bluuebunny/crossref_metadata_2025_split huggingface dataset:
1923 Bleeding Varices in a Non-Cirrhotic
Authors: Zarrin Arash , Choksi Vivek , Dave Kairavee , Kaplan Steven R. 
Published: October 2019

INTRODUCTION:
Extra-hepatic portal vein obstruction (EHPVO) presents with manifestations of portal hypertension, including variceal bleed. Cirrhosis is the leading cause of portal hypertension (90%), and EHPVO can mask as cirrhosis, especially in a patient with risk factors such as alcohol abuse and incarceration.

CASE DESCRIPTION/METHODS:
37 y/o male with h/o DVT and alcohol abuse presented to our ER for abdominal pain and hematemesis. He was a chronic alcoholic but quit drinking 6 months prior. On admission, he was afebrile, mildly tachycardic but not hypotensive. Examination showed non-specific diffuse abdominal tenderness and jaundice. Labs showed Hb 5.8 g/dL, platelets 66/mcL, INR 2.13. Liver enzymes were normal, except T Bili of 5.1 mg/dL, and albumin 3.8 g/dL. Entire cirrhotic work-up was negative. CT abdomen showed nodular liver, splenomegaly, mild ascites, and gastroesophageal varices. Doppler US showed hepatopedal flow within the main portal vein. Triple-phase CT showed portal vein thrombosis (PVT) with cavernous transformation. EGD revealed large esophageal varices with red wale sign, which were banded. No gastric or duodenal varices. Colonoscopy revealed diffuse melena up to the terminal ileum, but no varices. Liver biopsy was negative for cirrhosis. The patient was found to have a heterozygous Factor V Leiden (FVL) gene mutation. Anticoagulation was not initiated due to recent bleed. He was re-admitted, unconscious after massive GI bleeding at home. Repeat banding was performed. SMA angiography and portography showed complete occlusion of the main SMA, splenic vein, and PV.

DISCUSSION:
For patients with portal hypertension secondary to portal vein thrombosis, the Bevano VI guidelines on portal hypertension recommend primary prophylaxis with non-selective beta-blockers and endoscopic variceal ligation. Failure of primary prophylaxis requires secondary prophylaxis with TIPS. However, surgical devascularization, such as the modified Sugiura procedure, is a great option with lower rates of re-bleeding and higher rates of survival compared to surgical shunts. Decompressive portal therapy is an important treatment aspect for our patient due to his need for lifelong anticoagulation in the setting of inherited thrombophilia.
1925 GIST Kidding: Primary Gastric Synovial Sarcoma Presenting as Hematemesis
Authors: Bialick Steven , Schwartz Stephen , Khiew Yii Chun , Budina Anna , Hartner Lee 
Published: October 2019

INTRODUCTION:
Synovial sarcoma (SS) is an uncommon subtype of mesenchymal derived solid tumors that is characterized by its unique histologic pattern. It is most often found in the extremities and rarely, the digestive tract, which can lead to gastrointestinal bleeding. Gastric tumors of mesenchymal origin often have overlapping radiographic and endoscopic appearances, which presents a significant challenge in diagnosis. We report one of only 3 confirmed cases of primary gastric synovial sarcoma of the lesser curvature in a patient who presented with hematemesis.

CASE DESCRIPTION/METHODS:
A 26-year-old male presented with a two-week history of worsening abdominal pain and intermittent hematemesis. He denied any history of hematochezia, melena, early satiety, weight loss, recent NSAID use or alcohol ingestion. Exam was notable for epigastric tenderness without rebound or guarding. Labs revealed microcytic anemia and thrombocytopenia without transaminitis or elevated lipase. Abdominal CT showed an 8 cm mass along the posterior gastric body with suspicion for intratumoral hemorrhage, highly suggestive of a gastrointestinal stromal tumor (GIST) [Figure 1]. EGD revealed a large, ulcerated, non-bleeding, non-circumferential, submucosal mass on the lesser curvature of the stomach, also concerning for a GIST [Figure 2]. Endoscopic ultrasound showed neither hepatic invasion nor lymphadenopathy. Partial gastrectomy pathology supported the endoscopic biopsy results, which showed high grade, monophasic, atypical spindle cells with t(X;18)(SYT-SSX) chromosomal translocation by fluorescence in situ hybridization (FISH). Immunohistochemistry (IHC) was strongly positive for TLE1 staining, but negative for C-KIT and DOG-1, to which GISTs are immunoreactive, confirming a diagnosis of primary gastric synovial sarcoma [Figure 3]. He tolerated 6 cycles of sarcoma-directed chemotherapy without evidence of progressive disease.

