bluuebunny/crossref_metadata_2025_split huggingface dataset:
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%).