bluuebunny/crossref_metadata_2025_split huggingface dataset:
1390 Impacted Fully Covered Self-Expanding Metal Biliary Stent Within an Uncovered Metal Stent by Exuberant Granulation Tissue Growth Successfully Removed After Treatment With Argon Plasma Coagulation (APC)
Authors: Fayyaz Mohammad 
Published: October 2019

INTRODUCTION:
We describe the case of an impacted, fully covered, self-expanding metal biliary stent within an uncovered metal stent because of exuberant granulation tissue growth at the ampullary orifice. The stent was successfully removed after treatment of granulation tissue with Argon Plasma Coagulation (APC).

CASE DESCRIPTION/METHODS:
A 95-year-old lady underwent placement of an uncovered self-expanding metal stent for a tight stricture of the distal bile duct by another gastroenterologist several years ago. The stricture was initially felt to be a malignant stricture but subsequently turned out to be a benign stricture. However, the biliary tree was frequently obstructed with excessive tissue ingrowth and recurrent stone formation requiring placement of a fully-covered self expanding metal stent within the uncovered metal stent, exchanged every nine months. During one of the ERCPs for stent exchange, the covered metal stent could not be removed because of exuberant growth of granulation tissue around the ampullary orifice covering the edges of the stent. The stent was left in place, the stones were extracted with a stone-extraction balloon and the granulation tissue was treated with APC. The plan was to bring the patient back for an ERCP and stent exchange after resolution of the granulation tissue. The patient ended up being hospitalized with stent occlusion and cholangitis after three months. At that time an ERCP was performed and the granulation tissue was noted to have completely resolved. The stent was occluded with stones and debris. The stent was removed without difficulty and a new stent was placed. The same exact situation recurred two years later. The granulation tissue was treated again with APC and stent was cleaned out with a stone-extraction balloon. The patient was brought back in three months for an ERCP and easy stent removal.

DISCUSSION:
Fully covered self-expanding metal stents have been used successfully for a variety of malignant and benign conditions and are generally easily removable. Occasionally exuberant growth of granulation tissue at the biliary orifice can preclude stent removal. Attempts to remove the stent forcibly can result in stent disruption and can lead to serious complications. In these situations the best approach is to treat the granulation tissue with APC and bring the patient back after resolution of the granulation tissue for an easy stent exchange.
1391 Too Much of a Good Thing: HIV and Immune Reconstitution in a Patient With IGG4-Related Pancreatitis
Authors: Berger David M. , Glazman-Kuczaj Galina , Kanevsky Julie 
Published: October 2019

INTRODUCTION:
Autoimmune pancreatitis accounts for 2% of cases of chronic pancreatitis. Autoimmune pancreatitis is differentiated into Type I (IgG4-related disease) and Type 2 (with normal IgG4 levels). Nearly 40% of patients with IgG4-related pancreatitis have involvement of salivary or lacrimal glands.

CASE DESCRIPTION/METHODS:
A 65 year-old-female with a history of HIV on anti-retroviral therapy (ART) (CD4 count of 588 cells/uL and undetectable viral load) and submandibular gland swelling presented with two weeks of epigastric discomfort and watery yellow diarrhea. The patient was noted to have elevated alkaline phosphatase to 802 U/L, aspartate aminotransferase to 284 U/L, alanine aminotransferase to 518, as well as total bilirubin of 2.8 mg/dL and direct bilirubin of 1.8 mg/dL. Amylase was 79 u/L and Lipase was 75 u/L. Four months prior to admission ART was changed from emtricitabine/tenofovir/raltegravir to bictegravir/emtricitabine/tenofovir; at that time CD4 count was 318 cells/uL. Liver tests were normal at that time. ART was held at the time of admission. Abdominal ultrasound demonstrated a diffusely enlarged, hypoechoic pancreas, consistent with pancreatitis. Magnetic resonance cholangiopancreatography showed abnormal morphology of the pancreas with loss of lobulation in the distal pancreatic body and tail, as well as irregularity of the pancreatic duct. Endoscopic ultrasound-guided biopsy with biliary stenting was performed. Prednisone was started empirically at 1 mg/kg/day for suspected IgG4 pancreatitis with rapid improvement in symptoms and liver tests. ART regimen was resumed simultaneously. Biopsy showed fibrosis with chronic inflammation, as well as the presence of IgG4 positive plasma cells. One month later, the patient's liver tests have returned to baseline.