DISCUSSION:
Intramural gastric spindle cell malignancies are difficult to distinguish from one another, and require different disease-tailored therapies. Though GISTs account for 90% of these tumors, other rare pathologies exist. These include synovial sarcomas, which are characterized by a variable degree of epithelial differentiation associated with a disease-specific gene translocation. In patients with hematemesis found to have endoscopic and radiographic findings suspicious for GIST, ICH and FISH analyses are crucial to differentiate between mesenchymal malignancies to guide effective therapy.
1926 Gastrointestinal Bleeding in a Patient With Latent Tuberculosis and Remote T-Cell Lymphoma
Authors: Castillo Gabriel , Bhakta Dimpal , Argyropoulos Kimon , Moen Farnoush M. , Williams Renee L. 
Published: October 2019

INTRODUCTION:
Immunosuppressed patients such as those with malignancies are susceptible to reactivation of tuberculosis (TB), which can affect the gut. CMV should also be considered as a cause of colitis in these patients.

CASE DESCRIPTION/METHODS:
A 68-year-old man with a history of T-cell lymphoma of the kidney and nasal cavity and latent TB presented with weight loss and cough. He was cachectic and had diffuse rhonchi in the lung bases. CT of the chest showed areas of cavitation. Multiple sputum cultures positive for acid-fast bacilli (AFB) and a positive mycobacterium tuberculosis (MTB) PCR confirmed active TB infection. The patient developed repeated episodes of melena with a hemoglobin level of 5.0 g/dL, MCV of 71.5 fL, iron of 4.5 ug/dL, transferrin saturation of 1%. Colonoscopy revealed extensive diverticulosis in the sigmoid colon and evidence of a prior cecectomy with ulceration of the ileocolonic anastomosis. Biopsies showed dense mature lymphocytic infiltrate and granulation tissue with no evidence of T-cell lymphoma. A CT revealed a 4 cm segment of terminal ileum with mild wall thickening, mucosal hyperenhancement and thickened folds of a distal loop of jejunum. Stool AFB culture and MTB PCR were both positive, indicating a probable diagnosis of TB enteritis. A push enteroscopy showed a 60 mm infiltrative lesion with ulcerated bases and three smaller lesions of similar appearance on the anterior wall of the stomach along with jejunal ulceration. Ulcer biopsies revealed large cells with inclusions consistent with CMV enteritis. Stains for AFB were also positive. Biopsies of the stomach lesions revealed an ulcerative oxyntic mucosa with dense atypical lymphoid infiltrate. Markers were consistent with a diagnosis of Burkitt’s Lymphoma (BL). The patient was treated with TB therapy, ganciclovir, and R-CHOP.

DISCUSSION:
Immunosuppression due to this patient’s BL likely led to dissemination and reactivation of latent TB and susceptibility to infection with CMV. The stomach and bowel are the most common sites of extranodal involvement in BL. The incidence of TB in malignancy is highest in non-Hodgkin’s lymphoma like BL. Bowel involvement in TB is seen in less than 5% of cases in the United States. Common endoscopic findings include ileal or ileocecal disease, non-confluent involvement of the colon, and nodular mucosa with areas of ulceration. The diagnosis can be made by biopsy showing caseating granulomas, a positive TB culture or PCR result, or by clinical suspicion with improvement following treatment.
1927 A Puzzling Case of Rising Salicylate Levels
Authors: Lambert Karissa , Hamed Amira , Hamed Ahmed Said , Ali Eslam 
Published: October 2019

INTRODUCTION:
Pharmacobezoar, with a prevalence of 0.4%, is a mass or concretion of medication found in the gastrointestinal tract, which can cause severe and life-threatening complications if not timely identified.

CASE DESCRIPTION/METHODS:
64 year old Caucasian female with a history schizoaffective disorder presented with shortness of breath and altered mental status following intentional ingestion of salicylates. Physical examination revealed tachycardia and tachypnea. She was disoriented. Laboratory examination revealed: partial pressure carbon dioxide 23 mmHg, pH 7.45, bicarbonate 9 mEq/L, anion gap 23 mEq/L, lactic acid 4.6 mmol/L, salicylate level 1143 ug/mL. Thyroid stimulating hormone, blood glucose, hepatic function, and renal function were normal. QTc not prolong on electrocardiography. Computed tomography (CT) of brain unremarkable. Patient was intubated for respiratory compromise. Bicarbonate drip, intravenous fluids with subsequent vasopressor requirement, and activated charcoal were initiated. Emergent dialysis started. Blood gas, salicylate level, and chemistry panel were frequently monitored. Despite dialysis, gastric lavage, and whole bowel irrigation, salicylate levels continued to be elevated >300 ug/mL at day 3. Given concern of salicylate-bezoar formation, abdominal CT performed and was unrevealing. Esophagogastroduodenoscopy was performed and revealed blood in entire stomach and a foreign body wrapped around pills, which was removed. Thereafter, there was a steady decline of salicylate level to undetectable. Hospital course further complicated by continued encephalopathy with unrevealing magnetic resonance imaging of brain and electroencephalography requiring ventilation support, and oliguric acute renal injury. Decision made by family to discontinue life prolonging measures, and patient expired after a 2 week hospitalization.

