bluuebunny/crossref_metadata_2025_split huggingface dataset:
2527 Posterior Perforation Arising From a Duodenal Diverticulum
Authors: Leung David , Gaddipati Kishore 
Published: October 2019

INTRODUCTION:
Duodenal diverticulums (DD) are present in 6-22% of the general population on autopsy, however, it is uncommon to be symptomatic. We present a rare case of a patient who developed a posterior perforation of a duodenal diverticulum.

CASE DESCRIPTION/METHODS:
An 82-year old male presented with a chief complaint of weakness. On admission, the patient was found in septic shock, thought to be from pneumonia and started on antibiotics. Due to a lack of bowel movements over several days, a KUB was ordered and showed ileus of the proximal small bowel. The following day he developed large melanotic stools and laboratory workup revealed a hemoglobin of 5.6. The patient was resuscitated and underwent an endoscopy. A large ulcer covering 50% of the duodenal circumference with a large tract was discovered (Figure 1). A follow-up CT abdomen (Figure 2) demonstrated fluid and edema surrounding the pancreas, pneumoperitoneum, and fluid collection in the third portion of the duodenum. Additionally, a UGI with gastrografin (Figure 3) showed a diverticulum in the third portion of the duodenum with extravasation of contrast into the retroperitoneum indicating perforation. Surgery revealed a diverticulum of the second portion of the duodenum. The perforation was found to lead into the retroperitoneal space and directly into the body of the pancreas. Unfortunately, the patient would develop multi-organ failure secondary to fulminant septic shock and passed away.

DISCUSSION:
It is uncommon for duodenal diverticulums to be symptomatic with only about 10% doing so. They can present with upper abdominal pain, obstruction, ulcer, diverticulitis, perforation, and pancreatitis. Bleeding can occur but is rare. DD can be classified as primary acquired diverticula or secondary diverticula, which is caused by peptic ulceration. They are thought to be caused by herniation of the mucous membrane through the muscular coat at sites weakened by the passage of blood vessels or aberrant growth of pancreatic tissue. Perforations associated with duodenal diverticulums are typically located in the anterior portion of the duodenum or stomach however, spontaneous non-traumatic posterior perforation is a distinct clinical rarity, not commonly encountered. Posterior perforations tend to present late due to insidious onset. These ulcers perforate into the retroperitoneal space or lesser sac. Local inflammatory reaction and fibrosis of the adherent retroperitoneal space tend to seal off these perforations which may explain their vague symptoms.
2533 Primary Mesenteric Lieomyosarcoma: A Rare Case Report
Authors: Affas Saif , Zamorasifuentes Jose , Mendes Juliann , Barawi Mohammed 
Published: October 2019

INTRODUCTION:
Sarcomas are a rare, heterogeneous group of neoplasms with varied histolopathological presentation, that share a common mesenchymal cell line origin. Soft tissue sarcomas tend to grow along tissue planes and can compress surrounding tissue, leading to the formation of pseudocapsules and finger-like projections that can infiltrate into adjacent tissue. Despite this, sarcomas rarely metastasize to regional lymph nodes. Sarcomas in the gastrointestinal tract encompass both gastrointestinal stromal tumors (GISTs) and leiomyosarcomas, which are rare neoplasms arising from smooth muscle cells and commonly misdiagnosed at GISTs. Mesenteric leiomyosarcomas usually present as a gradually enlarging, painless abdominal mass with associated symptoms usually arising from compression by the tumor.

CASE DESCRIPTION/METHODS:
A 68-year-old African-American female with history of hypertension, diabetes mellitus, and latent tuberculosis presented with decreased oral intake secondary to nausea, vomiting, and diarrhea for 2 days and unintentional 10-pound weight loss over a 2-month period. Physical examination revealed right upper quadrant tenderness. Computed tomography (CT) with IV contrast of the chest, abdomen, and pelvis showed a large right-sided solid mesenteric tumor causing extrinsic compression of the proximal and mid-portion of the right ureter with prominent right-sided hydronephrosis. CT guided biopsy revealed a smooth muscle neoplasm concerning for leiomyosarcoma with uncertain malignant potential. A right-sided ureteric stent was inserted to relieve extrinsic compression. An explorative laparotomy showed the tumor to be encasing the right ureter. Excision of the tumor along with right mid ureter was done with restoration of ureteric continuity via ureteroureteral anastomosis.

