bluuebunny/crossref_metadata_2025 huggingface dataset:
2537 Case of an Incidental Small Bowel Adenocarcinoma Upon Surgical Evacuation of a Retained Video Capsule Endoscopy in a Patient With Crohn's Disease
Authors: Moon Nabeel
Published: October 2019

INTRODUCTION:

Here we report the case of a patient with Crohn's disease in whom a video capsule got lodged in a small bowel stricture and upon surgical evacuation of the capsule small bowel adenocarcinoma was incidentally found. This case emphasizes that it is important to consider small bowel adenocarcinoma in Crohn's disease patients with obstructive signs. This case also demonstrates the management of a retained capsule in Crohn's patients.

CASE DESCRIPTION/METHODS:

A 28 year old male with history of Crohn's disease presented for an evaluation of bright red blood per rectum and severe anemia. Initial evaluation with a colonoscopy and EGD revealed no source of bleeding and thus a video capsule was placed. Two days after placement of the capsule the patient began having severe abdominal pain. A KUB revealed that the capsule was still at the ileocecal valve, indicating that it was possibly stuck in a stricture. The patient was started on IV methylprednisolone in order to reduce inflammation to allow for passage of the capsule. Upon further evaluation, surgical intervention was necessary to remove the capsule. In the operating room the surgeons visualized a tumor in the jejunum arising from a Crohn's stricture. Despite multiple inspections of the resected small bowel the capsule could not be located. An intraoperative x-ray revealed the capsule to be in the splenic flexure of the colon indicating that the capsule passed through the stricture prior to resection. The final pathology revealed metastatic poorly differentiated adenocarcinoma.

DISCUSSION:

Small bowel adenocarcinoma is a recognized however overlooked complication of Crohn's disease. In patients with non-concerning colonoscopies with signs of obstruction (such as a retained capsule) and severe anemia, small bowel adenocarcinoma should be strongly considered. Capsule retention is often diagnosed via abdominal x-ray such as in our case. A retained capsule often remains asymptomatic however carries the risk of perforation, secondary obstruction, or ulceration. Double-balloon enteroscopy is considered the primary method for capsule retrieval however surgical exploration is often done. The concern for the capsule being lodged in a stricture in our patient made surgery the best option. We did first attempt IV methylprednisolone and within the five day interval prior to surgery the capsule had passed into the colon. In Crohn's disease patients, immunosuppressive medications such as steroids and infliximab have been shown to facilitate capsule passage.
2539 Case of a Young Man With Small Bowel Obstruction After Trauma
Authors: Lysek Michael , Stibbe Jason R. , Raines Daniel
Published: October 2019

INTRODUCTION:

In few reports, trauma has been associated with small bowel obstruction. These cases typically happen in children; however, in adults this is a rare phenomenon. We present a case in a young male with a history of MVA 5 years prior, who presented for small bowel obstruction related to his prior trauma.

CASE DESCRIPTION/METHODS:

A 27 yo male presented with recurrent abdominal pain for six months. He had intermittent diarrhea, abdominal bloating, and a 15 lb weight loss over that time. Physical examination was normal. Basic laboratory studies were significant for T bili of 1.4 mg/dl (normal 0.1 - 1.0). Diagnostic EGD, colonoscopy, and CT scan of the abdomen/pelvis were normal. Due to concern for a potential diagnosis of small bowel Crohn's disease, a video capsule study was performed, which showed a hold-up in the mid small bowel for over 2 hours, without any other abnormalities. Due to this, an upper double balloon enteroscopy was performed, which was revealing for a stenosis in the distal jejunum. The stenosis was marked with submucosal india ink injection. Biopsies of the stenosis were unrevealing. Previous medical history was negative with the exception of a motor vehicle accident complicated by intra-peritoneal bleeding five years ago, which was managed conservatively without surgery. Review of this patient's medications was negative for any NSAID use. He had no history of radiation exposure or abdominal surgery. He had never experienced any symptoms of abdominal pain or bloating prior to the onset of symptoms 6 months ago. Family history is negative for celiac disease or inflammatory bowel disease. Surgical resection of the stenotic segment was performed. The patient recovered from surgery without complication. Histopathology from the resected segment was consistent with benign small bowel without inflammation or other pathologic features. The conclusion of the medical providers was that this patient developed a symptomatic stricture as the result of previous MVA with hematoma.

DISCUSSION:

Small bowel obstruction from trauma has been highlighted in few cases in children; however, trauma-causing small bowel obstruction (SBO) in adults is more rare. Throughout the cases we reviewed, the timeline of this trauma causing SBO ranged from thirteen weeks to eight years after the initial event.2,3,4 In this case, the man presented five years after his MVA with symptoms of bowel obstruction, with a prior hematoma being the cause of this obstruction. This case highlights MVA as a cause of SBO in adults.
2550 Henoch-Schönlein Purpura Mimicking Crohn's Disease in a 65-Year-Old Male
Authors: Lee Edwin J. , Kang Sohyun , Miller John W. , Marino Danielle E.
Published: October 2019

INTRODUCTION:

Henoch-Schönlein purpura (HSP) is a small vessel vasculitis typically seen in children, often presenting with abdominal pain, purpuric rash, arthritis, and hematuria. Also known as immunoglobulin A (IgA) vasculitis, it is mediated by the deposition of immune-complexes containing IgA in the skin, gut and kidneys. Although rarely seen in adults, adult cases are associated with a more severe course than in pediatric patients. We present the case of adult-onset HSP with GI involvement.

