic vein thrombosis presented with hematemesis. She underwent an EGD that demonstrated type 1 isolated gastric varices without active bleeding that was doubted as the source. Colonoscopy found old blood in the terminal Ileum and the ascending colon. She was started on a beta-blocker for variceal bleeding prophylaxis. The patient was informed that there is limited literature on safety of VCE in pregnancy with a theoretical risk of capsule retention. As such pregnancy is deemed a relative contraindication to VCE. Therefore patient decided to pursue clinical monitoring. One week later the patient returned with similar symptoms. During this admission the manufacturer of the capsule was unable to provide any safety data as it had not been studied in pregnant patients. The Obstetrics (OB) service discussed the risks and benefits of VCE during pregnancy. The risk of a retained capsule is that it may require an x-ray of the abdomen and/or surgery. The patient was currently in the 2nd trimester which is the usual recommended trimester for any necessary surgery. Moreover the gestational age was beyond embryogenesis and per ACOG recommendations x-ray should be completed for maternal well-being. Since there were no safer alternatives and maternal wellbeing supersedes fetal health, VCE was performed. It found a small duodenal erosion but otherwise passed into the colon and was a normal examination of the small bowel. Hence recurrent bleeding was attributed to known gastric varices. She is now in her 30th week, following up with OB and per their review the fetus is doing well. She has had no more admissions for gastrointestinal bleeding.

DISCUSSION:

Elective VCE in pregnant patients should ideally be postponed until after delivery due to a lack of safety data. Nevertheless, VCE may be considered in indications related to maternal symptoms that put the mother or child at risk, such as small bowel bleeding. Accordingly, the FDA has assessed pregnancy as a relative contraindication to VCE.
1953 Blue Rubber Bleb Nevus Syndrome: A Diagnostic and Therapeutic Conundrum in Patients With Gastrointestinal Involvement Causing Chronic Anemia
Authors: Rashid Mamoon Ur , Inayat Faisal , Amjad Waseem , Khan Muzammil Muhammad , Ullah Waqas , Zafar Hammad , Munir Ahmed , Hussain Ishtiaq , Hurairah Abu
Published: October 2019

INTRODUCTION:

Blue rubber bleb nevus syndrome (BRBNS) is a rare vascular anomaly syndrome consisting of multifocal venous malformations. It frequently presents a diagnostic and therapeutic challenge in patients with gastrointestinal involvement.

CASE DESCRIPTION/METHODS:

A 55-year-old male presented with symptomatic anemia. Physical examination showed paleness and tachycardia. Laboratory studies showed hemoglobin 5.8 g/dL with normal white cell count. Peripheral blood smear showed microcytosis and hypochromia. Coagulation studies and routine biochemistry values were normal. He received packed-red cells and iron supplementation. He underwent upper and lower endoscopies. Colonoscopy showed multiple scattered venous blebs throughout the colon. They ranged in size from 2 mm to 8 mm. None of these blebs were actively bleeding. These lesions were not amenable to endoscopic treatment. Treatment was conservative with PPIs, blood transfusions and iron replacement.

DISCUSSION:

BRBNS is a rare, multifocal vascular malformation. According to a PubMed search, a total of around 200 cases are reported to date. Although data is sparse, it more commonly occurs in the skin (93%) and gastrointestinal tract (76%). A thorough physical examination and diagnostic workup for any symptomatic site should be performed in all suspected cases. Gastrointestinal involvement is a great masquerader as these patients experience severe anemia for years without diagnosis. In these patients, bleeding from the gastrointestinal tract is the most important clinical feature of BRBNS owing to the risk of excessive bleeding. Antiangiogenic agents such as interferon, corticosteroids, or sirolimus may be an effective treatment option for gastrointestinal BRBNS. In future, more cases should be reported in order to understand the etiological factors and treatment approaches.
1958 An Unusual Ca(u)se of Upper Gastrointestinal Bleeding
Authors: Pisipati Sailaja , Abdalla Abubaker , Harrison Clark A.
Published: October 2019

INTRODUCTION:

Duodenal varices (DVs) represent 17% of ectopic varices (EVs), have a 4-fold increased bleeding risk when compared to esophago-gastric varices (EGVs), and mortality rate up to 40%. There are no guidelines on the ideal management of DVs. We report a case of massive hemorrhage secondary to DV managed successfully with transjugular intrahepatic portosystemic shunt (TIPS).

