bluuebunny/crossref_metadata_2025_split huggingface dataset:
2763 A Case of Intermittent Organo-axial Gastric Volvulus
Authors: Gurala Dhineshreddy , Fady Haddad , Deeb Liliane 
Published: October 2019

INTRODUCTION:
Gastric volvulus is a rare clinical entity defined as twisting of the stomach along its long or short axis leading to gastric outlet obstruction (GOO). Commonly symptoms are acute and include retching, abdominal pain, and vomiting. Chronic intermittent manifestations of this entity constitute a diagnostic challenge as conclusive findings in imaging are only present during symptomatic periods and due to the intermittent nature of the disorder, a volvulus may spontaneously resolve before imaging studies are performed. Herein we illustrate a rare case of an intermittent organo-axial gastric volvulus that responded to conservative measures.

CASE DESCRIPTION/METHODS:
A 92-year-old female presented with intermittent epigastric pain and food intolerance of a few weeks duration. She reported dysphagia one year prior to presentation. Upper gastrointestinal (UGI) series showed gastric organo-axial rotation with no obstruction. Symptoms resolved at that time without any intervention. Physical examination revealed epigastric tenderness. Vitals and laboratory tests were unremarkable. UGI series showed a large para-esophageal hernia, an intrathoracic stomach with a gastric organo-axial rotation and partial obstruction at the level of gastroduodenal junction [Figures 1 and 2]. A contrast computed tomography (CT) scan of abdomen confirmed the same findings [Figure 3]. Endoscopic as well as surgical gastropexy were offered but the patient refused any intervention in view of her poor functional status. She was managed conservatively with intravenous fluids and bowel rest and was discharged 5 days later.

DISCUSSION:
Gastric volvulus was first described in 1866 as a torsion of the stomach around its short or long axis. Based on the axis of rotation, it was classified into organo-axial, mesentero-axial or combined. Organo-axial volvulus is common in adults, constitutes about 59% of cases and peaks after the 5th decade of life. It is mainly seen in the context of diaphragmatic abnormalities such as para-esophageal Hiatal hernias and diaphragmatic eventration. Diagnosis is challenging due to non-specific presenting symptoms. Contrast CT of abdomen and UGI series are gold standard diagnostic modalities. Endoscopic and surgical gastropexy is the mainstay of therapy. Heightened awareness is warranted in patients presenting with GOO in the setting of UGI tract anatomical abnormalities, since delayed diagnosis and management may lead to life-threatening complications and mortality rates up to 50%.
2764 An Unusual Presentation of Gastric Kaposi's Sarcoma
Authors: Akhavan Shahrzad Anita , Koya Nisha , Oak Rachana , Chum Christopher , Trillo John 
Published: October 2019

INTRODUCTION:
Kaposi sarcoma (KS) is a low grade angioproliferative tumor. AIDS-related KS is the most common and aggressive form of KS. The prevalence of AIDS-related KS is up to 30%. Skin is the most commonly affected organ in 78% of cases, The gastrointestinal (GI) tract is the most commonly affected extracutaneous site, and often asymptomatic. In advanced cases, patients may present with GI bleeding, diarrhea, protein-losing enteropathy, intussusception, or perforation. Although only 20% of KS patients experience GI symptoms, some studies have found that up to 80% of KS patients have GI lesions at autopsy. With the advent availability of HARRT therapy, the incidence of Kaposi sarcoma has decreased dramatically. Our objective is to present an unusual presentation of Kaposi sarcoma and its endoscopic findings leading to the diagnosis of KS, to share how endoscopy can be used as a tool for diagnosing and assessing the GI involvement in KS.

CASE DESCRIPTION/METHODS:
A 35-year-old African American male with HIV, syphilis, and hepatitis B complains of swelling of his legs and scrotum for 2 months. Physical examination revealed abdominal distension, bilateral lower extremity edema, and one skin nodule on his right foot. Laboratory studies revealed Hgb 8.7 g/dL, MCV 95.3 fL/cell, WBC 7500/cmm, CD4 count < 80 cells/uL, and albumin 1.4 g/dL. CT imaging revealed significant abdominal ascites (Figure 1). The patient underwent paracentesis removing 3.5 L of milky fluid. Fluid culture, gram stain and cytology were negative. Given the ascites and hepatitis history, an esophagogastroduodenoscopy (EGD) was completed in evaluating for possible esophageal varices. EGD revealed a nodular fungating lesion that extends diffusely from the gastric body into the duodenal bulb and sweep (Figures 2 and 3). Biopsy revealed cylindrical cells positive for HHV-8, confirming the diagnosis of gastric Kaposi's sarcoma (KS). Immunohistochemical analysis of the skin nodule biopsy confirmed KS. Computed tomography scan of the chest was consistent with pulmonary metastases. Patient is being treated with HAART and will be started on chemotherapy.

