bluuebunny/crossref_metadata_2025_split huggingface dataset:
1913 A Unique Presentation of Asymptomatic Mantle Cell Lymphoma at Screening Colonoscopy: Beware of a Lumpy-bumpy Mucosa
Authors: Park Sa Ra , Hays R. Ann , Figueroa Esteban J. 
Published: October 2019

INTRODUCTION:
Mantle cell lymphoma (MCL) is a rare aggressive subtype of non-Hodgkin’s lymphoma. Most cases of MCL initially present with diffuse lymphadenopathy. The gastrointestinal (GI) tract is involved in 15–30% of cases and can manifest as a rare clinical entity called multiple lymphomatous polyposis (MLP). Because of its rarity, a clinical syndrome of MLP is not well defined and its presentation varies. Prior case reports describe the presence of GI symptoms in patients with MLP. We present an unusual case of an asymptomatic patient who was found to have MLP on screening colonoscopy and subsequently diagnosed with MCL.

CASE DESCRIPTION/METHODS:
A 55 year-old female presented for a screening colonoscopy with a family history of colon cancer. Her last screening colonoscopy 5 years prior was unremarkable. She denied any change in bowel movement, blood in her stool, abdominal pain, chest pain, or shortness of breath. Her CBC and CMP one year prior were unremarkable. At colonoscopy numerous small nodular, submucosal polypoid lesions with a prominent vascular pattern were found in the terminal ileum; the mucosa of sigmoid, descending, transverse, and ascending colon had a diffuse subtle nodular appearance. With narrow band imaging, numerous <1 mm nodules with atypical vascular pattern were visualized. Biopsies of all lesions were obtained for histology and flow cytometry, which confirmed a diagnosis of mantle cell lymphoma. Subsequent laboratory evaluation revealed a normal CBC and BMP, mildly elevated AST and ALT to 40–50s U/L, and an elevated LDH of 400 U/L. PET CT scan demonstrated left cervical lymphadenopathy (up to 1.9 cm), mesenteric lymphadenopathy (up to 1.2 cm), and uptake at the ileocecal junction. She was begun on a regimen of rituximab, cytarabine, and bendamustine by oncology.

DISCUSSION:
This case illustrates an unusual presentation of MLP in that it was discovered in an asymptomatic at time of her screening colonoscopy. It is important to recognize this rare endoscopic entity as early diagnosis and treatment improve the prognosis. The diagnosis of MLP should be considered whenever multiple submucosal polypoid lesions are encountered during endoscopy. Histopathology and flow cytometry are key to confirming the diagnosis; therefore, it is important to submit representative biopsies of these lesions for both histology and cytology to avoid delay in diagnosis, need for repeat procedures, and delay in treatment.
1915 Delayed Post-Polypectomy Bleeding Case Report, Using Cold Snare Technique
Authors: Kutaimy Raya , Ravi Anand K. , Ehrinpreis Murray N. 
Published: October 2019

INTRODUCTION:
Most cases of colorectal cancer develop from colorectal polyps, therefore their early detection and removal decreases the risk of colorectal cancer death. Hot snare is the most commonly used endoscopic technique to eradicate colonic polyps with some inevitable post polypectomy bleeding. Cold snare polypectomy has been used recently because of its low risk of immediate and delayed post polypectomy bleeding.

CASE DESCRIPTION/METHODS:
A 66 y/o female with a history of ascending colon cancer status post right hemicolectomy presented for routine screening colonoscopy. She has a history of coronary artery disease status post stenting, systolic congestive heart failure and mechanical aortic valve for which she is on warfarin for anticoagulation. Warfarin was stopped 7 days before the procedure, without bridging. Colonoscopy showed two small polyps in the descending and sigmoid colon, and these were removed using cold snare. She was stable after colonoscopy and was discharged. Warfarin was restarted on the next day. Five days later she presented to the hospital complaining of bright red bleeding per rectum and bright red blood with stool. Hemoglobin had decreased from 11.4 (gm/dl) on the day of admission to 9.8 (gm/dl) the next day. Repeat colonoscopy was performed and a large clot was seen in the descending colon at one polypectomy site. There was no active bleeding from the clot though there was some minimal oozing with manipulation. The clot was not removed due to concerns of a large defect underneath that might bleed again. The surgery team was consulted during the procedure. Both GI and surgery teams decided not to proceed with any intervention. Another small non-bleeding ulcer in the sigmoid colon measuring 5 mm was seen and likely represent the site of previous polypectomy. She was monitored after the procedure, her symptoms and hemoglobin improved. Warfarin was restarted and discharged in stable condition.