DISCUSSION:
A pharmacobezoar should be of concern with persistent elevation of the medication comprised. Specifically with salicylate bezoar, timely diagnosis and appropriate therapy is required to prevent potential serious complications, such as cerebral and pulmonary edema, renal failure, and death. Furthermore, psychiatric illnesses have been identified as risk factors. Recognizing risk factors and clinical findings may facilitate early diagnosis and treatment.
1931 The Use of Hemostat Spray in Refractory Rectal Cancer Bleeding
Authors: Serrao Steve , Rodrigues Medora , Imbertson Erick 
Published: October 2019

INTRODUCTION:
We present a case of a patient with a history of T4b N0 M0 rectal cancer with diverting colostomy followed by radiation and chemotherapy. He presented with hemodynamically significant rectal bleeding.

CASE DESCRIPTION/METHODS:
A large four centimeter external fungating mass with fresh blood and clots noted on digital rectal exam. Patient had a similar episode of bleeding earlier for which he underwent IR embolization. The patient presented with 200–300 ml of bright red blood per rectum associated with tachycardia and hypotension, leading to ICU admission. The initial hemoglobin was noted to be 5 g/dl. He received 2 units of packed red blood cells (PRBC) with subsequent rise in hemoglobin to 7.8 g/dl. significant hematochezia continued, requiring an additional 2 units of PRBC. Endoscopic examination of rectum revealed that the cancer had circumferentially infiltrated the wall the entire remnant rectum. The rectum lacked distensibility. The floor and lateral surface of the rectum was covered in well-organized clots, fresh bleeding was noted along the walls of the rectum which looked pale, and necrotic (Figure 1). The heavy clot burden was removed with a combination of cold snare dissection and the use of a Roth net. The rectal mucosa was washed with water and two actively bleeding vessels on the floor of the rectum as well as friable tissue with active bleeding along the lateral walls were noted (Figure 2). To avoid contact with water in the instrument channel, the instrument channel of the colonoscope was flushed with 150 cc of air before Cook Hemospray catheter was introduced. Care was taken to avoid contact with the catheter and pools of blood or water in the rectum. We opted to disconnect the suction during the process of application. The Cook Hemospray device was then used with a spray catheter to apply a total of 25 sprays. Profusely bleeding sites were first prioritized after which the oozing friable mucosa were sprayed. The individual puffs of hemostat powder coalesced to achieve an even layer of powder over the entire surface of the rectal mucosa. This initial application achieved complete hemostasis from the vessels and the mucosa. We opted not to wash the powder 2 minutes after application. The final grayish white appearance resembled the lunar surface (Figure 3).

DISCUSSION:
Patient was downgraded from the ICU with a post procedure Hgb of 9.8 g/dl and no evidence of rectal bleeding or a drop in the hemoglobin for 72 hours post procedure, not needing additional PRBC transfusions.
1933 A Case of a Hidden Varix: Massive Duodenal Variceal Hemorrhage Requiring Emergent TIPS
Authors: Penninti Pranav , Valadez David , Gonzalez Lisandro , Walters Michael , Diallo Souleymane Y. , Walker John , Echavarria Juan , Brady Charles 
Published: October 2019

INTRODUCTION:
Variceal hemorrhage is a potentially life-threatening cause of bleeding in cirrhotic patients. While typically associated with esophageal or gastric varices, clinically significant variceal hemorrhage may occasionally originate from the small bowel, colon, rectum or biliary tract. Duodenal variceal hemorrhage is an uncommon cause of GI tract bleeding and is associated with a mortality rate up to 40%. We present a case of severe duodenal variceal hemorrhage necessitating emergent transjugular intrahepatic portosystemic shunt (TIPS) and variceal coil embolization.