DISCUSSION:
KS is a rare neoplasm, and an AIDS-defining illness in HIV patients. About 40-51% of HIV patients with cutaneous KS will develop gastrointestinal KS, which is typically asymptomatic until growth is extensive enough to cause abdominal pain. This case illustrates the importance of endoscopic evaluation in HIV patients for early detection of gastrointestinal involvement of KS.
2766 An Atypical Case of Metastatic Lung Cancer Presenting as Abdominal Pain and Anemia
Authors: McDonald Emmanuel , Pinglo Monica , Panicker Linoj , Frontela Odayls , Avila Mark , Sobrado Javier 
Published: October 2019

INTRODUCTION:
Lung cancer is the second most common cancer in both men and women. In 2019, the United States estimate number of lung cancer cases are 228,150 resulting in 142,670 deaths. The most frequent sites of metastasis include liver, adrenal glands, bone, and brain. The majority of patients have advanced disease at clinical presentation. There are very few reported cases of lung cancer metastasis to stomach and duodenum. Gastric metastasis account for only 4.5% and metastasis to the small intestine account for only 5.8%. There are very few reported cases of lung cancer metastasis to stomach and duodenum. In these previously described cases, lung cancer diagnosis was already known prior to the presentation of abdominal pathology.

CASE DESCRIPTION/METHODS:
In this case, 59 year old female with no significant past medical history presented to the gastroenterologists’ office for abdominal pain. On laboratory examination, patient was found to have iron deficiency anemia which led to full gastroenterologic work-up. EGD was performed that showed a gastric lesion. Biopsies were taken resulting in the diagnosis of poorly differentiated carcinoma. The patient returned for biopsy and lab results, and was found to be weak and fatigued with a hemoglobin of 6. Patient was sent to the emergency room where imaging revealed a 2.4 cm endobronchial and intraparenchymal mass in the right upper lobe with distant metastases, in the left adrenal gland. There was also a 5.5 cm left cerebellar mass. An endobronchial biopsy of the right upper lobe mass, disclosed the diagnosis of non-small cell carcinoma. The gastric and lung biopsies were compared and confirmed to be similar in histology.

DISCUSSION:
Previously reported cases of primary lung carcinoma metastasizing to the abdomen included symptoms such as melena, dysphagia, obstructive jaundice, or perforation in patients with known diagnosis of primary lung cancer. This case is unique from prior published cases because the patient was not aware of primary lung carcinoma and the only presenting symptom was generalized abdominal pain followed by anemia. Through this case we want to emphasize the atypical presentation of metastatic lung cancer. We would also like to highlight thorough endoscopic and laboratory work up of any patient with anemia and abdominal pain. All age related screening test should be performed to exclude all differential diagnoses.
2767 Acute Gastric Volvulus - A Rare Complication of a Paraesophageal Hernia
Authors: Baruwa Etti Abisola G. 
Published: October 2019

INTRODUCTION:
Gastric volvulus is a rare clinical entity that involves rotation of the stomach along its long axis (organoaxial) or short axis (mesenteroaxial) through a perpendicular line connecting the greater and lesser curvatures. The most commonly observed association in adults is with a paraesophageal hernia.