CASE DESCRIPTION/METHODS:

A 65-year-old retired male dairy farmer with recent travel to Southwest US presented with a 6-week history of abdominal pain in the setting of a subacute, diffuse, purpuric rash. After admission, computed tomography (CT) imaging revealed ileitis with fat stranding and mesenteric vascular engorgement, concerning for Crohn's disease (Figure 1). Patient was also found to have proteinuria and arthralgia. Stool infectious work-up was unrevealing. Skin biopsy of the rash identified leukocytoclastic vasculitis and IgA deposition. Patient then underwent colonoscopy with ileoscopy, which scattered areas of congested appearing mucosa with deep purplish discoloration surrounded by normal mucosa (Figure 2). Scattered, nonspecific, rare small erosions and focal erythema were also seen throughout colon and rectum (Figure 3). Biopsies indicated mildly active ileitis and focal areas of active colitis with foci of hemorrhage in the right and transverse colon; there was no evidence of chronicity. Though non-specific, histologic findings were consistent with IgA vasculitis, rather than Crohn's. Patient was started on intravenous (IV) steroids and azathioprine. His rash and abdominal pain improved considerably after 48 hours of treatment.

DISCUSSION:

HSP, although more common in children, can be seen in adults, and should be included on the differential diagnosis when abdominal pain and/or GI bleeding is seen with concurrent skin, renal, & musculoskeletal findings. HSP is associated with significant morbidity and mortality due to the rapid progression of the disease and recognition can be delayed, particularly in adults. This case of adult-onset HSP was quickly diagnosed and treated with appropriate anti-inflammatory therapy. HSP can mimic Crohn's disease, by history and imaging, but the endoscopic findings are very different. The case illustrates some of the endoscopic and radiographic findings of HSP, promoting awareness among adult gastroenterologists.
2555 Immune Check Point Inhibitor Enteritis: A Case of Severe Duodenitis From Nivolumab Therapy
Authors: Keyes Erin , Hammami Muhammad B. , Beck Kendall R.
Published: October 2019

INTRODUCTION:

Nivolumab, an immune checkpoint inhibitor, is an immunotherapy that has shown remarkable benefit in treating a wide range of cancers. However, by activating the immune system, these agents can cause immune-related adverse events (irAE). The gastrointestinal (GI) system is commonly affected, and typically presents with lower GI inflammation, such as colitis. Upper GI involvement is rarely reported. We present a case of nivolumab-associated duodenitis refractory to systemic corticosteroids but resolved after treatment with infliximab.

CASE DESCRIPTION/METHODS:

A 61-year-old man with a history of squamous cell carcinoma of the head and neck presented with intense cramping abdominal pain several weeks after nivolumab initiation. Given concerns for an irAE, he was initially treated with prednisone for 2 weeks, with minimal improvement in symptoms. He underwent esophagogastroduodenoscopy (EGD), which showed granularity and erythema of the duodenum with pathology consistent with duodenitis. He was referred to our institution, and treated with a course of IV solumedrol, which resulted in worsening abdominal pain and severe (grade 3) watery diarrhea. He was admitted to the hospital, and infliximab 5 mg/kg was initiated for suspected steroid-resistant immune checkpoint inhibitor-associated duodenitis/enterocolitis. He was noted to have rapid improvement in diarrhea and abdominal pain within 24 hours, with total resolution within nine days. After a second infusion of infliximab, he underwent a small bowel enteroscopy, which was unremarkable. His rapid improvement following infliximab further confirmed suspicion for an immune-checkpoint inhibitor medicated duodenitis/enterocolitis.

DISCUSSION:

As the use of checkpoint inhibitor immunotherapy grows, it is imperative that gastroenterologists be able to recognize and promptly treat GI immune-related adverse events, especially less common presentations involving the upper GI tract. Our case of nivolumab-associated duodenitis is an example of a rare immune-related adverse event that was refractory to steroids but responded to infliximab. Given no clear guidelines for duration of infliximab treatment, recommendations were extrapolated from IBD literature, with subsequent infusions recommended at two and six weeks. It has been reported that one-third to two-thirds of patients with immune-related GI toxicities do not respond to high dose systemic steroids or experience a relapse of symptoms. These are the patients that should be considered for infliximab.
2558 Mesenteric Panniculitis in a Young Adult: Case Report and Literature Review
Authors: Then Eric O. , Cercio Oleandro , Ofosu Andrew , Are Vijay S. , Culliford Andrea , Gaduputi Vinaya
Published: October 2019

INTRODUCTION:

Mesenteric Panniculitis (MP) is an inflammatory condition of adipose tissue located in the small bowel mesentery. The exact cause is unknown although current literature has described some associations that may lead to its development. These include infection, paraneoplasic syndrome, history of multiple abdominal surgeries and lymphoma among others. Here we present a rare case of mesenteric panniculitis accompanied by retroperitoneal fibrosis.

CASE DESCRIPTION/METHODS:

The patient is a 31 year-old female with a medical history of cholecystectomy, appendectomy and Roux-en-Y gastric bypass surgery who presented to our emergency department complaining of diffuse abdominal pain, lower back pain and non-bloody vomiting for one day. Physical exam was remarkable for a scar over her right lumbar area and splenomegaly. Notable laboratory workup included an alanine transaminase of 54 IU/L, aspartate transaminase of 192 IU/L, alkaline phosphatase of 154 IU/L, total bilirubin of 0.5 mg/dL and hemoglobin of 10 gm/dL. While in the emergency department the patient underwent computed tomography of the abdomen which showed retroperitoneal fibrosis with lymphadenopathy, left sided hydronephrosis and mesenteric panniculitis (Figures 1 and 2). The patient was then admitted for further management. During her admission the gastroenterology service was consulted and their impression was mesenteric paniculitis secondary to multiple abdominal surgeries. The rheumatology service was also consulted and recommended obtaining serologies for IgG-4; ANA; ANCA; ACE; and SPEP all of which returned within normal limits. During her course the patient underwent left nephrostomy tube placement to relieve the left hydronephrosis and was otherwise treated consertivately. She was then discharged home with pain medications and follow up appointments.