CASE DESCRIPTION/METHODS:

A 69-year-old gentleman presented with hematemesis, hematochezia, dizziness and near-syncope. He was diagnosed with cryptogenic cirrhosis, non-alcoholic steatohepatitis in the past after negative autoimmune and infectious work-up. Prior doppler ultrasound showed elevated portal flow velocity; esophagogastroduodenoscopy (EGD) a month prior revealed portal hypertensive gastropathy (PHG) but no EGVs, and normal duodenum. Given prior hepatic encephalopathy, TIPS was not performed. He had abdominal surgeries in the past. He was hemodynamically unstable with benign abdominal exam. Labs revealed acute blood loss anemia with Hgb 9.1 (baseline 13), thrombocytopenia and coagulopathy. Following initial resuscitation with fluids, blood products, octreotide and pantoprazole infusion, urgent EGD was performed. There were no EGVs, but features of diffuse PHG, as well as a compressible mucosal bulge with a nipple sign representing a varix in the second portion of the duodenum were seen. Given the insufficient evidence to support endoscopic therapy in ectopic varices, interventional radiology was consulted. CT angiogram demonstrated patent portosystemic veins. TIPS was performed with a decrease in portal gradient from 16 to 2 mmHg. Rifaximin, lactulose and zinc were commenced. He remained hemodynamically stable following this and did not require further intervention. A year later, he remains free of further bleeding episodes or hepatic encephalopathy.

DISCUSSION:

Bleeding DVs are rare and potentially life-threatening. Diagnosis should be suspected in all cases of gastrointestinal hemorrhage, particularly in the absence of EGV or another source. Standard management has not yet been established. TIPS is a relatively safe and effective means of controlling acute DV bleeding. EVs may re-bleed despite a reduction of portosystemic pressure gradient < 12 mmHg or by 25–50% of baseline; hence the “12 mmHg rule” does not apply. Our patient recovered successfully following TIPS without needing additional therapy. Reducing the pressure gradient to very low values can result in successful outcomes with TIPS in DVs.
1959 A Case of Gastrointestinal Hemorrhage Due to Sevelamer-Induced Colonic Ulceration
Authors: Cheong Janice , Sahay Tanya
Published: October 2019

INTRODUCTION:

Lower gastrointestinal bleeding is a common reason for gastroenterology consultation in hospitalized patients. Many medications lead to gastrointestinal tract injury, yet not often are these definitively recognized as the etiology of bleeding. In dialysis patients, noncalcium phosphate binders including sevelamer are used for management of hyperphosphatemia. Many adverse effects are reported, but gastrointestinal ulceration is only reported in the literature in case reports. We describe a case of rectal ulceration caused by sevelamer presenting as acute lower gastrointestinal bleed.

CASE DESCRIPTION/METHODS:

A 59-year-old Caucasian man with coronary artery disease with history of drug eluting stents on dual antiplatelet therapy, congestive heart failure, hypertension, diabetes mellitus and end stage renal disease on hemodialysis was admitted for a traumatic subdural hemorrhage after a car accident. He also reported a history of constipation and had previously experienced intermittent low-volume hematochezia attributed to hemorrhoids. He had no other prior history of gastrointestinal bleed. During hospitalization, while undergoing rehabilitation, he developed brisk hematochezia with associated hemodynamic instability. On exam, he was hypotensive with systolic blood pressure in the 80s. Physical examination revealed dark red blood in the rectal vault. Laboratory results showed hemoglobin of 7.9 g/dL (baseline of 9 g/dL), platelets of 145,000/μl and an international normalized ratio of 1.1. Upper endoscopy was normal. Colonoscopy showed scattered punched-out ulcerations in the rectum with firm and adherent clot overlying a large ulceration in the 6 o’clock position. No endoscopic intervention was indicated. The patient clinically stabilized and was discharged home several days later. The histology from rectal biopsies showed colonic mucosa with ulcer and granulation tissue, associated with crystalline debris. Findings were consistent with sevelamer induced colitis. In discussion with the patient’s nephrologist, sevelamer was stopped. Hematochezia has not recurred.

DISCUSSION:

Here, we present another case of sevelamer induced colitis this time with ulceration leading to gastrointestinal hemorrhage. Literature is lacking on rates of sevelamer inducing ulceration. However, given the large number of dialysis patients on this medication, gastroenterologists should be aware of and consider this etiology for gastrointestinal hemorrhage in this patient population.
1977 A Rare Cause of Small Bowel Bleeding From a Duodenal Varix
Authors: Ali Mohammed Fahad , Brennan Gregory T. , Samarasena Jason , Lee John
Published: October 2019

INTRODUCTION:

Ectopic varices are rare and by definition occur outside of the esophagus and stomach. They can be found in the rectum, duodenum or be peristomal. An estimated 2–5% of variceal bleeds are due to ectopic varices with the majority occurring either in the rectum or duodenum. The diagnosis of ectopic duodenal varices can be challenging given their location. There is a paucity of data regarding optimal diagnosis and management of bleeding duodenal varices.