CASE DESCRIPTION/METHODS:
60 year old female with a known paraesophageal hernia that was expectantly managed. She presented to the ED with a 10 hour history of intractable vomiting, dry heaves, epigastric discomfort and pleuritic chest pain. She denied constipation, fevers or chills. Vital signs were notable for tachycardia, tachypnea, hypoxia requiring 2 L of supplemental oxygen via nasal cannula. She was in obvious painful distress. Lung auscultation revealed decreased breath sounds throughout all lung fields. Her abdomen was not distended but was tender in the right upper quadrant region without guarding or rebound tenderness. Initial work up included cardiac evaluation for acute coronary syndromes which was negative. Liver enzyme and lipase levels did not support a diagnosis of hepatitis or pancreatitis as the etiology of her presentation. Chest X-ray demonstrated a massive hiatal hernia. CT Angiogram of her chest revealed a very large hernia occupying much of the mid thorax, which was significantly increased compared to the prior study. Her hospital course was complicated by persistent epigastric discomfort, nausea, and inability to tolerate oral intake. Upper GI series was obtained to further evaluate the paraesophageal hernia, and it demonstrated findings consistent with an organoaxial gastric volvulus with evidence of gastric outlet obstruction. She underwent laparoscopic paraesophageal hernia repair, gastropexy with gastrostomy tube insertion. Post operatively, she was able to tolerate a regular diet and discharged successfully.

DISCUSSION:
An acute gastric volvulus is a potentially life-threatening condition that requires a high index of clinical suspicion. Its intermittent nature, vague symptoms, and rarity of the disease may make diagnosis difficult. Gastric volvulus is seldom considered when a patient presents with abdominal or chest pain, associated with nausea and vomiting. A prompt and correct diagnosis followed by immediate surgery remains a key factor in reducing the associated morbidity and mortality. Keeping this diagnosis in mind may help to avoid the many potential adverse outcomes associated with this uncommon disease.
2768 Helicobacter pylori Infection: An Important Consideration in Patients With Suspected Cannabinoid Hyperemesis Syndrome
Authors: Kline Kevin , Bilal Mohammad , Parupudi Sreeram 
Published: October 2019

INTRODUCTION:
Cannabinoid Hyperemesis Syndrome (CHS) is a clinical diagnosis made by the combination of chronic marijuana use, episodes of cyclic nausea and vomiting, and concurrent stereotypical behavior including use of hot showers for symptom relief during these episodes. CHS represents an emerging problem in part due to the legalization of marijuana in parts of the United States. Despite its recognition, other more common etiologies of chronic, episodic nausea and vomiting should be considered within the correct clinical context. We performed a single center analysis to understand the burden of H. pylori infection in patients diagnosed with CHS.

CASE DESCRIPTION/METHODS:
We used our electronic medical record to identify all patients 18 years or older with an active diagnosis of CHS from May 2017 to May 2019. Patient charts were reviewed and the presence of H. pylori infection (defined as positive urea breath test, stool antigen, tissue stain or culture) was verified. 30 patients with CHS were identified, and 19 (63%) of these were tested for H. pylori. 6 (32%) of those patients were diagnosed with active infection. All six patients were prescribed standard triple or quadruple therapy, but only one was documented to have completed the therapy in whole. The treated patient was a 52 year-old male who had a longstanding history of episodic nausea and vomiting. Prior upper endoscopy at an outside facility showed duodenal ulcers. He was admitted to the hospital for intractable nausea and vomiting in setting of marijuana abuse. H pylori stool antigen resulted positive during admission. The patient followed-up in outpatient clinic after completing triple therapy and reported complete resolution of nausea and vomiting despite ongoing daily marijuana use.

DISCUSSION:
This is the first report of the rates of concurrent infection of H. pylori in individuals diagnosed with CHS. The reported prevalence of H pylori in the United States varies widely, with the largest analysis of gastric biopsies revealing a rate of 7.5% with general trends higher in African Americans and populations close to the United States-Mexico border. In CHS patients with H. pylori, compliance issues may contribute to persistent and untreated infection. Our single center analysis suggests that H. pylori rates may be higher than the general population in patients with CHS, but larger patient databases will be needed ascertain true treatment rates, and response to therapy.
2769 Large Gastric Gastrointestinal Stromal Tumor With Spontaneous Rupture of Necrotic Fluid Collection
Authors: Marple Eric J. , Magulick John , Cho Ryan 
Published: October 2019

INTRODUCTION:
Gastrointestinal stromal tumors (GIST) are the most common mesenchymal tumor of the gastrointestinal tract. Fluid collection within GISTs is very rare with only several case reports documented. We present the first case of spontaneous rupture from a large gastric GIST with necrotic fluid collection which has been documented on endoscopic exam.