DISCUSSION:
In this patient with a recent change in ART medications and newly elevated liver enzymes, drug-induced liver injury (DILI) can be considered initially. Imaging in this case showed diffuse edema and pancreatitis. Recent research suggests that patients with IgG4-related disease have over-activity of a specific class of cytotoxic CD4+ T cells driving the cytokine release that leads to its characteristic fibrosis. We suspect that this patient's flare of IgG4 pancreatitis may have been triggered by a recent change in her ART regimen. This allowed proliferation of all CD4+ T cell lines, leading to an response resembling the Immune Reconstitution Inflammatory Syndrome, resulting in the patient's clinical presentation.
1393 Calcified Gastroduodenal Artery Aneurysm Presenting as a Pancreatic Mass
Authors: Laharwal Mehak M. , Bhurwal Abhishek , Safarova Maya , Rahni David 
Published: October 2019

INTRODUCTION:
Gastroduodenal artery (GDA) aneurysm is among the rarest visceral artery aneurysms (VAAs) with an estimated prevalence of 1.5%. Rarely does it present with an outpouching which can sometimes mimic pancreatic malignancy with vastly different outcomes. We report a case of incidental GDA aneurysm which was mimicking a pancreatic mass where EUS was valuable in diagnosis and management.

CASE DESCRIPTION/METHODS:
A 63-year-old male with a past medical history of heroin and cocaine abuse, presented to the emergency room with shortness of breath and hypoxia. CT angiography revealed acute bilateral pulmonary embolism along with a pancreatic mass. This finding prompted a triple phase CT scan revealing a round 2.8 × 2.6 cm lesion with peripheral thin calcifications identified as a partially thrombosed GDA aneurysm. Additionally, a 2 × 1.5 cm hypodense area was also noticed. However, it was unclear if this was an outpouching from the aneurysm or a separate pancreatic mass. To better delineate the structure, an endoscopic ultrasonography was then performed. The main pancreatic duct and the pancreatic parenchyma were normal with the exception of a calcified abnormality within the GDA. These calcifications were partly contiguous with the GDA aneurysm. No other structural pathology was reported. Pancreatic biopsies were negative for malignancy. Development of the calcified pseudoaneurysm of the GDA was attributed to cocaine abuse. Thereafter, he underwent successful embolization of the aneurysm due to the high risk of bleeding from the aneurysm. He was thereafter discharged with no further complications.

DISCUSSION:
The most common etiologies of the GDA aneurysms are pancreatitis and atherosclerosis. Unruptured GDAs may present as abdominal pain or obstructive jaundice or remain asymptomatic. Pancreaticoduodenal and GDA aneurysms may manifest with rupturing into stomach, bile or pancreatic ducts in 50-75% of the cases with mortality approaching 50%. Incidentally found GDA aneurysms, as demonstrated in this case, must be treated irrespective of the size and presence or absence of symptoms since the potential of rupture is unrelated to its size. Given the high mortality, it is imperative to diagnose these lesions early. EUS provides valuable information and is useful in diagnosis as is noticed in our case. Therefore, EUS should definitely be considered in cases where diagnosis of GDA aneurysm is considered.
1395 Nivolumab-Induced Hemorrhagic Pancreatitis
Authors: Rogers Wesley , Mehta Amit , Mukewar Saurabh , Niec Rachel , Issa Danny , Wan David 
Published: October 2019

INTRODUCTION:
The checkpoint inhibitor nivolumab is an anti-PD-1 monoclonal antibody (mAb) that treats malignancy. Increased usage of checkpoint inhibitors has led to an increasing incidence of immune-related adverse events (irAEs) such as immune checkpoint inhibitor-induced pancreatic injury (ICIPI). We report a case of nivolumab-induced pancreatitis that progressed to fatal hemorrhagic pancreatitis.

CASE DESCRIPTION/METHODS:
A 61-year-old man diagnosed with small cell lung cancer with brain, adrenal, and osseous metastases presented with a one-day history of epigastric pain radiating to the back after starting a biweekly dose of nivolumab forty days prior. On admission, he had a lipase of 2700 U/L. His abdominal CT scan was consistent with acute interstitial pancreatitis. The patient was treated with hydromorphone as needed and Lactated Ringer's. He was continued on his home dexamethasone and discharged. Fourteen days after initial presentation, the patient reported increased abdominal cramping. MRCP findings were consistent with acute hemorrhagic pancreatitis with organizing complex peripancreatic fluid collections. He became febrile and hypoxic, and twenty-three days after initial presentation, chest CT scans showed acute respiratory distress syndrome or multifocal pneumonia. The patient decompensated and eventually died of cardiopulmonary failure secondary to hemorrhagic pancreatitis and worsening of his underlying malignancy.