CASE DESCRIPTION/METHODS:

A 46 year old woman with a history of cirrhosis from alcohol and nonalcoholic steatohepatitis was referred to our center for ongoing small bowel bleeding. Previous endoscopic evaluation included an unremarkable EGD, colonoscopy revealed blood through the colon without lesions, and capsule endoscopy showed blood in the proximal small bowel (at less than 30% small bowel transit time). We performed a push enteroscopy which showed a submucosal bulge with overlying ulceration and intermittent active bleeding in the third portion of the duodenum. Hemostasis was achieved with two hemoclips and the location was marked with tattoos. On initial discovery, the lesion was most consistent with a submucosal tumor such as a GIST (Figure 1) and she was referred for surgical resection. However, surgery was unsuccessful because of dense adhesions from a prior unrelated surgery. A repeat examination of the lesion 6 weeks later with endoscopic ultrasound showed a large varix (Figures 2 and 3). The patient has otherwise been doing well without any recurrent GI bleeding.

DISCUSSION:

Varices typically appear as bluish enlarged vessels or bulges and are commonly tortuous and easily compressed with instrumental pressure. Ectopic varices can be confused with thickened folds or submucosal lesions as in this case. Differentiation of these lesions is paramount in choosing appropriate management. It is important to consider ectopic varices on the differentials of both GI hemorrhage and submucosal lesions. EUS is the preferred test to characterize such lesions. Varices typically appears as round anechoic structures arising from the lamina propria or submucosa. Color Doppler is used to detect blood flow, which will confirm the vascular nature of the structure. Options of endoscopic hemostasis of bleeding duodenal varices include hemoclips, sclerotherapy, TIPS, balloon-occluded retrograde transvenous obliteration or surgical resection.
1979 GI Bleed Secondary to Gangliocytic Paraganglioma Treated With Radiation Monotherapy
Authors: Van Jeremy , Esteban Marcus Juan , Oikonomou Ioannis
Published: October 2019

INTRODUCTION:

Gangliocytic Paraganglioma (GP) is a rare, usually benign tumor typically found in the 2nd part of the duodenum. The rarity of the tumor hasn’t allowed development of treatment guidelines. Mainstay of treatment involves endoscopic or surgical resection. Adjuvant chemotherapy or radiation has been utilized in a few cases. The case described is of a patient with GP presenting with hematochezia. The patient’s gastrointestinal (GI) bleed was treated with radiotherapy alone, which is the first case to our knowledge in the literature.

CASE DESCRIPTION/METHODS:

A 78 year old male with past medical history of multiple comorbid cardiovascular conditions and Multiple Myeloma presented with a six month history of hematochezia. Complete Blood Count showed a hemoglobin (hgb) of 8.6 g/dL with a baseline hgb of 11 g/dL four months prior. Esophagogastroduodenoscopy (EGD) showed a 3 cm ulcerated, friable periampullary mass. Biopsies demonstrated epithelioid, spindle and “large” cells associated with GP. Computed Tomography (CT) scan of the abdomen showed a 5.1 cm soft tissue density appearing to originate from the pancreatic head and abutting the duodenum with no regional lymphadenopathy or distant metastasis (mets). Due to the patient’s comorbidities and high perioperative mortality risk, radiation monotherapy was pursued for treatment. After fourteen radiotherapy sessions, the patient’s GI bleed resolved. Repeat EGD showed decreased vascular markings in the duodenal mass.

DISCUSSION:

GP is a rare tumor composed of epithelioid, spindle and ganglion cells. Tumor behavior is usually benign with rare invasion of nearby structures and lymph node mets. CT scan and endoscopic ultrasound (EUS) are generally recommended for staging. Our patient underwent CT Scan, but EUS was deferred due to little utility with an increased perioperative mortality. Local surgical resection is the most common treatment, but endoscopic resection has shown lower morbidity and mortality in selected cases. The size of the tumor and invasion depth dictates treatment modality. Our patient’s tumor size (>5 cm) and pancreatic head origin would have necessitated pancreaticoduodenectomy in a healthy patient. Due to his comorbid conditions and positive literature data on adjuvant radiotherapy for benign paragangliomas of the pancreatic head and neck, our patient underwent successful monotherapy with radiation for control of bleeding. This case shows benefit of radiotherapy alone for control of bleeding due to GP in high risk surgical patients.
1980 A Case of Downhill Esophageal Varices Secondary to Metastatic Disease From Renal Cell Carcinoma and Resultant Superior Vena Cava Syndrome
Authors: Van Jeremy , Singh Shubha
Published: October 2019

INTRODUCTION:

Downhill esophageal varices (DEV) are a rare form of varices associated with superior vena cava (SVC) obstruction. Obstruction leads to retrograde blood flow through collateral channels, including the esophageal venous plexus. This case describes a patient with hematemesis due to DEV from an enlarged paratracheal lymph node (PLN) secondary to metastatic disease (mets) from renal cell carcinoma (RCC).