DISCUSSION:
Cold snare polypectomy is being increasingly used as it is safe and efficient for small polyp removal. Newer polypectomy snares designed for cold snare polypectomy have been developed. This equipment may further decrease complications from smaller polypectomies. We present a case of rare delayed post polypectomy bleeding with the development of a large post polypectomy ulcer, even though anticoagulation was interrupted 7 days before the procedure. We used the traditional polypectomy snare. Results could have been different if the more modern cold snare polypectomy equipment used.
1918 A Case of Recurrent Pneumatosis Intestinalis and Portal Venous Gas
Authors: Fennell Siobhan , Novak Jeffrey , Marwil Zachary 
Published: October 2019

INTRODUCTION:
Mesenteric ischemia (MI) is caused by inadequate blood flow through the mesenteric vessels resulting in ischemic bowel. The most serious cases cause gangrenous bowel, leading to pneumatosis intestinalis (PI) and portal venous gas (PVG), often an ominous sign.

CASE DESCRIPTION/METHODS:
This is a case of a 63-year-old male who presented to the hospital with hematemesis and severe anemia. After massive transfusion, an EGD revealed actively bleeding gastric ulcers, requiring serial EGDs for successful control of bleeding. A CT revealed gastric distention with thickening of the duodenum and bilateral femoral vein opacities, later confirmed as deep vein thromboses. An IVC filter was subsequently placed, as he was not a candidate for anticoagulation. The patient was subsequently discharged on oral pantoprazole. Of note, there was no history of NSAID use or evidence of H. pylori. Repeat EGD 2 months later noted mild gastritis, but no ulcers were seen. A screening colonoscopy at the time noted only diverticulosis. He was continued on pantoprazole. 3 months later he presented to the hospital with acute onset nausea, vomiting, and diarrhea. A CT revealed PI at the gastric fundus, as well as PVG. An infectious work-up was negative, lactate was normal, and his symptoms resolved quickly. A subsequent repeat CT noted resolution of the PVG and reduction in PI. He represented to the hospital 1 month later again with nausea, vomiting, and diarrhea. A CT noted small bowel dilatation with air fluid levels, PI at the esophagus, stomach, and jejunum, and significant PVG. The initial lactate level was mildly elevated and his symptoms resolved quickly after bowel decompression. A subsequent CTA noted a significant reduction in PVG without evidence of vascular occlusion. A follow up EGD showed diffuse subepithelial hemorrhages without any evidence of recurrent ulcers. A subsequent CTE noted a thrombus above the IVC filter and an evolving hepatic infarction. He was asymptomatic at the time, however, he was admitted to the hospital for anticoagulation. He has since remained on warfarin without any recurrence of symptoms, PI, or PVG. A follow-up CTA showed a full resolution of venous thromboses.

DISCUSSION:
Previous case reports have described the development of PI and PVG secondary to underlying MI. This case highlights an example of MI secondary to an increase in the resistance of mesenteric blood flow due to venous thromboses. When investigating IP and PVG, underlying venous thromboses should always be considered.
1928 A Rare Case of Hematemesis Due to a Large Gastric Pyloric Gland Adenoma
Authors: Boston Iman J. , Chen Patrick , Wille R. Christopher 
Published: October 2019

INTRODUCTION:
Accounting for less than 3% of all gastric polyps, pyloric gland adenomas (PGAs) are rare tumors that usually arise from the stomach or, less commonly, the esophagus, duodenum, pancreas, or gallbladder. PGAs rarely cause symptoms and hematemesis as the presenting symptom has not been previously described in the literature. We present a rare case of hematemesis secondary to a large gastric PGA.