DISCUSSION:

Mesenteric Panniculitis is characterized by inflammation of the small bowel mesentery, specifically the adipose tissue that surrounds it. Current data suggests that MP is a male predominant syndrome with a ratio of 3:1 when compared to females. Symptoms of MP are non-specific and include abdominal pain, diarrhea, weight loss, and fever. Biopsy is the gold standard for diagnosis, but imaging such as CT scan may also aid in its identification. There is no consensus regarding treatment, but many cases have been successfully treated with prednisone. Prognosis of MP is usually favorable with no follow up required if it is not associated with malignancy.
2559 Adenosquamous Carcinoma of the Ileum: A Rare Entity Found Incidentally
Authors: Yacyshyn Sara , Chen Patrick , Krishnamurthy Padmini
Published: October 2019

INTRODUCTION:

Primary small bowel malignancy accounts for 0.6% of all new cancer cases in the U.S. and 1-3% of gastrointestinal tract neoplasms. The common subtypes of malignant small bowel tumors include carcinoid (44%), adenocarcinoma (33%), lymphoma, (15%) and sarcoma (8%). Adenosquamous carcinoma (ASC) is even more rare with only a few cases reported in the literature. The infrequency with which this malignancy is diagnosed and it's late and nonspecific clinical presentation contribute to delayed diagnosis and consequently worse prognosis.

CASE DESCRIPTION/METHODS:

A 58-year-old African American male presented for a surveillance colonoscopy. His initial screening colonoscopy at 53 years of age showed six polyps, of which, one was a 1 cm sized tubular adenoma. He had no history of gastrointestinal symptoms. During the colonoscopy and routine terminal ileum (TI) intubation, a 4 cm sized mass with central ulceration was visualized. The rest of the colonoscopy was significant only for two small hyperplastic polyps in the rectum. Endoscopic biopsies of the mass showed atypical epithelium. Further, abdominal computed tomography (CT) scan showed no lymphadenopathy or evidence of metastatic disease. He underwent exploratory laparotomy with ileocecectomy and pathology of the mass revealed poorly differentiated, high grade adenocarcinoma with areas of squamous differentiation, arising from a villous adenoma and extending into the muscularis propria (pT2).

DISCUSSION:

ASC can involve any organ including lungs, pancreas, liver, gallbladder and the gastrointestinal (GI) tract. ASC of ileum is an extremely rare diagnosis. Published case reports show that metastases of small intestinal ASC is common at the time of diagnosis. Our patient was fortuitous enough to have been diagnosed with ileal ASC in an early stage without evidence of metastasis, due to TI intubation during a routine colonoscopy. Surgical resection was likely curative for this patient. To our knowledge, no study has been published to evaluate the prevalence of TI malignant tumors during routine colonoscopy. In addition, intubation of the TI is currently not required during routine colonoscopy. This raises the question if there is utility in measuring TI intubation rates as a potential quality indicator for colonoscopists in the future.
2561 Not All That Ulcerates Is Crohn's: A Malignant Mimic of Small Bowel Crohn's Disease
Authors: Witt Danielle , Spenney Jerry G. , Peter Shajan , Edwards Adam L.
Published: October 2019

INTRODUCTION:

Capsule endoscopy (CE) is indicated in the evaluation of suspected Crohn's disease (CD) when ileocolonoscopy and radiographic studies are negative or inconclusive. However, it should be recognized that mucosal breaks or ulcers alone are not always diagnostic of CD.

CASE DESCRIPTION/METHODS:

A 55 year-old man from India who immigrated to the US as a child was admitted to an outside hospital with 6 months of bilateral lower quadrant abdominal pain and iron-deficiency anemia. After normal upper endoscopy and colonoscopy, CE showed an ulcer and inflamed mucosa in the ileum. On this basis he was diagnosed with CD and treated with prednisone. The next month he was admitted to our institution with ongoing abdominal pain and unintentional weight loss but no diarrhea or hematochezia. On exam his vital signs and body mass index were normal. His abdomen was soft without organomegaly or palpable mass. He was tender to palpation in the bilateral lower quadrants. Stool was brown. Laboratory results were Hgb 8.3 g/dL, iron studies consistent with iron-deficiency, albumin 2.8 g/dL, C-reactive protein 150 mg/L, and erythrocyte sedimentation rate 45 mm/hr. CT enterography showed wall thickening of the mid-ileum with mucosal enhancement and mesenteric root adenopathy. Retrograde double balloon enteroscopy 90 cm into the ileum revealed a 15 mm shallow ulcer 80 cm proximal to the ileocecal (IC) valve and a similar ulcer 15 cm proximal to the IC valve. Biopsies showed ulcerated mucosa with infiltrating atypical cells that stained positive for ERG, a highly specific endothelial marker, and negative for other immunostains, leading to a diagnosis of primary intestinal angiosarcoma.