CASE DESCRIPTION/METHODS:

A 65 year old male with past medical history of RCC s/p right nephrectomy with mets to the brain and mediastinum presented with a one day history of hematemesis and significant drop in hemoglobin. Esophagogastroduodenoscopy (EGD) was remarkable for large DEV in the proximal to mid-esophagus with white nipple sign. Band ligation was deferred given no active bleeding. Liver function tests were normal, vascular duplex of the abdomen was unremarkable, and CT chest with IV contrast showed extrinsic compression of the distal brachiocephalic veins (BV) and proximal SVC from a 4.6 cm necrotic right PLN. Radiotherapy was used to decrease the lymph node size and resultant extrinsic venous compression.

DISCUSSION:

DEV are a rare entity compared to uphill varices (UV) found in the distal esophagus due to portal hypertension. Hematemesis is more common with UV because of their location in the superficial sub-epithelium and increased acid exposure. DEV are located proximally in the submucosa, have more protection against acid, and have less than a 0.1% chance of causing hematemesis. After diagnosis with EGD, there are no clear guidelines on management. In this patient, banding was deferred given high risk of bleeding and perforation due to weakness in the proximal esophageal posterior wall and lack of serosa. After diagnosis on EGD, CT chest revealed the underlying cause of bleeding: SVC obstruction. The gold standard imaging study is direct venography but CT chest is an adequate alternative study. No surgical intervention was performed given the precarious nature and location of the lymph node and stenting of the SVC was deferred given the risk for re-bleed if placed on anticoagulation. Thus, radiotherapy was ultimately determined to be the next best step to decrease the extrinsic compression of the SVC from the lymph node. Chakinala RC, Kumar A, Barsa JE, et al. Downhill esophageal varices: a therapeutic dilemma. 2018 Nov 1. 1–6. Gebreselassie A, Awan A, Yaqoob H, Laiyemo A. Superior Vena Cava Obstruction: A Rare Cause of Recurrent Esophageal Variceal Bleeding. 2018 Feb 26. 2226.
1984 Helicobacter pylori-Negative MALT Lymphoma Presenting as Massive Recurrent Gastrointestinal Hemorrhage
Authors: Harne Prateek , Mukherjee Samiran , Lowe Dhruv , Manocha Divey
Published: October 2019

INTRODUCTION:

Extranodal marginal zone lymphoma or low-grade B cell lymphoma of mucosa-associated lymphoid tissue (MALT), an uncommon type of non-Hodgkin lymphoma (NHL), accounts for 5–10% of NHL in the US (18.3 cases per 1 million person-years1). It usually presents as gastro-esophageal reflux, nausea, anorexia, weight loss or occult GI bleeding2. Massive GI bleeding is unusual and rare.

CASE DESCRIPTION/METHODS:

Here we present a 68-year-old woman who presented with weakness and syncope after large volume hematemesis. Physical exam showed tachycardia, hypotension and conjunctival pallor. Her hemoglobin and hematocrit on admission were 8.5 g/dL and 25.6 %. She was managed with IV fluids, packed RBC transfusion and Pantoprazole and Octreotide infusions. An EGD within 24 hours showed erythematous, friable, spontaneously oozing mucosa with neovascularization in gastric fundus which was treated with bipolar cautery. A biopsy was not obtained due to recent bleeding. She was discharged on oral Pantoprazole. Two days later she was readmitted due to severe recurrent hematemesis with similar findings on repeat EGD. Bleeding was controlled with APC and biopsies were obtained from the gastric fundus. Due to the recurrent bleeding, an angiogram was performed. Active bleeding could not be seen. Prophylactically, left gastric artery was embolized. Biopsies revealed low-grade B cell MALT lymphoma with negative H.pylori. She was treated with 20 fractions of radiotherapy with the intention to cure. She did not experience further episodes of bleeding and has remained in remission since.