CASE DESCRIPTION/METHODS:
A 94 year-old female with a history of hypothyroidism and occasional nonsteroidal anti-inflammatory drug-use presented with hematemesis and hematochezia. She complained of acute-onset nausea, vomiting and diarrhea. Patient was hemodynamically stable at the time of presentation. Admission laboratory studies were significant for a hemoglobin of 7.2 mg/dl compared to 11.4 mg/dl two weeks prior. An esophagogastroduodenoscopy (EGD) was performed and revealed a 4 cm polyp-appearing mass with a short stalk in the mid-greater curvature of the body of the stomach. The tissue was friable and spontaneously bled with minimal friction from the snare, thus likely the etiology for the patient’s symptoms. The polyp was removed in piecemeal fashion using hot snare. Submucosal epinephrine was injected and four DuraClips were deployed over the polypectomy site. The patient declined to undergo a colonoscopy. Following her EGD, patient did not exhibit any additional signs or symptoms of continued bleeding and was discharged home in good condition. Pathology revealed pyloric gland adenoma with high-grade dysplasia.

DISCUSSION:
This case emphasizes the need for increased awareness regarding the presence of PGAs. These lesions have been shown to arise in chronically damaged mucosa and were associated with autoimmune gastritis in 33.9% of patients, active Helicobacter pylori-associated gastritis in 30.2% of patients, and normal gastric mucosa in only 3.8% of patients. Patients are usually elderly females with an average age of 75 years; though signs and symptoms are variable, laboratory evaluation frequently reveals anemia. This diagnosis is rare but the malignant potential was reported between 12 to 30% of cases in two large studies making improved classification and management necessary.
1932 The Answer Is on Your Skin: A Case of GI Bleeding Secondary to Kaposi Sarcoma
Authors: Penninti Pranav , Haddad Nael , Malakouti Mazyar , Camero Alfredo , Wright Randy P. 
Published: October 2019

INTRODUCTION:
GI tract bleeding in AIDS patients carries with it a significant degree of morbidity, with a unique differential including different opportunistic infections and malignancies. Kaposi Sarcoma (KS) is a form of malignancy associated with the human herpes-virus 8, recognized as an AIDS defining illness, and is typically recognized by violaceous cutaneous lesions. KS can also have widespread involvement of the visceral organs including the GI tract, where it can manifest as anything from GI bleeding to diarrhea, abdominal pain, nausea/vomiting and weight loss. Here, we describe a case of AIDS-related KS leading to profound GI bleeding.

CASE DESCRIPTION/METHODS:
A 29 year old male with a history of AIDS (CD4 of 44 cells/mm3and viral load of 18,000 copies/mL) in the setting of anti-retroviral therapy (ART) non-compliance presented with subacute onset shortness of breath, palpitations and malaise over the prior week. Upon review of systems, he endorsed diarrhea and melena over the same timeframe, while denying any other GI tract symptoms. Vital signs on presentation were significant for tachycardia to 103 bpm. Physical exam was notable for violaceous small lesions in buccal mucosa, hard palate, arms and back. His initial labs indicated severe anemia with a hemoglobin level of 4.9 g/dL with a ferritin level of less than 10 indicating severe iron deficiency anemia. After initial resuscitation, the patient underwent upper and lower endoscopy. His EGD showed multiple small round, heaped up ulcers in the gastric antrum, body, and fundus, along with similar ulcers in the second part of the duodenum. His colonoscopy showed similar lesions found in the transverse colon and rectum as illustrated in the images below. Biopsies taken from those lesions along with skin punch biopsies confirmed the diagnosis of Kaposi Sarcoma. He was discharged on Emtricitabine/Tenofovir and Darunavir/Cobicistat with follow up after several months showing dramatic improvement in his skin lesions and resolution of his gastrointestinal symptoms.

DISCUSSION:
The endoscopic appearance of KS in the GI tract is unique, often appearing as hemorrhagic nodules or plaques, however still requires tissue biopsy for diagnosis. Treatment is centered on ART with the use of systemic chemotherapy typically only needed in case of severe symptoms or lack of response to ART. Our case is a testament to the broad differential to be considered in HIV/AIDS patients with GI bleeding, of which Kaposi Sarcoma should be considered.
1942 A Rare Source of Gastrointestinal Bleeding Discovered With Capsule Endoscopy
Authors: Harris Michael , Settergren Noah , Giang Jimmy , Dionisio Paula 
Published: October 2019

INTRODUCTION:
Melanoma accounts for 5% of all skin cancers, with lentigo maligna melanoma (LMM) accounting for 10–15% of melanomas. The LMM variety harbors a risk of invasive progression up to 20%. Studies have shown that the small bowel is a preferred site for melanoma metastasis due to its high vascularity, and approximately 60% of patients diagnosed with melanoma skin cancer will have gastrointestinal (GI) metastasis. The usual time for primary melanoma to GI metastasis is 60–90 months. Metastatic melanoma is a rare cause of GI bleeding but should be considered in all patients with history of cutaneous melanoma. This case report presents a man with history of LMM who presented with melena and capsule endoscopy identified small bowel metastasis of the primary cutaneous melanoma.