DISCUSSION:
Mesenteric leiomyosarcomas are rare and aggressive soft tissue tumors most commonly arising in the ileum. Biopsy is not recommended for local resectable tumors; however, it should be considered if metastatic disease is suspected or if preoperative imatinib is being considered prior to resection in the setting of a large locally advanced lesion. Treatment options depend on invasion of adjacent structures, including either local or en bloc resection. However, no nodal dissection is needed due to the rarity of nodal metastases.
2543 Duodenal Traditional Serrated Adenoma (TSA) Presenting as Small Bowel Intussusception
Authors: Urquhart Siri A. , Quinn Kevin P. , Alexander Glenn L. 
Published: October 2019

INTRODUCTION:
Intestinal intussusception is the telescoping of a proximal into an adjacent distal segment of the gastrointestinal (GI) tract. Intussusception is rare in adults, accounting for less than 5% of all mechanical bowel obstructions. Approximately 80-90% of intussusceptions in adults are secondary to an underlying pathological process, including malignant lesions, polyps, or Meckel's diverticulum. Therefore, when intussusception occurs in adults, further investigation to determine the etiology is warranted.

CASE DESCRIPTION/METHODS:
A 48 year-old female without significant past medical history developed severe, episodic abdominal pain six to eight weeks prior to presentation with associated nausea and occasional emesis. Recent CT scan of the abdomen and pelvis with contrast demonstrated small bowel intussusception in the area of the ligament of Treitz (Figure 1). Laboratory investigations were notable for microcytic anemia. She was referred to gastroenterology and underwent extended esophagogastroduodenoscopy (EGD) which revealed a 4 cm mass in the fourth portion of the duodenum (Figure 2). Initial mucosal biopsy suggested a possible tubulovillous adenoma with low-grade dysplasia. She subsequently underwent surgical resection of the small bowel mass with duodeno-jejunostomy. Surgical pathology revealed a traditional serrated adenoma (TSA) with low-grade dysplasia forming a cluster of polyps ranging from 0.5 to 4.3 cm in size (Figure 3). She did well postoperatively and was discharged on post-operative day 6. She will be undergoing colonoscopy after recovering from surgical intervention.

DISCUSSION:
Of the three types of serrated adenomas, TSA is the least common, accounting for only 5% of serrated polyps. These are commonly found in the colorectum and have rarely been described in other portions of the GI tract. The first case of TSA of the duodenum was not described until 2004. More recently, TSAs have been detected throughout the upper GI tract. However, reports of TSAs causing small bowel intussusception have not been described. This novel case highlights the importance of considering this in the differential for any adult with proximal small bowel intussusception. Importantly, TSAs of the upper GI tract may represent more aggressive lesions with high malignant potential and should be excised to rule out the possibility of a developing malignancy.
2544 Black Speckled Duodenal Mucosa
Authors: Saleem Sheikh A. , Heisig David 
Published: October 2019

INTRODUCTION:
Pseudomelanosis of the duodenum is characterized by a collection of pigment-laden macrophages in the tips of duodenal villi. It is a rare incidental endoscopic finding seen in elderly patients and is of unknown clinical significance. We describe a case of an elderly patient who presented with GI bleeding and was found to have pseudomelanosis duodeni.

CASE DESCRIPTION/METHODS:
An 83 yo Caucasian female with a history of hypertension, chronic kidney disease, hypothyroidism and atrial fibrillation presented to the hospital with hemodynamically stable GI bleeding. Her home medications included aspirin, furosemide, metoprolol, levothyroxine and coumadin. An EGD was done which showed black speckled appearance of the duodenal mucosa. The duodenal biopsy showed a mild inflammatory component in the lamina propria with focal aggregates of iron containing brown pigment laden macrophages. Review of her past medical records revealed that she had an UGI series done about two years ago which showed irregular duodenal mucosa concerning for small ulcers however the patient declined an endoscopy at that time.