DISCUSSION:

Studies show the indolent nature of GI MALT lymphoma3, but our case illustrates the life-threatening presentation of a rare low-grade B cell MALT lymphoma as massive and recurrent hematemesis with negative underlying H.pylori infection or autoimmune process45. H.pylori positive localized MALT lymphoma is treated with the eradication of infection. H pylori negative, localized and recurrent disease is treated with radiotherapy6. Chemotherapy and/or immunotherapy is given when patients fail to respond to radiotherapy or develop metastasis. Long term endoscopic and laboratory follow up is needed as gastric MALT lymphoma is associated with a significant risk of gastric adenocarcinoma8 and increased incidence of gastric cancer and residual NHL. Our case emphasizes the importance of early diagnosis and timely intensive radiotherapy of a localized but aggressive gastric MALT lymphoma which induced remission and cessation of GI bleeding.
1990 The Successful Treatment of a Gastroduodenal Artery Rupture With Extravasation Into the Duodenal Lumen
Authors: Drame Awa
Published: October 2019

INTRODUCTION:

Gastroduodenal artery (GDA) aneurysms are rare, accounting for about 1.5% of all visceral arterial aneurysms. Two main entities of aneurysms exist: pseudoaneurysms occuring secondary to chronic pancreatitis and true aneurysms, less common and associated with artherosclerotic risk factors. The most serious complication of aneurysms is rupture with mortality rate of up to 70%. Early diagnosis is paramount to patient’s survival. GDAs may rupture into the superior mesenteric vein causing bleeding esophageal varices or into the peritoneum causing hemorrhagic shock or into the gastro-intestinal tract (GIT) causing hematemesis, melena or hemobilia. We herein report the case of a GDA rupture into the gastro-intestinal tract (GIT) which presented with sudden onset of abdominal pain and hypotension. Melena and hematochezia, typical clinical presentation associated with GIT bleed were absent secondary to severe opioid-induced fecal impaction. Despite this, high suspicion and early angiographic intervention helped in saving the patient’s life.

CASE DESCRIPTION/METHODS:

A 72-year-old male with a remote history of ulcerative colitis and active metastatic stage IV prostate adenocarcinoma to the brain, spine and bladder presented to the hospital with abdominal pain, hematuria and hypotension. He was admitted a week prior with similar complaints (right-sided flank pain and hematuria). In the ED, BP 94/46 with a leukocytosis of 11 and hemoglobin of 6.8. Foley catheter was placed with return of 400 cc of frank blood. He received 2 units of blood and was admitted to the ICU. Physical examination on admission was significant for abdominal distention, tenderness and hypoactive bowel sounds. He rapidly decompensated despite aggressive fluid resuscitation and vasopressors. He went into PEA arrest and ROSC was obtained after multiple ACLS rounds. CT A/P showed contrast extravasation at the posterior wall of the gastric body. Our GI service performed emergent EGD. There was a single deep, cratered and punched-out ulcer measuring 4 cm that was spurting blood. 3 clips were applied to control the bleeding. The following day, IR successfully embolized the GDA. Blood pressure stabilized and the patient was weaned off the ventilator and extubated. He was discharged hemodynamically stable.

DISCUSSION:

Giving the rarity of GDA rupture, there are no clear screening or follow-up guidelines. Decisions about diagnostic and therapeutic procedures should be prompt and made on an individual basis.
2003 Extragastric Dieulafoy’s Lesion: A Rare and Often Missed Cause of Upper Gastrointestinal Bleeding
Authors: Sherrill Zachary , Chand Gaurav , Mank Gerald
Published: October 2019

INTRODUCTION:

Dieulafoy’s lesions (DL) are an important, potentially life threatening, cause of gastrointestinal (GI) bleeding. Dieulafoy’s lesions are dilated, aberrant, submucosal arteries that erode overlying GI mucosa in the absence of an underlying ulcer, aneurysm, or intrinsic mural abnormality. They account for approximately 1.5% of acute upper GI bleeding and 70% of these lesions are found within 6 cm of the gastroesophageal junction. Although uncommon, DL have been reported in the duodenum, distal stomach, and esophagus. We present a case describing the discovery and management of an extragastric DL within the duodenum.

CASE DESCRIPTION/METHODS:

An 83-year-old male with multiple comorbidities, on warfarin therapy, presented to the hospital by instruction of his primary care physician for evaluation of a low hemoglobin (Hgb). He has a history of chronic anemia with regularly monitored Hgb. The patient endorsed 4 days of painless, dark, loose stools. He reported a similar episode to this several years prior and underwent upper and lower endoscopy, which were unrevealing. Capsule endoscopy at that time did show a small bowel arteriovenous malformation, but otherwise unremarkable. On admission, the patient was hemodynamically stable with mild pallor noted on exam. Initial workup revealed Hgb of 6.8 g/dL and an INR of 3.1. Upper endoscopy was performed revealing a single spurting spot of active bleeding in the second part of the duodenum consistent with a DL. The area was successfully treated with epinephrine, coagulation, and hemostatic clips. He remained hospitalized for five days post-procedure for medical optimization. His Hgb remained stable and his warfarin was resumed.