DISCUSSION:

Primary intestinal angiosarcoma is a rare soft tissue sarcoma that may present with abdominal pain, GI bleeding, obstruction, or weight loss. Tumors, detected on 2-4% of CEs, are in the differential diagnosis for small bowel CD along with infection, ischemia, vasculitis, lymphoma, Behcet disease, radiation enteritis, and drug-induced enteritis. In suspected CD, there is no reference standard or uniform criteria for diagnosis by CE. And, many of the lesions that lead to a diagnosis of CD are non-specific with the specificity of CE for CD as low as 53% and the positive predictive value <60% in some studies. Thus, findings of CE should be interpreted with an adequate degree of skepticism and a broad differential diagnosis considered to minimize mimics being mistaken for CD.
2566 Essential Thrombocythemia and AVM-Related Gastrointestinal Bleeding: A Rare Paradoxical Phenomenon
Authors: Mulat Baruh , Nawaz Waqas , Hertan Hilary
Published: October 2019

INTRODUCTION:

Essential thrombocythemia (ET) is a myeloproliferative neoplasm characterized by excessive platelet production. It usually presents with thrombotic events. However, rarely, essential thrombocythemia may present with gastrointestinal (GI) bleeding. This phenomenon is seen paradoxically at very high platelet counts. We present a case of GI bleeding secondary to arteriovenous malformation (AVM) in a patient with platelet counts >1 million/uL.

CASE DESCRIPTION/METHODS:

A 74 year old male with history of hypertension, myeloproliferative disease, on hydroxyurea therapy, complicated by deep vein thrombosis requiring inferior vena cava filter placement, ischemic stroke, was admitted to inpatient rehabilitation after suffering from acute ischemic stroke 2 weeks ago. The patient was started on clopidogrel for acute stroke. He was found to have melena and gradual drop in hemoglobin (11.5 g/dL down to 6.5 g/dL). Complete blood count showed progressive rise in his platelet count (from 937 k/uL to 2.4 million/uL). Upper endoscopy revealed one small AVM in the fourth portion of the duodenum, treated successfully with hemostatic spray. Clopidogrel was switched to aspirin and hydroxyurea dose was increased for cytoreductive therapy as suggested by hematology. Subsequent colonoscopy revealed two non-bleeding AVMs in the cecum, treated with argon plasma coagulation (APC).

DISCUSSION:

ET is known to increase the risk of thrombotic events, including cardiovascular events, deep vein thrombosis, pulmonary embolism, retinal artery occlusion, digit ischemia and hepatic or portal vein thrombosis. However, ET also increases the risk for bleeding paradoxically with incidence rates ranging from 5-30 percent at the time of diagnosis. In GI tract, the bleeding is mostly from AVMs in ET. This phenomenon has been associated with qualitative defects and alteration in the platelets aggregation due to depletion of high-molecular weight von Willebrand factor multimers and development of an acquired von Willebrand disease. Interestingly, incidence of bleeding in ET correlates with the severity of thrombocytosis, mostly seen with extreme thrombocytosis (platelet counts >1 million/microL) [2-3]. Previous bleeding episode and use of antiplatelet drugs may further increases the risk of bleeding. Hydroxyurea is used for cytoreduction with platelet apheresis reserved for extreme cases where platelets exceed 1.5 Million/μl.
2567 A Rare Manifestation of a Bleeding Tubulovillous Duodenal Polyp Presenting as an Upper Gastrointestinal Hemorrhage
Authors: Dasu Neethi R. , Khalid Yaser , Itidiare Michael , Walters Richard , Suga Herman
Published: October 2019

INTRODUCTION:

Duodenal polyps are rare findings, they have been reported in only 0.3-1.5% of individuals who undergo upper endoscopy (EGD). They are histologically classified by mucin phenotype into intestinal (89.1%), morphologically tubular or tubulovillous adenomas, and gastric type (10.9%); grossly as sessile or pedunculated polyps, nodules, excrescences. They can be located either in the duodenal bulb, ampullary region, or distal duodenum. Duodenal polyps carry a low probability for malignant transformation, around 90% are non-neoplastic. We present a case of a 76-yr-old male who presented with hematemesis, an atypical and unusual manifestation.

CASE DESCRIPTION/METHODS:

A 76-year-old male presented for feeling “off” and increased respiratory secretions. Gastroenterology was consulted following an episode of coffee-ground hematemesis which was noticed while checking residuals after tube feeding. The patient's hemoglobin was 9.9 g/dL and he was hemodynamically stable thus EGD was not done. His hematemesis was thought to be secondary to apixaban and aspirin so both were stopped. However, his hemoglobin decreased to 6.6 g/dL and orogastric lavage revealed 1 liter of coffee-ground emesis. Subsequently, the patient underwent an emergent EGD which revealed a 10 mm pedunculated polyp in the proximal duodenum with active bleeding. The polyp was resected with hot snare and clipped twice with a resolution of bleeding and stabilization of his hemoglobin. The biopsy of the polyp tissue revealed a pedunculated, intestinal-type tubulovillous adenoma with minute foci of high-grade dysplasia (HGD).