DISCUSSION:
Pseudomelanosis duodeni was first reported by Bisordi and Kleinman in 1976 and is most commonly seen in elderly female patients. The exact pathogenesis of the condition is still unclear. It is seen in association with certain medical conditions such as hypertension, chronic kidney disease and diabetes mellitus. Unlike pseudomelanosis coli, pseudomelanosis duodeni does not have a known association with anthraquinone containing laxatives but is seen in conjunction with sulfur containing antihypertensive medications and iron supplements. It has been postulated that coupling of absorbed iron with sulfur from antihypertensive medications leads to the formation of iron sulfide, the dark color pigment which is then taken up by the macrophages. Pseudomelanosis duodeni on endoscopy has the characteristic appearance of flat, black-speckled pigmented mucosa. Biopsy is the gold standard for diagnosis, and this demonstrates aggregates of pigment laden macrophages in the apical portion of the duodenal villi. The diagnostic and prognostic significance of pseudomelanosis duodeni is unknown. To date there is no evidence that this condition is a precursor for neoplasia or any other progressive pathology. Therapeutic chelation or endoscopic follow-up for pseudomelanosis duodeni is not recommended.
2552 A Rare Case of Ileocecal Intussusception in a Young Adult
Authors: Patino Sanja , Akhter Sharmin , Hutton Anneka , Eisner Todd D. 
Published: October 2019

INTRODUCTION:
Intussusception is a process in which a segment of bowel telescopes into the adjoining intestinal lumen. The pathophysiology is unclear but it is typically due to a pathologic lead point within the bowel, which is malignant in over 50% of cases. The clinical presentation of adult intussusception is non-specific, unlike the characteristic triad of abdominal pain, palpable abdominal mass, and bloody stool seen in pediatric patients. It is a rare cause of abdominal pain in adults, comprising only 5% of all intussusceptions.

CASE DESCRIPTION/METHODS:
A 29-year-old Peruvian male with no significant medical history presented with right lower quadrant abdominal pain and diarrhea for two weeks with an unintentional 15 pound weight loss. Abdominal CT demonstrated intussusception with likely underlying mass in the region of the ileocecal valve. Colonoscopy revealed an ileocecal mass (Figures 1 and 2) that was too large to pass with the endoscope. The patient subsequently underwent a right hemicolectomy and omental flap. Pathology of the mass showed diffuse large B-cell lymphoma (DLBCL), germinal center type. Further evaluation revealed a positive HIV test with a CD4 count of 29 cells/mL.

DISCUSSION:
Adult intussusception is a rare clinical entity and requires prompt imaging and diagnosis to prevent severe complications. A retrospective review of 44 cases found that ultrasound and CT resulted in a combined preoperative diagnosis rate of 95.5%. Literature review suggests surgical resection is the optimal management in adults given the high incidence of underlying malignancies. Controversy remains regarding the ideal surgical approach between primary resection versus reduction followed by resection. Several retrospective studies propose resection without reduction is the best approach for ileocecal intussusception to avoid potential intraluminal seeding or venous tumor dissemination. Our patient was diagnosed via CT and treated by surgical resection without complications. Further diagnostic workup revealed the etiology to be a DLBCL in the setting of HIV/AIDS. This case highlights the importance of identifying an underlying mechanism for the development of intussusception in young adults. The incidence of primary lymphoma in the small intestine is rare and accounts for 1-4% of all gastrointestinal malignancies and 10-20% of small intestine malignancies. Through this case presentation, we hope to contribute to the limited available data on cases of adult intussusception.
2563 When Considering a Broad Differential to Diarrhea and Joint Pain: Don't Forget About Whipple's Disease
Authors: Miller Justin A. , Chastant William C. , DiBuono Bryan D. , Galliano Gretchen E. , Raines Daniel 
Published: October 2019

INTRODUCTION:
Whipple's disease (WD) is a rare systemic disease caused by bacteria Tropheryma whipplei and commonly overlooked as a diagnosis.

CASE DESCRIPTION/METHODS:
A 42-year-old man presented to the ED for intolerance chronic of diarrhea, lower extremity swelling, paresthesia, migratory monoarticular arthralgia, and weakness. Over 2 years he lost 60-pounds and had early satiety, intermittent dysphagia, and decreased concentration. Physical exam was remarkable for a scaphoid abdomen with mild diffuse tenderness, knee joint tenderness, lower extremity strength 4/5. Labs abnormalities: hemoglobin 6.5 g/dL, albumin 1.9, 25-OH vitamin D 5 ng/mL (nml > 30 ng/mL), CRP 25.4 mg/L. Bilateral lower extremity ultrasound showed a blood clot in the right deep femoral vein and bilateral baker's cysts. Colonoscopy and EGD examinations were unrevealing. Histologic exam of duodenum biopsies showed dilated fat vacuoles and a positive periodic acid-Schiff (PAS) stain confirming Whipple's Disease. Cerebrospinal fluid was negative and cognitive changes improved with electrolyte replacement. He was treated with a 14-day course of intravenous ceftriaxone followed by Bactrim doubled-strength twice a day. After intravenous antibiotics, the diarrhea resolved and he regained weight.