DISCUSSION:

Dieulafoy’s lesions are a rare cause of upper GI bleeding that should always remain on the differential diagnosis. While gastric DL are well-known, there are few reports describing DL of the duodenum. The scarce nature of their occurrence make these lesions difficult to diagnose. Thorough endoscopic evaluation is usually the first diagnostic test performed for acute upper GI bleeding. Thus, this is the primary modality used for the diagnosis of DL. Initial EGD is diagnostic in only about 70% of cases due to relatively small lesion size, intermittently active bleeding, and lesion location. This case represents a patient with acute on chronic anemia that had previously undergone a thorough investigation with few answers. Serial Hgb monitoring and follow-up endoscopy led to the discovery and treatment of his duodenal DL.
2006 Epigastric Artery Aneurysm Bleeding Post-Percutaneous Endoscopic Gastrostomy
Authors: Raza Syed Musa , Chiu Yiu-Ting , Samant Hrishikesh
Published: October 2019

INTRODUCTION:

Percutaneous endoscopic gastrostomy (PEG) is commonly used to provide enteral nutrition in patients unable to maintain adequate nutrition orally. There is limited data on aneurysmal bleeding following PEG. When this occurs, it is typically severe and is a life-threatening complication leading to hemorrhagic shock. Prompt recognition and treatment are imperative to survival. Extensive literature review revealed five case reports of post-PEG pseudoaneurysm. We present a summary of reported cases and their respective management.

CASE DESCRIPTION/METHODS:

We present a case of a 50-year-old female, status post orthotopic liver transplant, who had a complicated post-op course and ICU stay. The patient developed a cerebral infarct in Pons region which led to dysphagia. Therefore underwent PEG tube placement by “pull” technique. Later on, the patient experienced recurrent episodes of PEG site bleeding. She underwent EGD which showed massive upper GI bleed from percutaneous endoscopic gastrostomy fistula tract. Hemostasis was initially achieved using bear claw but also required endoclips and surgical intervention in the end. CT imaging revealed a pseudoaneurysm at the PEG site within the rectus muscle, arising from the epigastric artery, measuring 19.8 mm × 17.8 mm. It was treated with thrombin injection. The resolution of aneurysmal bleed was confirmed on follow up imaging.

DISCUSSION:

We found 5 similar cases with patients 70 to 85 years old, who predominantly had a pull technique PEG tube placement. Imaging confirmed gastrostomy site pseudoaneurysm, involing left gastric or gastroepiploic artery, was a complication in all cases which were either treated by lipiodol injection, angiographic embolization and/or thrombin injection. Our patient had a pseudoaneurysm involving epigastric artery which is a novel presentation. Placement of PEG with transillumination carries a risk of rare complication if inserted in an upper triangle involving superior epigastric artery. Therefore an attempt must be made to keep PEG away from the superior epigastric triangle. Pull technique is used much more commonly and It is unlikely to be the cause of these aneurysmal complications however, data is limited and more review studies are needed. Also, more evidence is needed to compare outcomes of the transillumination method vs US/fluoroscopic guidance placement.
2029 Perforated IVC Filter Leading to Duodenocaval Fistula and Massive Gastrointestinal Bleeding
Authors: Hayat Maham , Hanafi Muhammad Z. , Yohannan Bryce , Hayat Muhammad Hashim , Moten Aqsa , Grossen Alyssa , Bolkhir Ahmed
Published: October 2019

INTRODUCTION:

Inferior Vena Cava (IVC) filters are primarily indicated for patients with a history of deep venous thrombosis (DVT) or pulmonary embolism (PE) who have contraindications to anticoagulation. In most patients, the indication for placement of a filter is temporary. Although filter penetration of the IVC wall has been reported to range from 9% to 24% for all IVC filters, symptomatic perforation is rare and is reported to occur in about 0.4%-0.8% of cases. We are presenting a rare case of duodenocaval fistula presenting as massive gastrointestinal bleeding.