CASE DESCRIPTION/METHODS:
A 58-year-old female with a history of cryptogenic cirrhosis decompensated by ascites presented to the ER with melena and dull, generalized abdominal pain over 2 days. Vital signs were notable for tachycardia to 114 bpm and she was normotensive. Her abdomen was non-tender to palpation and rectal exam was notable for melenic stools. Her hemoglobin was 9.5 g/dL on presentation. She continued to have melena over the course of the day with associated tachycardia and a decrease in hemoglobin to 5.6 g/dL. She was transferred to the intensive care unit where she underwent an upper endoscopy revealing small esophageal varices with no stigmata of bleeding and a normal duodenum. However, she continued to have melena unresponsive to blood product resuscitation leading to profound hypotension. A stat CT Angiogram showed intraluminal hyperdensities within the second portion of the duodenum due to hemorrhage from adjacent varices. Interventional Radiology was consulted and performed a right hepatic vein to right portal vein TIPS. They also performed fluoroscopic guided coil embolization of large duodenal varices arising from the main portal vein. The patient’s hemoglobin stabilized and she had no further bleeding during the course of her hospitalization.

DISCUSSION:
Duodenal variceal hemorrhage is a rare and life-threatening manifestation of portal hypertension. Due to the rarity of the condition, there are no established guidelines regarding treatment. Endoscopic therapy aimed at achieving hemostasis, such as sclerotherapy and clipping have shown limited success in case reports. TIPS, as seen in this case, is a viable treatment option. Our case illustrates the importance of considering ectopic varices in cirrhotic bleeders. Moreover, it highlights the importance of utilizing angiographic evaluation for patients in whom the source of bleeding is not identified on endoscopy.
1941 Meckel’s Diverticulum in an Adult Presenting as Acute Gastrointestinal Bleeding
Authors: Palmer Quinton D. , Pandey Yadav , Goel Akshay , Kumar Ujjwal , Tharian Benjamin , Johnson Kemmian D. , Nadeem Urooba , Wadhwa Vibhor , Wang Xiaofei , Corley Kevin 
Published: October 2019

INTRODUCTION:
Meckel’s diverticulum (MD) is the most common congenital anomaly of the gastrointestinal (GI) tract. MD develops as incomplete obliteration of the vitelline duct forms a true diverticulum in the small intestine. It often presents in children as painless rectal bleeding, while adults are often asymptomatic. We are presenting an unusual case of MD in an adult with acute, frank GI bleeding.

CASE DESCRIPTION/METHODS:
A 35-year-old male presented with one day of bright red blood per rectum (BRBPR), LLQ abdominal discomfort followed by a near syncopal episode. Vital signs were stable on arrival. Physical exam significant for pallor and bright red blood in the rectal vault. Initial hemoglobin was 11.6 g/dl and hematocrit 33.5%. Computed tomography angiogram (CTA) abdomen and pelvis was negative for active bleed. Initial colonoscopy showed gross blood throughout colon without an identifiable source of bleeding. Esophagogastroduodenoscopy was also negative. Patient continued to have episodes of BRBPR with progression to hemorrhagic shock. Hemoglobin and hematocrit the next day decreased to 6.1 g/dl and 17.9%, respectively. However, repeat CTA was negative for active bleeding. Repeat colonoscopy showed blood in the terminal ileum. Technetium 99m pertechnetate scintigraphy demonstrated a focal area of ectopic gastric mucosa in the distal ileum. Laparoscopic small bowel resection was performed with symptom resolution.

DISCUSSION:
While uncommon in adults, MD should be included on the differential diagnosis of adults with obscure GI bleeding. GI bleeding in MD develops as ileal mucosa is exposed to acid secretion from ectopic gastric mucosa resulting in ulceration in 11.8% of symptomatic adults. Adults often present with melena; hence it is unusual for an adult to present with frank BRBPR. Technetium 99m pertechnetate scintigraphy, also known as Meckel’s scan, is regarded as the modality of choice for diagnosis in the pediatric population, due to its sensitivity of 85%, specificity of 95%, and overall diagnostic accuracy of 90%. Meckel’s scan is less reliable in adults with a sensitivity of 62.5%, specificity of 9% and diagnostic accuracy of 46%. One study illustrated that balloon assisted enteroscopy provided the highest accuracy for diagnosis of bleeding MD in adults and should be considered the preferred modality for preoperative diagnosis. Despite its rarity, awareness and understanding of MD in adults as well as its complications is imperative and may improve patient outcomes.
1954 Hyperplastic Polyp: A Rare Case of Recurrent Iron Deficiency Anemia
Authors: Rashid Mamoon Ur , Sarvepalli Deepika , Ullah Waqas , Zafar Hammad , Hussain Ishtiaq , Hasan Badar , Ur Rehman FNU Asad , Hurairah Abu 
Published: October 2019

INTRODUCTION:
Hyperplastic polyps are the most common polyps accounting for 17% of all the gastric polyps. Most polyps are asymptomatic but may present with anemia, bleeding or gastric outlet obstruction. Here, we are reporting a case of large benign hyperplastic polyp presenting with iron deficiency anemia.