DISCUSSION:
Nivolumab is a PD-1 mAb that works by enhancing the T-cell response to malignancies. Checkpoint inhibitors are known to cause irAEs including ICIPI due to their increased immune activation. However, reports of nivolumab-related pancreatitis are rare, with a reported rate of <1%. While anti-PD-1 mAbs often cause asymptomatic pancreatic enzyme elevations, nivolumab-related pancreatitis may also progress to serious complications, such as pseudocyst or chronic pancreatitis. The mainstay of treatment for irAEs is a combination of immunosuppression with glucocorticoids and/or a removal of the checkpoint inhibitor, depending on the severity of the irAE. Expert opinion currently guides steroid and checkpoint inhibitor management based on the intensity of the reaction: at lower severity the drug can either be stopped temporarily or not at all. This case adds to the growing presentations of nivolumab-induced pancreatitis. Though the incidence of pancreatitis as a result of checkpoint inhibition remains low, the progression to severe disease is possible.
1406 “Windsock” Duodenal Diverticulum Resulted in Recurrent Pancreatitis and Gastric Outlet Obstruction
Authors: Liu Yingheng , Saleh Jean 
Published: October 2019

INTRODUCTION:
“Windsock” or intraluminal duodenal diverticulum (IDD) is a rare congenital abnormality caused by an improper luminal recanalization of the foregut during embryological development. Most patients are asymptomatic. We present a case of recurrent pancreatitis and gastric outlet obstruction (GOO) caused by IDD in a young man with chronic alcohol use.

CASE DESCRIPTION/METHODS:
A 30-year-old man presented with severe nausea, vomiting and abdominal pain and found to have a third episode of acute pancreatitis in one month. Medical history was notable for alcohol abuse. However the patient stated that his last drink was more than a month ago. Lipase on admission was 130 U/L and he was found to have acute kidney injury (AKI) with creatinine 4.1 mg/dL. Magnetic resonance imaging without contrast revealed severe gastroduodenal obstruction and acute pancreatitis with pancreatic head pseudocysts. Esophagogastroduodenoscopy revealed nearly complete obstruction of the second portion of duodenum that the scope could not traverse. The patient was managed for acute pancreatitis, resulting most likely from paraduodenal pancreatitis causing GOO. After 10 days of aggressive treatment, the patient's pancreatitis has clinically much improved with better relief of the abdominal pain and resolution of the AKI. However he remained obstructed as large volume was drained from the nasogastric tube. A subsequent abdomen and pelvis computed tomography (CT) revealed interval decrease of the cluster pseudocysts previously seen by the pancreatic head but showed a “windsock” duodenal diverticulum. With conservative management, parental nutrition, intravenous fluids and pain control, the patient was able to tolerate frequent small portions of regular diet on hospital day 23. He was then discharged for elective surgery and resection of the IDD.

DISCUSSION:
Patients with IDD may present with chronic non-specific symptoms such as epigastric pain, nausea, vomiting, post-prandial fullness or rarely acute complications such as obstruction, hemorrhage, or pancreatitis. Radiologic diagnosis by CT or upper gastrointestinal series shows a typical “windsock” appearance hence the name. Endoscopic diagnosis may be challenging as the diverticulum can collapse and be unnoticed, or be mistaken for a polyp or a mass. Surgery has been the mainstay of treatment. However endoscopic techniques have been described in recent literature. IDD should be considered in the context of unexplained duodenal obstruction or recurrent pancreatitis.
1446 A Rare Tumor in the Common Bile Duct: A Case Report of Plexiform Neurofibroma in the Common Bile Duct
Authors: Alkayali Talal , Salem Ahmed I. , Ricardo Juan , Amer Bahaa , George Justin , Rahal Kinan 
Published: October 2019

INTRODUCTION:
Plexiform neurofibroma (PN) is a benign tumor that originates from nerves. This tumor is usually associated with neurofibromatosis type1 (NF1) and found in young patients. Common places of growth include head, neck and maxillofacial area. We report a rare case of common bile duct plexiform neurofibroma.