CASE DESCRIPTION/METHODS:

A 39-year-old male with a history of motor vehicle accident 10 years ago resulting in paraplegia and multiple lower extremity DVTs which required the placement of an IVC filter at that time was admitted to the hospital with one day of nausea, vomiting and hematochezia. History was very concerning for high volume bright red bleeding per rectum with associated non-bilious vomiting and dizziness. On arrival, he was hypotensive with a blood pressure of 60/40 mmHg, physical examination significant for actively oozing bright red blood per rectum. Labwork was remarkable for a Hemoglobin of 7.0 mg/dL and a BUN of 35 mg/dL. A CT scan of abdomen/pelvis with contrast revealed an IVC filter strut travelling through the IVC wall and perforating to the adjacent small bowel with active extravasation of the IV contrast to the small bowel, suggestive of a fistulous communication between IVC and a perforated loop of bowel. The patient was emergently taken to the operating room for exploratory laparotomy. IVC filter strut was found to be eroding through the IVC and into the duodenum confirming the CT findings. Transverse venotomy was performed and the filter was removed. An area of small bowel serosal tear was incorporated into the enterectomy segment, and end to end small bowel anastomosis was performed. IVC was repaired, and hemostasis was secured. Post-operatively, patient stayed stable clinically and hemodynamically with cessation of hematochezia.

DISCUSSION:

Duodenocaval fistula is a very rare complication of IVC filter placement, with around 10 reported cases in the literature. Even though it is rare, our case highlights the importance of a thorough and timely sensitive workup for an unstable patient with gastrointestinal bleeding and history of an IVC filter placement to rule out IVC penetration into surrounding viscera, since this can lead to significant morbidity and mortality if not recognized early during the clinical course.
2044 Metastatic Breast Cancer: Another Crohn’s Mimic?
Authors: Penn Natalie M. , Agostini-Vulaj Diana , Huber Aaron R. , Dunn Andrew L. , Skalski Kamila , Marino Danielle E.
Published: October 2019

INTRODUCTION:

In the US, breast cancer (BC) is the 2nd most common cancer diagnosed in women. Approximately 30% of women diagnosed with BC develop metastatic disease. Usually, it spreads to the liver, brain, bones and lungs; rarely it spreads to the GI tract. We present a case of metastatic breast cancer (MBC) to the GI tract that initially mimicked Crohn’s disease.

CASE DESCRIPTION/METHODS:

A 66 yo female with a history of right-sided, invasive, lobular BC, s/p lumpectomy, radiation, and adjuvant hormonal therapy presented to her physician with complaints of irregular bowel habits and reflux. An EGD revealed a hiatal hernia and inflammation of the antrum with normal biopsies. A colonoscopy revealed abnormal rectal mucosa with edema, friability and narrowing; biopsies showed prolapse-type changes. Due to progressive and worsening symptoms, a flexible sigmoidoscopy was done. This revealed raw and inflamed tissue in the distal rectum with severe stricturing, requiring dilatation. Repeat biopsies were unremarkable. Crohn’s disease was in the differential as the responsible etiology for the rectal stricture; thus, an MR enterography was done. Multiple skip lesions throughout the GI tract, consistent with Crohn’s disease, were demonstrated and mass-like thickening (without inflammatory changes) in the antropyloric region was also evident (Figure 1). EGD/EUS revealed pyloric stenosis with a thickened and edematous pylorus and duodenal bulb (Figure 2), and hypoechoic tissue in the muscularis propria of the distal antrum/pylorus. FNA and mucosal biopsies were nondiagnostic. Repeat colonoscopy demonstrated a significant distal rectal stricture without mucosal abnormalities. Repeat biopsies, this time, demonstrated poorly differentiated MBC with IHC staining consistent with the patient’s previous lobular mammary carcinoma (Figure 3). The patient subsequently underwent an ex-lap gastrojejunostomy and was found to have a large bulky mass on the serosal surface of her pylorus and duodenum. She is currently on salvage therapy for MBC.

DISCUSSION:

Our case demonstrates that diagnosing MBC to the GI tract may prove evasive. In a patient with a history of BC and persistent/worsening GI symptoms, it is imperative that one keeps the differential broad and includes MBC to the GI tract as a real possibility. Early endoscopic evaluation with biopsies and appropriate IHC staining of samples should be performed in suspected cases. MBC should be on the list of etiologies that can mimic Crohn’s disease.
2051 Tofacitinib Improves Refractory Crohn’s Disease-Associated Arthritis
Authors: Gordon Benjamin , Longman Randy , Scherl Ellen J.
Published: October 2019

INTRODUCTION:

Tofacitinib is a Janus kinase (JAK) inhibitor shown to be effective in several inflammatory conditions, though it has limited efficacy in luminal Crohn’s Disease (CD). Here, we report the case of a woman with refractory CD-associated arthritis that improved markedly on tofacitinib.