CASE DESCRIPTION/METHODS:
A 78-year-old man with medical history of cutaneous melanoma and Mohs surgical resection 2 years prior presented to the emergency department for melena over a 2-week duration. One year before this admission the patient presented with similar complaints and esophagogastroduodenoscopy (EGD) with colonoscopy did not yield a bleeding source. At admission he was hemodynamically stable with a hemoglobin of 9.7. Hemoccult testing in the emergency department was negative, but the patient was admitted for monitoring. Gastroenterology was consulted and because the patient had a stable hemoglobin during his stay without hemodynamic compromise, and in-light of recent negative EGD and colonoscopy, the decision was made to follow-up outpatient with capsule endoscopy (CE). On review of CE footage, the patient was found to have an ulcerated mass with active bleeding in the small bowel. Biopsy confirmed the mass was metastatic melanoma. The patient was referred to oncology who found multiple boney and liver metastases and started him on Nivolumab and Zometa.

DISCUSSION:
Metastatic melanoma spreads to the small bowel in 60% of cases. As in this case, metastatic melanoma to the small bowel can cause an occult GI bleed, or even massive bleeding and hematemesis, with some cases of intussusception also reported. Whatever the presentation, one should have a high index of suspicion of metastasis in patients with a history of cutaneous melanoma and new GI bleeding. Negative EGD and colonoscopy should prompt an investigation with CE to rule out metastatic lesions.
1943 Gastrointestinal Plasmacytomas
Authors: Hasan Yazan , Gerke Henning , Abukhiran Ibrahim 
Published: October 2019

INTRODUCTION:
Plasmacytomas are tumors consist of abnormal plasma cells.They are divided into solitary plasmacytomas of the bone and extramedullary plasmacytomas (EMP). GI tract involvement is seen in 7% of EMP cases. The small intestine is the most commonly involved GI site, followed by stomach, colon, and esophagus.

CASE DESCRIPTION/METHODS:
A 57-year-old African American female with a history of multiple myeloma treated with chemotherapy followed by autologous stem cell transplant with failure to achieve remission. She presented with a two day history of melena, hematochezia and fatigue. Vital signs: BP 85/45 mmHg, HR 98 bpm, T 98.6 F, RR 18, Oxygen sat 96% on RA. Labs showed a drop in hemoglobin from 8.4 g/dL to 4.9 g/dL. Upper endoscopy showed 1.5 cm polyp in the gastric body (Figure 1a) that was removed. Colonoscopy showed multiple colonic polyps with a 1.5 cm polyp (Figure 1b) in the ascending colon that was removed. Histopathologic examination of stomach polyp (Figure 2a,d) revealed a malignant neoplasm consisting of plasmacytoid cells with inconspicuous nucleoli and abundant mitotic activity. The neoplastic cells were directly infiltrating the residual gastric epithelium and extending beyond the muscularis mucosa. Immunohistochemical staining showed the cells to be strongly positive for CD138 and lambda light chain, while negative for CD20, CD3, and Kappa light chain. These findings were consistent with a diagnosis of plasmacytoma. Histopathologic examination of the colon polyp (Figure 2e,f) showed similar morphology to the gastric polyp.