CASE DESCRIPTION/METHODS:
A 69-year-old female with history of cholecystectomy had incidental finding of dilated pancreatic duct (PD) on chest CT during pneumonia work up. Patient denied abdominal pain, weight loss, change in bowel habits, jaundice or itching. Physical examination was normal. Laboratory tests including CBC, LFT, CA 19-9 were unremarkable. MRCP showed extrahepatic biliary ductal dilation measuring 8 mm, minor intrahepatic ductal dilation involving left lobe, diffuse PD dilation from the ampulla to the body, involving the major and minor ducts with acinarization, and abrupt change in the main PD at the junction between the body and tail of pancreas, no masses were seen. EUS showed a CBD of 8 mm and a hypoechoic mass measuring 8.8 × 5.6 mm in the common hepatic duct (CHD) with mild dilation of the left hepatic duct measuring 6 mm. PD was dilated between the pancreatic head, and body measuring 8 mm without mural nodules, and 1.5 mm in the distal body and tail of pancreas. No obvious abnormality was visualized at the transition point. Previous findings were concerning for segmental main duct IPMN. ERCP performed, ampulla appeared normal without “fish mouth” appearance, and no filling defect in PD. Cholangiogram and biliary ductosccopy using Spyglass were performed and showed low-grade stricture in the CHD. Biliary epithelium was endoscopically normal in the strictured area. Biopsies obtained using Spybite. EUS and FNA of the hypoechoic area in the CHD was performed after the ERCP. Biopsies obtained with Spybite showed benign appearing ductal epithelium with fibrotic tissue. However, FNA cytology showed rare cluster of atypical glandular cells. Patient was referred to surgery. Pathology of the common bile duct showed a 7 mm plexiform neurofibroma with clear border resection without evidence of malignancy.

DISCUSSION:
PN is a rare benign tumor that develops from schwann cells in a bundle of nerves involving cutaneous nerves or internal nerve fibers. PN has substantial risk to transform into malignant peripheral nerve sheath tumors, therefore surgical resection is advised. PN is usually associated with NF1. However, few cases without clear etiology were reported with no link to the syndrome.
1459 A Curious Case of Progressive Iron Deficiency Anemia
Authors: Bhakta Dimpal , Latorre Melissa 
Published: October 2019

INTRODUCTION:
Iron deficiency anemia is a common condition that often leads to evaluation of the gastrointestinal tract for sources of blood loss. Parasitic infections are uncommon causes of gastrointestinal blood loss. Here we present a case of progressive iron deficiency anemia due to Trichuris trichiura (whipworm) infection.

CASE DESCRIPTION/METHODS:
A 65-year-old male, originally from the Philippines, with a past medical history of hypertension and coronary artery disease (on aspirin and clopidogrel) presented with progressive worsening fatigue for four weeks with new onset small volume rectal bleeding for three days. Travel history was notable for a recent trip to Mexico complicated by a self-limited diarrheal illness six weeks prior to presentation as well as frequent travel to the Philippines. Physical exam was notable for pallor and a rectal exam with no evidence of external hemorrhoids and brown stool. Labs were notable for hemoglobin of 7.5 g/dL from a baseline of 14 g/dL one year prior to presentation. Other pertinent labs included a mean corpuscular volume of 80 fL, iron saturation of 4% with a ferritin of 7 ng/mL. An upper endoscopy and colonoscopy was performed. The upper endoscopy was unremarkable with no source of blood loss anemia. The colonoscopy was notable for internal hemorrhoids and evidence of worms found in the cecum. A worm was obtained and sent for microscopic evaluation with final speciation revealing T. trichiura (whipworm). The patient also underwent a video capsule endoscopy as an outpatient two weeks after discharge which was unremarkable. The patient was treated with a three day course of mebendazole and initiated on iron supplementation with interval outpatient follow up revealing resolution of iron deficiency anemia within 6 weeks post-treatment with subsequent hemoglobin of 13.7 g/dL.