DISCUSSION:

The isolated occurrence of such adenomas is rare and presentation as an upper gastrointestinal hemorrhage is even rarer. Our patient presented with a malignant subtype although around 90% are benign. His neoplastic pedunculated polyp was identified in the second portion of the duodenum, which is another atypical occurrence. His polyp was 10 mm, but with HGD, the odds of being malignant are higher as was seen on biopsy. There are currently no definitive guidelines on how a duodenal polyp should be resected; further studies are needed to assess techniques that can decrease mortality and prevent a recurrence. EGD techniques that are currently used include endoscopic snare and electrocautery, which was successful in this case. EGD surveillance within 1-6 months is recommended due to an increased risk of colorectal neoplasia. It is also important for practitioners to keep in mind rarer causes of upper GI bleeding.
2571 Unicentric Castleman Disease as a Cause of Ileal Perforation: A Case Report
Authors: Itani Wafic , Wazir Ali , Tageldin Omar , Patel Raina A. , Kristoffer Neu
Published: October 2019

INTRODUCTION:

Castleman disease is describes a group of heterogenous lymphoproliferative disorders that share histopathologic features. It is divided into Unicentric castleman disease (UCD) and Multicentric Castleman disease. We present a case of a patient with one year history of recurrent small bowel obstruction (SBO), which was found to be due to UCD affecting the mesentery.

CASE DESCRIPTION/METHODS:

A 75 years old gentleman initially presented one year ago with an episode of SBO. He had no history of abdominal or pelvic surgery. CT scan showed a transition point near the terminal ileum and mesenteric/retroperitoneal lymphadenopathy. Patient underwent a colonoscopy which showed a stenotic ileocecal valve with active colitis in the terminal ileum and ascending colon suggestive of resolving intestinal ischemia. This time, patient was admitted with decreased oral intake due to SBO. He was found to have a low albumin of 0.8 and an AKI on CKD. He also had bilateral pleural effusions and new ascites. He was treated conservatively initially, but he developed new abdominal pain with X ray showing free air under the diaphragm concerning for intestinal perforation. Patient underwent emergent laparotomy, where he had a perforated terminal ileum and multiple large fibrotic lymph nodes in the associated mesentery. Pathology showed proliferation of atretic follicles. There were occasional penetrating capillaries and the mantle lymphocytes have an onion-skin pattern. The interfollicular zones showed increased plasma cells, but not prominent vascular proliferation. CD3 and CD20 stains showed an intact immune-architecture. The overall findings showed a mixed pattern of Castleman lymphadenopathy, with some features of both the hyaline vascular and plasma cell variants. He had IgA of 510 mg/dl and an abnormal SPEP with IgG lambda paraprotein of 0.39 g/dl. His hospital course was complicated by septic shock due to bacterial and fungal peritonitis. Patient eventually went into cardiac arrest and died.

DISCUSSION:

Mixed variant CD is mostly multicentric, however, some patients with UCD reveal features of both hyaline vascular type and plasma cell type. In this case, apart from abdominal pain and recurrent SBO episodes, there were no other complaints. Acute phase reactants, CBC, and serological testing for HIV, HHV-8, Hepatitis B, Hepatitis C, RPR and PPD were all unremarkable. UCD is usually asymptomatic and generally curable using surgical resection but in this case led to severe complication ending in patient's demise.
2576 Terminal Ileitis: A Rare Gastrointestinal Complication of 5-Fluorouracil Therapy
Authors: Hashmi Saad , Hoff Ryan T. , Chi Kenneth
Published: October 2019

INTRODUCTION:

Ileitis is often seen in Crohn's disease and infection. Less often, it is associated with other conditions, including vasculitides, neoplasia, ischemia and medication-related complications. Ileitis typically presents with right lower quadrant abdominal pain and diarrhea; in some cases, it causes a small bowel obstruction (SBO). There are very few case reports of 5-fluorouracil associated ileitis and it is not well-described in literature.

CASE DESCRIPTION/METHODS:

A 66-year-old male with stage IV gastroesophageal junction adenocarcinoma was started on radiation therapy to the upper esophagus along with continuous infusion of fluorouracil (5FU). On day four of 5-FU, the patient developed severe mucositis causing dysphagia and odynophagia, requiring hospitalization and PEG-tube placement. With initiation of tube feeds, patient developed nausea, vomiting and watery nonbloody diarrhea. CT abdomen/pelvis showed SBO, with thickening of the distal small bowel thickening suggestive of terminal ileitis (Figure 1). Despite cessation of tube feeds, he continued to have diarrhea. C. difficile PCR, enteric pathogen panel, GI pathogen panel, and Yersinia culture were negative. He remained afebrile and without leukocytosis. Colonoscopy revealed inflammation of the terminal ileum characterized by erythema and ulceration (Figure 2). Biopsies of the terminal ileum showed chronic active inflammation (Figure 3). The terminal ileitis was attributed to treatment with 5-FU. With supportive care, the patient's diarrhea resolved and he was discharged home. 5-FU was held and patient received radiation therapy alone. Repeat colonoscopy 2 months later showed endoscopically normal mucosa. Biopsies showed nonspecific chronic inactive ileitis.

DISCUSSION:

We report a case of diarrhea and SBO associated with terminal ileitis, which was likely related to 5-fluorouracil therapy. Histology showed chronic inflammation with crypt architectural distortion, which are similar to the findings associated with radiation induced enteritis. However, this patient received only radiation therapy to the upper esophagus, none to the abdomen or lower abdomen. Infectious etiologies of ileitis were ruled out, and the ileitis resolved with discontinuation of 5-FU. Terminal ileitis may be an important diagnostic consideration in patients receiving 5-FU. We suggest that colonoscopies performed for diarrhea associated with 5-FU should include intubation into the terminal ileum when possible.
2579 Calcium Disorders in Celiac Disease
Authors: Naseer Usman , Wazir Ali , Patel Raina A. , Rahman Haider , Chung Jae , LaPorte Mackenzie , Malecki Elise
Published: October 2019

INTRODUCTION:

Celiac disease is known to affect calcium homeostasis in various ways leading to osteoporosis and osteopenia. We present a case of active celiac disease complicated by hypocalcemia and osteoporosis.