CASE DESCRIPTION/METHODS:
A 91 year-old Caucasian female with a 3 month history of weight loss and progressive dysphagia to solids presented for evaluation. She was afebrile and hemodynamically stable with mild tachycardia. Initial labs revealed mild leukocytosis and low protein/albumin. Computer tomography demonstrated large 12 × 11 cm gastric mass with air-fluid level. Follow-up diagnostic esophagogastroduodenoscopy (EGD) showed a large fundic mass with two large cratered ulcerations with bridging mass in the proximal stomach with unremarkable histology on biopsy. Follow-up EGD with endoscopic ultrasound (EUS) demonstrated similar visualization with now small collection of purulent fluid though no fistula was appreciated. On EUS there was a larger heterogeneous hypoechoic mass bridging across all echo layers and a fluid echogenicity without doppler flow contained within the mass. Fine needle aspiration showed spindle cell neoplasm (CD117 +, DOG1 +) compatible with GIST. Given comorbidity and advanced age, she was not considered a surgical candidate. After starting Imatinib, she was offered therapeutic EGD was for possible decompression of the fluid collection within the tumor, to relieve mass effect for palliation. On visual exam there was again evidence of more purulent material that was extruding from a small opening in the center of the mass. The endoscope was advanced into the small opening and revealed a large fluid filled cavity within the mass. After copious irrigation with suction the majority of the cystic fluid was removed and two plastic double pigtail stents were placed to allow full decompression of the cystic cavity. On follow-up exam, she reported improvement of her pain.

DISCUSSION:
GIST are most often found in the stomach but overall account for 3% of all gastric malignancies. The initial presentation is often asymptomatic but there are many cases of highly variable symptomatic presentations of larger GIST. GIST with cystic changes are considered rare, with only 11 cases reported to date. This case is the first documentation of a cystic GIST that spontaneously ruptured, forming a fistulous tract between the cavity and the stomach.
2782 Disguised as IBD: A Rare Presentation of Diffuse Large B Cell Lymphoma in a Young Male
Authors: Biglin Mary , Oikonomou Ioannis 
Published: October 2019

INTRODUCTION:
About 1-4% of all gastrointestinal malignancies are primary non-Hodgkin Lymphoma (NHL) and the most common pathologic subtype is diffuse large B-cell lymphoma (DLBCL). Risk factors include environmental exposure, Epstein Barr Virus (EBV), immunosuppression, Helicobacter Pylori (H.Pylori), and human T-cell leukemia virus type 1. The majority of patients are males over the age of 40. Patients can present with vague abdominal pain, dyspepsia, vomiting, weight loss, and bleeding. Endoscopic findings vary and include ulcers, erosions, nodules, mass, erythema, and gastric fold thickening. With appropriate therapy, the 5 year survival can be up to 90%. This case illustrates a rare presentation of gastric DLBCL, emphasizes the importance of both a broad differential diagnosis in the immunocompromised and prompt endoscopy in those with alarm symptoms.

CASE DESCRIPTION/METHODS:
An 18 year old male with selective IgA deficiency and a family history of Crohn’s in his father presented with 3 months of cramping abdominal pain, diarrhea with small amounts of blood and tenesmus. He also reported night sweats and a 10 pound weight loss. History was negative for fevers, localizing infectious symptoms, arthralgias, skin or visual manifestations of IBD. Laboratory evaluation revealed normal WBCs at 7.2 × 109/L with relative lymphocytosis [lymphocytes: 68% (Norm 18-52%), Neutrophils: 22% (Norm 18-52%)]. The rest of labs including Hbg, liver enzymes, albumin and CRP were normal. Given concern for Crohn’s, EGD and colonoscopy were performed. Colonoscopy to the terminal ileum with ileal and colonic biopsies was normal. EGD revealed a 1 cm non-bleeding cratered gastric ulcer with elevated edges and mild erythema in the gastric body. Biopsy of the ulcer demonstrated atypical dense lymphoid cell infiltrate with morphology and immunohistochemical features consistent with EBV + DLBCL. Duodenal biopsies were negative for Celiac disease. Gastric biopsies were negative for H. Pylori. He completed chemotherapy with R-CHOP and is in remission.