DISCUSSION:
WD most commonly affects men (86%), farmers (35%), and those with occupational exposure to soil or animals (66%). Transmission is thought to be fecal-oral since sewage workers are more prevalent carriers. Common symptoms are weight loss, arthralgia, diarrhea, and abdominal pain. Arthralgia is the sentinel symptom preceding others by ∼6 years. Less common include skin hyperpigmentation, endocarditis, and CNS symptoms (severe disease). Three diagnostic tests exist: PAS-staining, PCR of the 16S ribosomal RNA of T. whipplei, and immunohistochemistry (IHC) via rabbit anti-T. whippleiantibodies. Diagnostic criteria include: 1) small intestine biopsies positive on PAS stain for bacillus material in the lamina or 2 positive tests from other origins. Initial testing is done with EGD and duodenal biopsies submitted for PAS staining and PCR testing ± IHC. If extraintestinal symptoms, PAS staining and PCR testing ± IHC on tissue or fluid samples. CSF should be tested by PCR in all cases. After diagnosis, treatment starts with a 2-week course of IV of antibiotics (4 weeks if CNS infection or endocarditis) followed by one year of Bactrim. Relapse occurs in 17-35%, years later.
2568 A Unique Case Presentation of Small Bowel Intussusception
Authors: Kulkarni Archana , Appasamy Ragunath 
Published: October 2019

INTRODUCTION:
Intussusception is a life-threatening condition and can cause ischemia of the small intestine if not intervened promptly. When present in adults, intussusception typically is caused by a neoplasm, adhesions of the small bowel, or resultant of weight loss surgeries. Below we describe a unique intervention provided to a case presentation of intussesception.

CASE DESCRIPTION/METHODS:
21 y.o. year old female with a past medical history of chronic abdominal pain, PTSD, suicide attempts, gender dysphoria, gastroesophageal reflux disease, depression, presented to the emergency department with secondary to abnormally low hemoglobin, abdominal pain, nausea and vomiting. She described pain in the epigastric abdominal region. She had no known family history of colon cancer, colonic polyps or other malignancies. She was noted to have a hemoglobin of 4.4 with no overt bleeding. She was tested negative for celiac serologies. She was evaluated with a CT scan of the abdomen and pelvis with IV contrast which showed long segment of proximal jejunal intussusception with associated inflammatory changes. The surgical team approached the gastroenterology team to attempt to reduce the intussusception prior to surgical resection. As a result of which a push enteroscopy was performed where in a normal esophagus, with erythematous mucosa in the gastric fundus and gastric body were seen. The duodenum was normal. An intussusception was encountered after the C-loop of the duodenum, around the proximal jejunum. This was reduced with the scope. A vascular appearing jejunal mass was seen. Biopsy was not attempted given the vascular appearance. A tattoo was applied. The patient subsequently underwent jejunal resection with small bowel anastomosis. The pathology of the mass resulted as benign hamartomatous polyp with surface erosion and no dysplasia. The patient's symptoms and anemia resolved post operatively. In addition she was evaluated with an upper endoscopy and flexible sigmoidoscopy previously which were within normal limits.

DISCUSSION:
Hamartomatous polyps of the small intestine can be associated with Cowden syndrome, Bannayan-Riley Ruvalcaba syndrome (BRRS), and juvenile polyposis syndrome (JPS). The above mentioned patient is unique as she does not meet criteria for any of these syndromes. In addition the emergent symptom relief was provided by endoscopic reduction of the intussusception providing the surgeons for a planned elective procedure rather than an emergent procedure.
2569 Eosinophilic Gastroenterocolitis: A Diagnostic Conundrum and a Rare Cause of Small Bowel Strictures
Authors: Omer Anam , Pinillios Hugo L. 
Published: October 2019

INTRODUCTION:
Eosinophilic gastroenterocolitis (EGE) is a rare disorder that can have several gastrointestinal manifestations depending on the site and depth of involvement. The diagnosis involves demonstration of eosinophilic infiltration of bowel wall and exclusion of other causes of peripheral eosinophilia. We present a rare case of eosinophilic gastroenterocolitis that presented as chronic diarrhea and partial gastric outlet obstruction.