CASE DESCRIPTION/METHODS:

A 38-year-old woman with history of CD and enterocutaneous fistula status post right hemicolectomy presented with severe sacroiliitis and arthritis for 20 years. Her Harvey Bradshaw Index (HBI) was 7, notable for “terrible wellbeing” secondary to arthritis and 2 soft stools daily. Her CD-associated arthritis was refractory to sulfasalazine, mycophenolate mofetil, methotrexate, adalimumab and ustekinumab. Family history was notable for a father with rheumatoid arthritis. Exam demonstrated sacral spine tenderness, bilateral knee effusions, and right ankle effusion. Laboratory work-up was notable for negative HLA-B27, rheumatoid factor and double stranded DNA antibody. MRI lumbosacral spine showed fluid signal in the right sacroiliac joint, concerning for sacroiliitis. Based on her CD and imaging, she met criteria for ankylosing spondylitis. Given her continued joint pain, she was initiated on tofacitinib 10 mg twice daily. Within one month of treatment, the patient noted significant improvement in joint pain and stiffness, with HBI now 2, only notable for two soft stools daily. Five months after initiating tofacitinib, her CD-associated arthritis was still in remission.

DISCUSSION:

Tofacitinib, an oral JAK inhibitor, has been shown to have efficacy in rheumatoid arthritis, psoriasis, and ulcerative colitis (UC). In UC, tofacitinib improves clinical and endoscopic response and remission. By contrast, tofacitinib has been shown to have limited efficacy in inducing clinical response and remission in CD, although it has been associated with decreased CRP and fecal calprotectin. Yet, there are case reports detailing tofacitinib’s use for extraintestinal manifestations of CD, including pyoderma gangrenosum. Despite its use in other inflammatory arthritides, to our knowledge, this is one of the first case reports characterizing improvement of CD-associated arthritis with tofacitinib. This case demonstrates that tofacitinib can quickly improve CD-associated arthritis refractory to other biologic therapy. Although tofacitinib may have a limited role in luminal treatment of CD, future studies should evaluate its use for extraintestinal manifestations of CD, including CD-associated arthritis.
2058 A Case of Disseminated TB in a Patient With Colonic Crohn’s Disease on Anti-TNF Therapy
Authors: Hopp Grace , Patel Harsh D. , Garapati Karthik , Wright Randy P.
Published: October 2019

INTRODUCTION:

Abdominal tuberculosis (TB) comprises 5% of all tuberculosis cases and can involve organs such as the intestinal tract, peritoneum, and liver. One of the many risk factors for development is use of an anti-tumor necrosis factor agent. We present a rare case of disseminated tuberculosis involving the peritoneum in a young female with well-controlled Crohn’s disease on biologic therapy.

CASE DESCRIPTION/METHODS:

A 44-year-old female with Crohn’s pan-colitis (in remission; on maintenance Azathioprine and Adalimumab since 2015); presented with worsening abdominal pain and distension over three weeks. She reported fever, chills, and night sweats. On arrival, she had a low-grade fever with diffuse abdominal tenderness to palpation and shifting dullness. Laboratory tests revealed a CRP of 115, CA-125 of 472, and an indeterminate Quantiferon-Gold. A CT abdomen/pelvis showed ileocecal valve inflammatory changes, nodular omental thickening with ascites and a pleural effusion (Figures 1–3). A transvaginal ultrasound was normal. A diagnostic paracentesis revealed lymphocyte predominant ascitic fluid with a SAAG of 0.4. Fluid cytology was unremarkable; however, the culture returned positive for Mycobacterium TB. An omental biopsy was performed and was positive for AFB with necrotizing granulomas. AFB sputum culture was also positive. She was started on RIPE therapy for disseminated TB. There was low concern for an IBD flare and given on-going treatment of active tuberculosis, no additional therapy was initiated.

DISCUSSION:

Abdominal tuberculosis can occur by a few mechanisms and can involve multiple sites, one being the intestines. Both intestinal tuberculosis and Crohn’s disease may present with abdominal pain, diarrhea, bleeding, constitutional symptoms, and even fistula formations. Imaging and endoscopy are usually needed to differentiate the two. In tuberculosis, the ileocecal region is affected in 75% of cases, the ulcers are transverse, and bowel wall thickening is asymmetric. Ascites is usually present, with a SAAG of < 1.1. In Crohn’s disease, the ulcers are longitudinal, bowel wall thickening is symmetric, and there is no ascites. It is important to recognize these distinctions given the clinical overlap of disease and symptomology. TNF alpha-inhibitors increase the risk of developing tuberculosis. There is little data available to assist in reinitiating biologics in the setting of disseminated TB. Most often these medications are restarted after the completion of TB therapy with close follow-up.