CASE DESCRIPTION/METHODS:

The patient is a 74-year-old male with known Celiac disease diagnosed 25 years ago. He had known hypocalcemia with secondary hyperparathyroidism treated with calcium and calcitriol supplements to maintain calcium levels (Corrected Calcium: 8.5 mg/dl with PTH of 89 pg/ml and 25-hydroxy Vitamin D of 80 ng/ml). The patient had a mechanical fall, a few months ago and subsequent DEXA scan showed osteoporosis (Bone mineral density of L1-L4 vertebral bodies was 3.5 standard deviation below normal). The patient was treated with an infusion of zoledronic acid. A week later the patient presented with malabsorptive diarrhea likely due to reported non-compliance with a gluten-free diet. On admission labs, he was noted to have severe hypocalcemia (ionized 0.8, corrected calcium was 6.7). Of note, his PTH had increased to 385. Incidentally, his INR was also noted to be mildly elevated at 1.5. Despite this, he had no apparent symptoms of hypocalcemia. During the admission, the patient had an EGD and biopsies were done showing mucosal changes consistent with celiac disease confirming dietary non-adherence. Hypocalcemia was treated with IV infusion of Calcium and he was discharged on increased doses of Calcitriol and calcium supplements with close follow-up with endocrinology.

DISCUSSION:

Celiac disease affects the small intestine including duodenum, the primary site of absorption of divalent ions including calcium. The intraluminal dietary fats bind to this calcium decreasing the absorption of fat-soluble vitamins K & Vitamin D. The parathyroids release more PTH in an attempt to maintain serum calcium levels through increasing osteoclastic activity. Other mechanisms active in celiac disease also increases bone resorption (See Figure 2). Bisphosphonates are a standard treatment for preventing osteoporotic fractures, by reducing osteoclastic activity. In this patient with active celiac disease, with low availability of dietary calcium, this resulted in hypocalcemia. This can be mitigated with closer observation and adjustment of doses of vitamin D and calcium supplementation when administering bisphosphonates.
2580 Nothing but NET: A Case of Neuroendocrine Tumor in the Duodenal Bulb
Authors: Baliss Michelle , Bilal Mohammad , Merwat Sheharyar
Published: October 2019

INTRODUCTION:

Neuroendocrine tumors (NETs) are rare neoplasms that comprise approximately 2% of all malignant tumors in the gastrointestinal system. The ileum remains the most common site of NETs in the small intestine, making up >70% of small bowel NETs. Duodenal NETs are exceedingly rare, comprising 2-3% of all gastrointestinal NETs and 1-3% of all duodenal tumors. We present a rare case of a patient diagnosed with a duodenal bulb NET.

CASE DESCRIPTION/METHODS:

A 66-year-old male with a past history of gastroesophageal reflux disease and hypertension presented to the gastroenterology clinic with a chief complaint of intermittent halitosis for the past year. The symptoms were unrelated to food intake. His recent dental examination was normal. He did not have a family history of gastrointestinal malignancies. His physical examination was unremarkable. Laboratory data including Helicobacter pylori antigen was unremarkable. He underwent esophagogastroduodenoscopy which demonstrated a 15 mm nodule in the duodenal bulb (Figure 1). Histopathological examination of the nodule showed a well-differentiated neuroendocrine tumor. Neuroendocrine immunohistochemical stains were positive for chromogranin and synaptophysin. Ki-67 was positive in 1% of tumor cells. CT scan of the abdomen revealed a 1.2 × 0.8 × 0.7 cm well-defined hyperattenuating structure in the posterior wall of the duodenal bulb (Figure 2). On endoscopic ultrasound, the lesion appeared to be located within the deep mucosa and submucosa without invasion of adjacent structures (Figure 3). The patient has been referred to medical oncology.

DISCUSSION:

The duodenum is an uncommon location for NETs. Duodenal NETs are typically small, single-lesion neoplasms, the majority of which are non-functional and diagnosed during the 6th decade of life. Unlike NETs of the jejunum and ileum that lack a gender preference, duodenal NETs carry a slight male predominance. Metastasis to regional lymph nodes is seen in ∼60% of cases and to the liver in less than 10% of cases. The absence of neuroendocrine clinical syndromes in >90% of duodenal NETs coupled with the rarity of this malignancy creates a noteworthy diagnostic challenge. It is therefore not surprising that the majority of these cases are diagnosed incidentally during work-up for other symptoms. With a rising annual incidence of NETs, it is important for gastroenterologists to keep this diagnosis in mind as a differential for any nodule in the duodenum.
2582 Diagnosis of Meckel's Diverticulum With Double Balloon Enteroscopy
Authors: Kim Denny , Chang Steven , Gross Seth , Latorre Melissa , Popov Violeta
Published: October 2019

INTRODUCTION:

Meckel's diverticulum (MD) is the most common congenital malformation of the gastrointestinal (GI) tract, present in 2-4% of the population. Typically, it presents as GI bleeding and is usually diagnosed in childhood. However, some patients may remain asymptomatic through adulthood or present later in life with complications. We describe an unusual case of an adult male presenting with abdominal pain and maroon stools, who underwent an extensive workup and was eventually diagnosed with MD only after a double-balloon enteroscopy (DBE).