CASE DESCRIPTION/METHODS:
A 69-year-old male with a history of chronic back and neck pain and GERD was evaluated for chronic iron-deficiency anemia, treated multiple times with oral and IV iron supplements. The patient had been taking NSAIDs for chronic pain. On labs, patient hemoglobin of 9 with a low iron profile. The patient was scheduled for screening colonoscopy and EGD to further investigate anemia. On EGD patient had a large polypoid lesion about 25 mm in size in the prepyloric antrum extending into the duodenal bulb, likely cause of iron-deficiency anemia. There was also a small superficial clean-based ulcer on the antral lesion. Colonoscopy showed small internal hemorrhoids. Patient was discharged home on PPI and counseled to stop NSAIDs. Pathology report of the biopsies showed fragments of a benign hyperplastic polyp, negative for H pylori. The patient was afterward referred to interventional endoscopist for EUS and polyp excision.

DISCUSSION:
A hyperplastic gastric polyp is usually an incidental finding on upper endoscopy. With a prevalence of 6.35%, they are seen equally in elderly males and females in their 60s–70s. Hyperplastic polyps are believed to occur as a result of the reactive and inflammatory hyperproliferation of gastric foveolar cells, and Helicobacter pylori are believed to be the precursor. Diagnosis is usually made based on the results of endoscopy and subsequent biopsy of the suspicious area for the histological exam. On endoscopy, they appear as an area of hyperemia with a smooth dome-shaped surface, mostly in the antral area. As the size increases, they become pedunculated and the surface gets eroded resulting in chronic blood loss and anemia. Rarely, gastric outlet obstruction occurs when the large polyps prolapse though the pylorus. Since large polyps (>2 cm) are associated with carcinoma in 0.6%–2% cases, it is important for the pathologist to look carefully for any dysplastic foci and carcinomatous changes in the tissue specimen. Once the diagnosis of hyperplastic polyp is confirmed, treatment consists of endoscopic resection of any polyp measuring >1 cm in size and eradication of H.pylori, when present.
1955 An Ulcerated Lipoma as the Cause of Obscure Gastrointestinal Bleeding
Authors: Vitolo Melissa , Coben Robert 
Published: October 2019

INTRODUCTION:
GI bleeding remains one of the most common reasons for GI consultation, with top causes including peptic ulcer disease, erosive disease, angiodysplastic lesions, varices, Mallory Weiss tears, dieulafoy lesions, and malignancy. Obscure GI bleeding (OGIB), defined as recurrent or persistent bleeding or anemia despite negative endoscopic evaluation, makes up 5% of all GI bleed cases. Approximately 75% of OGIB are found to have small bowel lesions. We outline a case of a rare cause of OGIB.

CASE DESCRIPTION/METHODS:
A 78-year-old female with history of HTN, HLD, CAD, STEMI s/p DES placement, biliary colic s/p cholecystectomy, is referred to GI clinic for symptomatic anemia. She was found to have a hemoglobin of 8 g/dL from baseline 11–12 g/dL. She had been on dual antiplatelet therapy with ticagrelor until 3 months ago, now on aspirin 81 mg. Anemia workup revealed iron deficiency. CT scan negative. Started on po iron with improvement in symptoms. Denied abdominal pain, weight loss, or overt bleeding. No NSAID use. No prior endoscopy or colonoscopy. No family history of GI malignancy. An upper endoscopy and colonoscopy were done. There was antral erythema, otherwise normal EGD. Duodenal and gastric biopsies were negative. Colonoscopy only notable for extensive diverticulosis and a small tubular adenoma. Capsule endoscopy identified active bleeding in the proximal small bowel and a potential submucosal mass. Push enteroscopy revealed a long polypoid lesion extending from the third to fourth portion of the duodenum, approximately 15 mm in width and at least 100 mm in length with visible ulcerated tip. Mucosa was otherwise normal. Endoloop was applied and tissue removed with a hot snare. Pathology resulted in a submucosal lipoma. She was followed with serial blood counts and continued on iron therapy. She is doing well with continued GI follow up.

DISCUSSION:
This case of an ulcerated lipoma as the cause of an OGIB is among a handful of other case reports and seem to be similarly found in patients on antiplatelet or anticoagulation therapy. Other cases have undergone surgical resection for symptomatic lipomas, however our case suggests that perhaps in those that are able to stop antiplatelet therapy and have a lesion within reach of an enteroscope, resection of the ulcerated portion may be sufficient treatment and may avoid invasive surgery.