DISCUSSION:
Gastrointestinal plasmacytomas are rare, accounting for approximately 7% of all EMPs. Endoscopically, GI plasmacytomas have variable morphological appearances including ulcers, polyposis, thickened folds, ulcerative masses, and constricting lesions. Differentiating GI plasmacytomas from other tumors require histopathological examination. GI plasmacytomas should be considered in the differential diagnosis of myeloma patients presenting with GI bleed.
1946 Recurrent Lower Gastrointestinal Bleeding Secondary to Hermansky-Pudlak Syndrome
Authors: Tambe Ajay , Sharma Anuj , Manocha Divey 
Published: October 2019

INTRODUCTION:
Hermansky-Pudlak syndrome (HPS) is a rare autosomal recessive disorder with a prevalence of 1 in 1,800 in Puerto Rico. It is characterized by oculocutaneous albinism with nystagmus, variable skin hypopigmentation, loss of visual acuity, and platelet storage pool deficiency resulting in bleeding diathesis. Hematochezia in HPS primarily occurs due to inflammatory bowel disease (IBD) presenting in first to third decades. However, lower gastrointestinal bleeding can occur even without evidence of endoscopic or histological findings of colitis.

CASE DESCRIPTION/METHODS:
A 20-year-old Puerto Rican male with history of HPS presented with 3 to 5 episodes of bright red blood per rectum for the past one week. The patient has been experiencing intermittent hematochezia since the age of 7 years. Previous work-up with double balloon enteroscopy 4 years ago showed small bowel erosions. Colonoscopy performed during that time showed normal findings, however biopsy was not performed. Meckel’s scan did not show any evidence of Meckel’s diverticulum. He did not experience any bleeding for 2 years before this presentation. His vital signs on presentation were stable. Laboratory findings showed hemoglobin of 13 gm/dl, platelet count of 330,000/ul and white blood cell count of 8,900/µL. International normalized ratio (INR) was 1.1, prothrombin time (PT) 14.6 seconds and partial thromboplastin time (PTT) 32.3 seconds. The patient was started on intravenous fluids, pantoprazole infusion and was given one dose of aminocaproic acid. Following the dose of amino-caproic acid, the patient’s hematochezia resolved and he did not have any recurrent bleeding episodes. He was discharged after 3 days, and followed up one month later, when he did not report of recurrent bleeding episodes.

DISCUSSION:
Previous studies have shown that mucosal inflammation can occur in absence of endoscopic abnormalities in symptomatic patients. The likely cause of hematochezia in our patient was mucosal inflammation along with platelet dysfunction. Patients with mild intermittent episodes of hematochezia can be managed conservatively. For acute bleeding episodes, desmopressin acetate (DDAVP) or aminocaproic acid can be used and in case of severe bleeding, platelet transfusion should be performed.
1947 Unintentional Bread Bag Clip Ingestion Leading to High Risk Duodenal Ulcer
Authors: McEntire Dan , Bank Jeffrey S. 
Published: October 2019

INTRODUCTION:
Ingestion of bread bag clips has been described as a surprisingly common cause of GI bleeding or bowel perforation.

CASE DESCRIPTION/METHODS:
A 21-year-old man with no previous medical history or known foreign body ingestion presented after several episodes of acute onset coffee-ground and bright red hematemesis and hematochezia. Vital signs were notable for hypotension (90/65 mmHg) and tachycardia (120 bpm). Hemoglobin decreased from 15.5 to 12.2 mg/dL over four hours, and he received two units of pRBCs without an appropriate response in his hemoglobin concentration. During his EGD, we identified a 14 mm cratered ulcer with a visible vessel and an adjacent foreign body in the duodenal sweep. The object was grasped by rat-tooth forceps, but each attempt to remove it was complicated by hypotension and tachycardia. He then underwent urgent duodenotomy, where a bread-bag clip was identified and removed. Post-operative recovery was uneventful.

DISCUSSION:
Ingestion of foreign bodies poses a significant risk of GI bleeding or perforation. Guidelines generally recommend timely endoscopic removal of disk batteries in the esophagus, sharp objects, objects >6 cm in length, or in patients with severe esophageal obstructive symptoms. Various retrieval devices are available, and an overtube may be used to protect the esophagus. Surprisingly, there are already several described cases of bread bag clip ingestion that describe esophageal, small bowel, or large bowel bleeding or perforation. The unique shape of these clips leads to snaring of mucosal tissue which may ultimately lead to progressive ulceration. Interestingly, described cases of bread bag clip ingestion occur after unknown or accidental ingestion and occurs most commonly in cognitively impaired patients. Identification of these objects is difficult due to radiolucency, and often goes unnoticed until symptoms begin. Some are amenable to endoscopic removal, while others require surgical resection.