CASE DESCRIPTION/METHODS:

A 29-year-old male with no significant medical history, presented with epigastric pain and melena for 2 days. He was initially hemodynamically stable with an admission hemoglobin of 8 g/dL. During his hospitalization, he passed intermittent maroon blood clots resulting in a hemoglobin drop to 6 g/dL, requiring 4 units of pRBCs. He had an extensive diagnostic workup including an EGD, colonoscopy, Meckel's scan, CT angiogram & push enteroscopy, which did not reveal a source of bleeding. Finally, a video capsule endoscopy showed active bleeding at 67% small bowel transit time. An anterograde DBE was then performed which showed no evidence of bleeding. Afterward, a retrograde DBE revealed a single bleeding diverticulum in the mid-ileum. The area was tattooed, and general surgery performed a laparoscopic small bowel resection of the Meckel's diverticulum. Pathology of the resected specimen was consistent with Meckel's diverticulum. The patient has remained asymptomatic since the surgery.

DISCUSSION:

We report the case of a young adult patient who presented with typical symptoms of Meckel's diverticulum but negative diagnostic examination with common practice Meckel's workup. A diagnosis was made only after the use of DBE after symptoms persisted, which calls to question whether certain imaging modalities are superior in adult-onset Meckel's than in the pediatric population in detecting MD. The sensitivity and specificity of Meckel's scan in children is 85% and 95%, respectively, but decreases to 62.5% and 9% in adults. A retrospective case-series found that DBE had a significantly higher mean diagnostic accuracy of 85.0% for MD compared to 21.4% for Meckel's scan. Mean diagnostic accuracies of other tests were as follows: VCE (36%), CT (32%), and angiography (10%). We suggest utilizing DBE much earlier in the diagnostic workup, in conjunction with capsule endoscopy, to better optimize diagnostic yield.
2583 Omental Infarction as a Cause of Acute Abdominal Pain
Authors: Muftah Abdullah , Muftah Mayssan , Tomolo Anne
Published: October 2019

INTRODUCTION:

Although rare, omental infarction is becoming an increasingly recognized cause of acute abdominal pain. The purpose of this vignette is to recognize omental infarction as a cause of acute abdominal pain and to discuss its management.

CASE DESCRIPTION/METHODS:

A 58-year-old male with history of aortic rupture, coronary artery disease, internal jugular thrombus, and prior stroke presented with three days of progressively worsening, constant, and sharp RUQ abdominal pain. It did not radiate and was unrelated to food intake. He had no relief with OTC pain medication. He denied fevers, nausea, vomiting, inability to tolerate food or liquids, change in bowel habits, or blood in his stool or urine. He denied alcohol, tobacco, or illicit drug use. On exam, the patient appeared uncomfortable; however, was afebrile with normal blood pressure, respirations, and heart rate. He had tenderness in the RUQ and epigastric regions with voluntary guarding but no rebound tenderness. Initial work up was without leukocytosis, transaminitis, acidosis, kidney injury, or elevated lipase. Abdominal x-ray was without free air. An abdominal CT was performed and showed a fat-containing mass lesion within the RUQ anterior to the liver measuring 2.7 × 1.9 cm with adjacent inflammation representing an omental infarction. The patient was managed with IV fluids and pain medication. No surgical intervention was warranted, and the patient was admitted to the medicine team for conservative management. Following 24 hours of observation, he was transitioned to an oral pain regimen and was advanced to a regular diet. He was discharged with pain medication to follow up with his primary care provider.

DISCUSSION:

Over 400 cases of omental infarction have been described in the literature. It most commonly occurs in middle-aged men. Pain is usually right sided, which may be secondary to longer, more mobile omentum that increases the risk of torsion and disruption of blood supply. Omental infarction can be both idiopathic or secondary to the presence of intra-abdominal pathology. Suspected risk factors for idiopathic presentations include obesity, laxative use, trauma, and excess exercise/strain. CT scan alone is sufficient for diagnosis given specific findings that include fatty oval shaped mass or hyper attenuating streaky infiltration. Management is typically conservative with IV fluids, pain control, and observation. Surgery is reserved for those with acute decompensation or progression of pain despite conservative measures.
2585 Distant Uveal Melanoma Presenting as Jejuno-Jejunal Intussusception After 11 Years!
Authors: Pandit Sarbagya , Wojtkowski Antoni , Thapa Pratikshya , Chalise Shyam
Published: October 2019

INTRODUCTION:

Metastatic melanoma of cutaneous origin is known to affect the GI tract. The jejunum and the ileum are commonly involved sites. Metastatic melanoma of uveal origin affecting the GI tract has been rarely reported.

CASE DESCRIPTION/METHODS:

A 46 year-old male with a diagnosis of right-sided ophthalmic uveal melanoma (diagnosed in 2007, treated with brachytherapy, with no evidence of recurrent disease) presented to Emergency Department with complaints of abdominal pain, nausea, and vomiting of 2 days. The CT scan of the abdomen showed a small bowel mass, measuring 4.3 × 4.6 × 6 cm causing intussusception. The patient underwent laparoscopic small bowel resection, and was found to have a jejunal mass causing intussusception. The mass was reported as malignant melanoma invading through the muscular wall into subserosal adipose tissue, and two lymph nodes were positive for metastatic melanoma. Next generation sequencing showed GNAQ and SF3B1 mutations, confirming metastatic uveal melanoma. The patient was initially started on a chemotherapy regimen and is now undergoing treatment with immunotherapy.