CASE DESCRIPTION/METHODS:
A 71-year-old male presented to the clinic for evaluation of a two-month history of watery diarrhea. He had recently been hospitalized for management of profuse diarrhea and dehydration. Extensive infectious work-up during the hospitalization was unrevealing. A colonoscopy with biopsies was negative for microscopic colitis and malabsorptive disorder, however, a prominent population of eosinophils suggestive of an allergic component was seen. The patient's symptoms were partially controlled on anti-motility agents. His current medication list was negative for any offending drugs. Physical examination revealed a mildly distended abdomen. Laboratory investigation showed a total leukocyte count 6.7 × 109/L. Differential count revealed polymorphs −50%, lymphocytes −34% and eosinophils −10%. Computed tomography with contrast showed segmental areas of narrowing in mid descending limb of the duodenum with partial gastric outlet obstruction. Esophagogastroduodenoscopy (EGD) showed multiple diaphragm-like strictures at the duodenal sweep which could not be passed with a regular EGD scope. Histologic examination of the specimens taken from the duodenal strictures revealed mildly increased plasma cells and eosinophils within the lamina propria with villous blunting, without increased intraepithelial lymphocytes. Numerous balloon-dilation sessions were needed to reestablish luminal patency. A diagnosis of eosinophilic gastroenterocolitis was made and the patient was started on a six-food elimination diet with complete resolution of his symptoms. Upon reintroduction, the culprit food were found to be cow's milk and wheat.

DISCUSSION:
EGE is classified based on the depth of eosinophilic infiltration as mucosal, submucosal and serosal. The most frequent sites of involvement include the stomach and the proximal small bowel. Diagnosis is often challenging and delay in treatment may lead to malabsorption and malnutrition. Although evidence of efficacy is lacking, treatment with dietary modification and corticosteroids has shown favorable outcomes.
2573 Appendicitis—Think Sarcoidosis? Appendicular Sarcoidosis Presenting as Acute Appendicitis
Authors: Pendela Venkata Satish , Munoz Anisleidys , Soliman Youssef , Soliman Megan 
Published: October 2019

INTRODUCTION:
Sarcoidosis is a chronic inflammatory multisystem disease. Organs typically affected include the lungs, lymph nodes and skin. Gastrointestinal involvement although not uncommon, is usually asymptomatic. Stomach is the most commonly involved gastrointestinal organ, but esophagus, appendix, colon, and rectum have also been implicated. Symptomatic appendicular sarcoidosis is extremely rare. We present a rare case of symptomatic appendicular sarcoidosis.

CASE DESCRIPTION/METHODS:
A 49 year old woman with a history of chronic low back pain and recurrent kidney stones presented to the office with vague abdominal pain for 3 days. Exam revealed a right iliac fossa tenderness. Lab work was significant for mild anemia (Hemoglobin 11 gm/dl) and elevated ESR (30 mm/hr). A CT abdomen showed acute appendicitis, and detected an appendicular mass. A prior MRI of the spine had shown a suspected metastatic lesion. CT chest revealed mediastinal lymphadenopathy, and a spiculated lung nodule. Laparoscopic appendectomy was performed, and the pathology revealed non-necrotizing granulomas raising suspicion for sarcoidosis. Bronchoscopic ultrasound-guided biopsy of the lymph nodes also revealed granulomas. Serum angiotensin converting enzyme levels were elevated (68 U/L). The patient's symptoms improved following initiation of corticosteroids.

DISCUSSION:
There are a number of differentials for granulomatous inflammation of the appendix, notably Crohn's disease, tuberculosis, histoplasmosis and Yersinia pestis infection.
1
Appendicular involvement of sarcoid is very rare and is most often diagnosed incidentally on a PET scan. The clinical presentation of appendicular sarcoidosis may range from pain to perforation and abscess formation.
2
Surgical intervention should not be delayed in patients with sarcoidosis presenting with right iliac fossa pain as there is a high risk of perforation. Such a systemic disease process typically involves other organs, and can be relatively controlled with systemic steroids.