bluuebunny/crossref_metadata_2025_split huggingface dataset:
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.
2060 Sclerosing Mesenteritis Treated Successfully With Ustekinumab: An Off-Label Use of Infliximab and Ustekinumab
Authors: Byriel Ben , Walker Megan J. , Fischer Monika 
Published: October 2019

INTRODUCTION:
Sclerosing Mesenteritis is a rare, non-neoplastic, inflammatory condition that affects the mesentery. It typically presents with a variety of gastrointestinal symptoms such as abdominal pain, nausea, vomiting, and diarrhea, but is largely variable. It is often treated successfully with steroids, estrogen modulators, anti-purine metabolites, and other antineoplastic agents. However, due to the wide ranging side-effect profiles of these medications, treatment limitations can arise when these options are exhausted. This case is particularly interesting considering the depth of the treatment algorithm pursued, and the potential change in management of sclerosing mesenteritis for future patients.

CASE DESCRIPTION/METHODS:
A 45-year-old male presented with intermittent left upper quadrant pain with associated nausea, vomiting, and diarrhea. CT scan of the abdomen revealed diffuse central mesenteric stranding and lymphadenopathy. Histopathology of the mesentery revealed fatty necrosis and foamy histiocytes, consistent with a diagnosis of sclerosing mesenteritis. Over the course of years, the patient was treated with prednisone, azathioprine, colchicine, cyclophosphamide, and methotrexate, but had persistent symptoms and intolerable medication side effects. He was started on infliximab, enabling him to decrease his prednisone dose to 12.5 milligrams daily and had symptom free remission. Six months later, he developed mesenteric large B cell lymphoma and infliximab had to be discontinued. The patient went into remission after R-CHOP chemotherapy. Due to chronic prednisone use, he had developed osteoporosis, bilateral cataracts, and diabetes mellitus type 2. Faced with a lack of other pharmacologic options and concern for continued glucocorticoid usage, an off-label use of ustekinumab was pursued. The patient was induced with a 520 milligram dose IV and continued on 90 milligram dose SQ every 8 weeks, leading to complete resolution of his symptoms. The patient was able to be weaned to 10 mg of prednisone daily, his lowest in 15 years, and is continuing to wean the prednisone with help of endocrinology.

DISCUSSION:
This case highlights successful utilization of infliximab and ustekinumab for steroid-dependent sclerosing mesenteritis. It may implicate the role of TNF-alpha and interleukins 12, 23 in the pathogenesis of the disease, and suggests alternative treatments to traditional pharmacologic therapy are available.
2065 A Rare Case of IgA Vasculitis Secondary to Infliximab Use in Crohn’s Disease
Authors: Vangimalla Shiva , Mirza Muhammad U. , Choden Tenzin , Malhotra Nidhi 
Published: October 2019

INTRODUCTION:
The advent of Infliximab (IFX) has revolutionized the treatment for inflammatory bowel disease. Although the most common adverse effects include infusion site reactions and loss of response due to antibody formation, there have been some reports of secondary autoimmune conditions. Herein, we report a rare case of IgA vasculitis likely as a result of IFX therapy.

CASE DESCRIPTION/METHODS:
A 53-year-old female with known fistulizing ileocolonic Crohn's disease (CD) on IFX since 2002, multiple bowel surgeries for her CD, rheumatoid arthritis, and postoperative deep vein thrombosis, presented with a 2-week history of progressive petechial rash on her bilateral lower extremities (Figures 1 and 2). Skin biopsy of one of the lesions was notable for granular deposition of IgA consistent with IgA vasculitis. She was initiated on oral Prednisone 1 mg/kg/day. Three weeks later, she was transitioned to oral Dapsone with a slow prednisone taper. The next day, the patient developed abdominal pain with nausea and vomiting. CAT scan of the abdomen was notable for a large thrombus in the descending thoracic aorta. A thorough workup for small vessel vasculitis was undertaken which was negative with pertinent negative tests including ANCA, Cryoglobulin levels, Rheumatoid Factor, serum electrophoresis, protein C & S, Anti-thrombin 4 level, Anticardiolipin antibody, and Beta-2 glycoprotein level. She was treated with anticoagulation for the aortic thrombus with IV heparin and then later transitioned to oral Rivaroxaban. Repeat CAT scan a month later showed resolution of the clot in the aorta. Regarding the Crohn’s disease, a decision was made to switch her therapy from IFX to Ustekinumab for maintenance of remission.

DISCUSSION:
IgA mediated vasculitis is a rare adverse reaction which can be caused by anti-tumor necrosis factor (TNF) agents and remains poorly understood. It has been described with all the commonly used anti-TNF agents and usually occurs after several months of use. In our patient, this occurred after several years of use. None of the other medications on her list were noted to have an association with IgA mediated vasculitis. Clinical symptoms can range from local cutaneous manifestations to multi-system involvement. In our patient, skin and large vessel (aorta) were involved. The resolution of symptoms may be achieved by discontinuing use of the culprit anti-TNF agent and initiating adjuvant treatment. Alternative non-anti-TNF therapies should be pursued for definitive treatment.
2066 Much Ado About Nothing: Isolated Raised ALP in IBD Patients Due to Macrocomplex
Authors: Gupta Kamesh , Singhania Rohit , Rizwan Shahid , Knox Spencer C. 
Published: October 2019

INTRODUCTION:
Macro-Alkaline Phosphatase (ALP) is a rare benign condition characterised by increased plasma ALP activity due to an immunoglobulin-bound form of ALP. Due to an autoimmune process, antibodies can be generated against any of the enzymes, leading to the formation of “macroenzymes”, which interferes with the correct laboratory measurement of the native enzymes. These have been identified for several enzymes including alkaline phosphatase (ALP), amylase, AST, creatine kinase, γ-glutamyl transferase and lactate dehydrogenase.

CASE DESCRIPTION/METHODS:
51-year-old woman with a long-standing history of ulcerative colitis and psoriasis presented for establishing care. She reported alternating diarrhea and constipation and musculoskeletal pains but no jaundice or itching. Her labwork showed normal levels of AST, ALT and total bilirubin but raised ALP (190 units/L, UNL-103). Hepatic origin of raised ALP was confirmed with mildly elevated GGT (42 U/L, UNL- 37). Repeat labs done at monthly intervals showed persistently elevated ALP ranging between 140-240 U/L. She underwent extensive workup to rule out an obstructive pathology, including a USG and MRCP which were unremarkable and liver biopsy which showed preserved hepatic architecture with minimal steatosis. Fractionation of her ALP via gel electrophoresis showed Macro-ALP complexes. She was followed up for a period of 2 years, with persistently elevated ALP but no obstructive symptoms or liver dysfunction.

DISCUSSION:
Isolated raised ALP is a common finding seen in up to 16% of hospitalized patient. However, this becomes concerning in patients with IBD due to its association with disorders of the hepatobiliary system, particularly Primary Sclerosing Cholangitis, seen in upto 5% of IBD patients The mean time from the development of symptoms of IBD to the diagnosis of PSC was 2.3 months. The biochemical parameters are consistent with cholestasis. Our patient was beyond the time frame for the development of PSC and showed no symptoms of signs of cholestasis. Macro-ALP as a cause of persistently elevated ALP has been reported twice earlier in literature. Strategies to identify macro enzymes include polyethylene glycol precipitation,counter-immunoelectrophoresis or gel electrophoresis. In general, the identification of macro-enzyme complexes is important to rule out pathological causes of raised serum enzyme activity and avoid unnecessary and potentially harmful diagnostic investigations.