DISCUSSION:

Malignant melanoma of cutaneous origin has high metastatic potential. The GI tract is one of the most common sites of metastasis, among which the jejunum and the ileum are the most common sites. Most metastases go unrecognized or do not present clinically with gastrointestinal symptoms. Uveal melanoma does not contain recurrent BRAF or NRAS mutations, which are present in metastatic cutaneous disease. Common sites of metastasis of uveal melanoma include the liver, lung, soft tissue, and bone, whereas cutaneous melanoma metastasizes to the lung, soft tissue, and the GI tract. Cutaneous melanoma metastases to the GI tract have been reported multiple times in the literature, while uveal melanoma metastases to small bowel causing intussusception have rarely been reported. In our case, the patient had no evidence of disease for 11 years before he suddenly presented with GI symptoms. In patients with a history of uveal melanoma, metastatic melanoma should be considered when presenting with unusual GI symptoms.
2590 Autoimmune Enteropathy: A Rare Cause of Chronic Diarrhea
Authors: Park Erica
Published: October 2019

INTRODUCTION:

Autoimmune enteropathy (AIE) is a rare condition that may be easily missed without careful review of the patient's history and laboratory values. It is characterized by intractable diarrhea, malabsorption, abdominal pain, and anorexia.

CASE DESCRIPTION/METHODS:

A 74-year-old female with history of hypertension presented with 5 weeks of persistent nausea, vomiting, and diarrhea. These symptoms occurred while traveling. She denied consumption of unusual foods, drinking water from lakes, or fevers. Following her trip, she went to Boston. There, she had 8 non-bloody, watery bowel movements. She also noted abdominal distention and pain. She was given a 5-day course of ciprofloxacin without improvement. Once home, she presented again with weakness and dehydration. Infectious stool studies proved negative. She was treated with supportive care once again. On follow up, she was noted to have an 8-pound weight loss. She continued to have persistent diarrhea, leading to presentation to her third hospital. Repeat stool studies were positive for rotavirus. CT was consistent with enterocolitis. Labs were notable for fecal calprotectin 934, hypoalbuminemia 1.5 g/dL, and elevated CRP (44.2 mg/L). The patient underwent upper endoscopy and colonoscopy. Findings included diffuse granular mucosa with flattened villi in the gastric antrum, duodenum, and terminal ileum. Pathology revealed patchy chronic enteritis with crypt loss. The patient was started on IV solumedrol with improvement in symptoms. She was discharged on a prednisone taper for autoimmune enteritis.

DISCUSSION:

AIE is a rare disease among adults. AIE is diagnosed histologically by villous atrophy of the small intestine, as seen in our patient. The significance of anti-enterocyte and anti-goblet cell antibodies in AIE is unclear. A recent case series has shown no association between the clinical course and the type of gut epithelial cell antibodies. Treatment of AIE continues to evolve. Steroids are typically first used in order to control active disease. However, steroid-sparing therapies are preferred for long-term maintenance as this is a disease that typically requires ongoing immunosuppression. Use of TNF alpha-inhibitors has been trialed in a small number of patients. A recent case study studied the use of vedolizumab, an integrin-binding antibody, on a patient with good response. Overall, more cases are needed in order to improve understanding of AIE and to discover improved therapies for this rare disease.
2591 Endoscopic Management of Ingested Wooden Splinter Impacted in the Duodenum: A Case Report
Authors: Hussain We'am , Triplett Drew , Musleh Mustafa
Published: October 2019

INTRODUCTION:

Wooden particles, such as splinters off wood spatulas or toothpicks, being ingested is a rare but life-threatening event. In this case report, we will describe a case of duodenitis and focal duodenal perforation by a wooden splinter mimicking superior mesenteric artery vasculitis.

CASE DESCRIPTION/METHODS:

A 59-year-old female with past medical history significant for celiac disease not adherent to a strict gluten free diet, migraines and osteoporosis, presented to the emergency department (ED) with periumbilical and upper abdominal pain radiating to the back for the past 5 weeks. The pain is described as “sharp and tight” and exacerbated by food, leading to distention and bloating. The patient did endorse having regular bowel movements. On physical exam, she was in no apparent distress after receiving fentanyl in the ED; her abdomen was soft, non-tender, with normoactive bowel sounds. Computed Tomography (CT) angiography of the abdomen showed mild stranding surrounding the superior mesenteric artery (SMA) as it passed over the duodenum, as well as inflammation of the duodenum alongside several surrounding mildly enlarged lymph nodes, consistent with suspicion for duodenitis, ulceration, or SMA vasculitis. She was noted to have elevated C-reactive protein of 5.2 mg/L. Patient had an esophagogastroduodenoscopy (EGD) for further evaluation, which showed a toothpick impacted in the third portion of the duodenum, in the duodenal wall, and causing minimal ulceration around the impacted area, alongside significant duodenitis with erosions in the vicinity. The toothpick was dis-impacted with a snare and brought back to the stomach, then it was grasped with a cold biopsy forceps and removed completely from the patient in one piece. Patient was started on omeprazole daily for 8 weeks. She was started on short course of levofloxacin and metronidazole, as full-thickness perforation of the duodenum could not be ruled out.

DISCUSSION:

Wooden particle ingestion is a life-threatening event, with a mortality rate estimation of 9.6-18%. Early diagnosis and treatment are critical for reducing morbidity and mortality; however, a correct diagnosis may be challenging as many patients do not recall swallowing a toothpick or wooden splints. The symptoms associated with toothpick or wooden splint ingestion may be non-specific, such as abdominal pain, fever, or nausea caused by localized perforation/impaction. The most common site of toothpick lodgment or perforation is the duodenum (23%).