DISCUSSION:
Parasitic infections, especially those without significant concurrent gastrointestinal symptoms, can lead to a diagnostic delay as a potential cause of iron deficiency anemia. Whipworm infections occurs through ingestion of whipworm eggs that are then passed in the feces of infected individuals. Many cases of T. trichiura infection are asymptomatic however a high worm burden can lead to diarrhea and anemia. The pathophysiology of resulting iron deficiency anemia from T. trichiura is thought to be from worm consumption of blood and possible colonic lesions leading to occult gastrointestinal bleeding. A thorough history, including travel history, remains crucial for diagnosis.
1462 Yellow Jacket in the Colon: An Incidental Finding During Screening Colonoscopy
Authors: Gollol Raju Narasimha Swamy , Aboutaleb Eslam , Ali Muhammad , Ali Eslam 
Published: October 2019

INTRODUCTION:
Findings arthropods in the GI system is rare, especially intact arthropods. We here by describe an intact yellow jacket found during a routine screening colonoscopy.

CASE DESCRIPTION/METHODS:
A 52-year-old Caucasian male presented for routine screening colonoscopy. His past medical history was significant for hypertension and anxiety. He had used standard polyethylene glycol solution bowel preparation the day prior to the procedure. Physical examination was unremarkable. Colonoscopic examination was unremarkable except for an intact dead yellow jacket in the descending colon. The insect was not retrieved.

DISCUSSION:
Findings arthropods in the GI system is rare. Ants and wasps in the stomach and cockroach, drosophila and flour bugs in the colon have been reported. In majority of the cases, these findings are likely due to inadvertent accidental ingestion. In some cultures, insects such as flour bugs are consumed intentionally and may be rarely found in the colon during colonoscopy. Majority of the reported arthropods in the GI system were intact denoting likely resistance of their complex exoskeleton to the human digestive system. Majority of the ingested arthropods pass through the GI tract uneventfully but rarely can cause barely noticeable local reaction to severe system anaphylactic reaction. Our patient denied any knowledge of how the insect could have entered in to his gastrointestinal tract. It is likely that he inadvertently swallowed the yellow jacket in his bowel preparation solution and the insect made it to the descending colon intact likely aided by the rapid transit effects of the polyethylene glycol solution.
1468 Left-Sided Chest Pain Following Colonoscopy: Think Outside the Colon!
Authors: Khan Zarak H. , Korpole Pranay R. , Jarodiya Vijay , Singh Tejveer , Sultani Nabil 
Published: October 2019

INTRODUCTION:
Colonoscopy is considered to be a low risk procedure performed regularly worldwide. The most common complications include hemorrhage and bowel perforation which are 1% and 0.1% respectively. The incidence of spleen rupture is estimated to be between 0.00005 and 0.017%. However, due to its nonspecific presentation many cases may be misdiagnosed and up to 11% of these patients will be discharged with a different diagnosis. Therefore, the actual incident is likely higher. We present a case of a 76-year-old female with spleen rupture 16 days after a routine colonoscopy.

CASE DESCRIPTION/METHODS:
76-year-old female with past medical history of atrial fibrillation on apixaban, coronary artery disease, recurrent bladder cancer and chronic obstructive pulmonary disease presented for sudden onset of chest pain. Pain was 10/10 in intensity and located in the left anterior chest wall with radiation to the left shoulder. She also had associated nausea without vomiting. Patient denied any history of trauma. Patient underwent an uncomplicated colonoscopy 16 days earlier during which a 1.3 cm polyp was excised. Upon presentation, vital signs were significant for a blood pressure of 96/58. Labs were significant for hemoglobin of 7.2 and INR of 1.6. CT scan of the abdomen showed findings suspicious for splenic rupture. Patient received 2 units of packed RBCs in the ED and was then taken to the OR for emergent exploratory laparotomy. Intra-operatively, the spleen was found to be ruptured and splenectomy was performed. She did not have any complications during or after the splenectomy and was discharged 6 days after the procedure in stable condition. Appropriate vaccinations were administered upon discharge.

DISCUSSION:
There are many proposed mechanisms for spleen injury during colonoscopy; these include tension on the splenocolic ligament, tension on pre-existing intra-abdominal adhesions and direct injury to the spleen during passage of the colonoscope through the splenic flexture. We speculate that our patient's use of apixaban might have played a contributing role. To our knowledge, only 5 cases of splenic injury have been previously reported with time of presentation greater than 16 days post-colonoscopy. Our patient's symptoms and location of pain are not typical for splenic injury. With our case, we intend to spread awareness about this not so uncommon and possibly fatal complication of colonoscopy with delayed and sometimes atypical symptoms.