DISCUSSION:
This case illustrates a rare presentation of primary gastric DLBCL, given his young age and presentation with bleeding (occurring in ∼10% of cases). Even though this patient had a seemingly classic presentation for Crohn’s Disease, it is critical to maintain a broad differential diagnosis in immunocompromised patients and prioritize endoscopy in those with type B symptoms (weight loss, night sweats) in order to lead to prompt diagnosis and treatment.
2785 Vanek's Tumor: A Rare Presentation of Abdominal Pain and Reflux Disease
Authors: Mertz Andrew , Junga Zachary , Damiano Mark 
Published: October 2019

INTRODUCTION:
Inflammatory fibroid polyps (IFPs), or Vanek’s tumors, are benign subepithelial tumors most commonly found in the stomach and small intestine. Histologically, they classically demonstrate spindle cell onion skinning with an abundance of eosinophilic infiltration. IFPs are most commonly found incidentally upon endoscopic evaluation, but may drive certain symptoms such as early satiety or epigastric pain depending on position. We describe a case of IFP successfully removed from the gastric antrum of a patient presenting with reflux and pain with resolution of symptoms after polypectomy.

CASE DESCRIPTION/METHODS:
A 47-year-old female with a history of gastroesophageal reflux with poor symptom control despite high dose twice daily proton pump inhibitor (PPI) therapy presented to the clinic for evaluation of worsening reflux. She also endorsed epigastric discomfort, chronic cough, and laryngitis. Her last upper endoscopy in 2015 was normal. Upper endoscopy was completed, which revealed the presence of a single pedunculated polyp measuring 1.2 cm in the gastric antrum near the pylorus. Polyp was removed with hot snare cautery and the residual defect was closed with clips. Given the endoscopic appearance, the lesion was initially thought to be hyperplastic. On pathologic review, the architecture and immunohistochemical profile was most consistent with an IFP. On follow-up several weeks later, the patient had improved reflux and abdominal pain symptoms and was then weaned off of her PPI without return of symptoms after several months.

DISCUSSION:
Although IFPs were initially postulated to be robust host responses to local injury with resultant inflammation, recent evidence has shown that IFP proliferation is driven by an activating mutation in the platelet derived growth factor receptor alpha (PDGFRA), which is suggestive of a neoplastic and possibly insidious etiology. While most are found incidentally and there are no guidelines on surveillance of these lesions, any large polyp in the stomach should be removed to reduce the risk of progression to malignancy. Furthermore, polyp removal may result in symptom improvement. Whether our patient’s symptom resolution was placebo-driven or actually a result of the IFP removal, our patient demonstrated a remarkable improvement exclusively with IFP polypectomy.
2786 Abdominal Pain in a Patient With Anorexia Nervosa
Authors: Lal Kailash , Slaby Isabella , Chiesa Drew 
Published: October 2019

INTRODUCTION:
Gastric ischemia is a rare cause of abdominal pain due to the rich blood supply to the stomach. The etiology for gastric ischemia is generally due to systemic hypotension, gastric volvulus, vasculitis or thromboembolism. Acute gastric ischemia can rapidly lead to morbidity and mortality due to the formation of large hemorrhagic and necrotic ulcers unless recognized early. We present a case of gastric ischemia in a patient with a psychiatric history.

CASE DESCRIPTION/METHODS:
A 60 year old female presented to the ER with acute epigastric pain and nausea. She denied any history of alcohol, aspirin or NSAID use. She had a history of anorexia nervosa and had a recent inpatient psychiatric admission after she was found eating garbage by her family. A few days after her discharge, she reported that she had eaten a large meal and felt that the food was “stuck” in her abdomen. The patient appeared uncomfortable, yet did not seem to be in severe distress. Her exam was only notable for mild abdominal tenderness without rebound or guarding. On computed tomography of the abdomen and pelvis, the patient was found to have a severely distended stomach, gastric wall pneumatosis, perigastric intravenous gas and portal venous gas. She was treated with nasogastric tube decompression, proton pump inhibitor therapy and intravenous antibiotics. A repeat CT scan done 24 hours later showed resolution of ischemic changes and gastric distention. An EGD performed on hospital day 3 noted erosions and large clean based ulcerations in the gastric fundus. Biopsies were negative for Helicobacter pylori infection.

DISCUSSION:
Due to this patient’s psychiatric history, as well as her benign clinical appearance and abdominal exam, appropriate treatment was initially delayed. Early identification and treatment of acute gastric ischemia, even in patients without typical risk factors for ischemia is vitally important. In patients with anorexia nervosa with binging behaviors, the clinical presentation of gastric dilation and ischemia may not correlate with radiologic findings. Severe gastric distension from binge eating may lead to gastric ischemia and ischemic gastroparesis.