bluuebunny/crossref_metadata_2025_split huggingface dataset:
2014 Over-the-Scope Clip as Salvage Therapy for Refractory Non-Variceal Upper Gastrointestinal Hemorrhage After Failed Conventional Management: A Case Series
Authors: Amarnath Shivantha , Philipose Jobin , Abergel Jeffrey , Khan Hafiz 
Published: October 2019

INTRODUCTION:
Elderly patients with cardiovascular co-morbidities are of higher mortality risk from non-variceal upper gastrointestinal hemorrhage (NVUGIH). Traditional endoscopic interventions with through-the-scope-clips, electrocautery and epinephrine injections have a high failure rate at managing bleeding from large visible vessels, especially bleeding from posterior duodenal bulb ulcers. Over-the-scope-clips (OTSC) are preferred by endoscopists for their versatile role in repair of fistulas, bowel perforations and NVUGIH. We report two NVUGIH cases where traditional endoscopic and angiographic interventions failed and over the scope clip was used as salvage therapy.

CASE DESCRIPTION/METHODS:
85-year-old female with Pulmonary Hypertension and Atrial Fibrillation was admitted for hypovolemic shock from hematemesis. Endoscopy revealed a large posterior duodenal bulb ulcer with adherent clot for which epinephrine injection was used. The ulcer’s size and location prompted angiography and coil embolization of the gastroduodenal artery (GDA). Patient was in hypovolemic shock again due to a massive bleed. She was high risk for surgical intervention due to pulmonary hypertension, and repeat endoscopy was performed for hemostasis. An 11/6 T-type OTSC clip was successfully deployed at a large vessel oozing blood, after removal of a large adherent clot by snare. No further intervention was needed afterward. 76-year-old male with extensive cardiac history was admitted with burns and inhalation injury from a house fire, requiring tracheostomy and gastrostomy placement. During hospitalization, patient had multiple episodes of melena and required blood transfusion. Endoscopy revealed two large anterior and posterior duodenal bulb ulcers, with a visible vessel, managed by electrocautery. Due to persistent bleeding, he underwent coil embolization of the GDA. Two days later, patient had recurrent bleeding. Repeat endoscopy with OTSC was used for successful hemostasis of a large visible vessel in the posterior duodenal bulb.

DISCUSSION:
Traditional endoscopic management carries a 20% re-bleeding risk and successful secondary hemostasis drops from 90% to 75%. Anatomic variation in blood supply to the duodenal bulb, either from branches of celiac axis or superior mesenteric artery may be the reason why our patients failed angiographic coil embolization of the GDA. To our knowledge, we report the first two cases where OTSC was used for successful salvage of NVUGIH that failed initial endoscopic and angiographic interventions.
2019 Lower Gastrointestinal Bleeding Due to Sevelamer-Induced Colitis
Authors: Zeidan Joseph H. , Simmelink Andrew , Saboori Shadab , Ahrens William , Moshiree Baha 
Published: October 2019

INTRODUCTION:
Acute lower gastrointestinal (GI) bleeding is uncommonly due to medication induced-colitis, reported in less than 6% of all lower GI bleeds. Identifying medications that may cause GI bleeding is particularly important in chronically ill patients at high risk for morbidity and mortality. A commonly used medication in patients with advanced renal disease is sevelamer, a phosphate binder in renal failure patients.

CASE DESCRIPTION/METHODS:
A 53-year-old female with end-stage renal disease presented with hematochezia for 2 days. She notes dark black stools for two weeks followed by rectal bleeding. Her past history is notable for a renal transplantation in 2008 with graft failure requiring hemodialysis. She has no history of NSAID use and her prior screening colonoscopy showed no evidence of colitis. Her medication list was extensive and included sevelamer and cinacalcet. The patient was hemodynamically stable. Initial labs showed a hemoglobin of 6.0 g/dl, baseline was 8.0-9.0 g/dl. She was resuscitated with intravenous fluids and received 2 units of blood. Next, the patient’s upper endoscopy showed gastric erythema only with no stigmata of recent bleeding. Her colonoscopy showed a macroscopically normal appearing colon however random biopsies revealed expansion of the lamina propria with significant population of increased eosinophils. Several crystals were embedded within the colonic mucosa and submucosa resembling sevelamer crystals. Based on the pathology, she was diagnosed with sevelamer-induced colitis and this medication was discontinued. Follow-up at 3 months showed the patient remained asymptomatic without further GI bleeding.

DISCUSSION:
Sevelamer is a common medication used in renal failure patients. It is a resin that binds and prevents absorption of phosphate within the GI tract and has been shown to cause GI issues such as nausea, vomiting and diarrhea. Rarely it can crystalize, become embedded in the GI tract and ulcerate and cause bleeding. A few case reports have described rectosigmoid ulceration and pseudotumor presentation of sevelamer induced colitis.1,2 Understanding and recognizing the potential for sevelamer-induced colitis is important with such a widely used medication.
2022 Beyond Skin Deep: Serious Gastrointestinal Complications Associated With Oral Chemotherapy for a Case of Basal Cell Carcinoma
Authors: Vasireddi Nikhil , Khakoo Nidah S. , Kasi Keerthana , Duggimpudi Arul Ruthwik , Vasireddi Neal , Doss Peter , Wirtshafter David , Minassian Haig , Vasireddi Srinivas S. 
Published: October 2019

INTRODUCTION:
Oral chemotherapy with Vismodegib for locally advanced Basal Cell Carcinoma (BCC) is widely used by dermatologists. In several isolated case reports, rare hepatotoxicity has been reported, but no consumer safety notifications have been issued by the manufacturer or the FDA to date.

CASE DESCRIPTION/METHODS:
A 62-year-old Caucasian female presented to emergency room with profound jaundice of her skin and scleral icterus that began two weeks after completion of Vismodegib oral chemotherapy for BCC of the left lateral forehead (Figure 1). Her past medical history was only significant for hypertension and pyrosis. The patient reports that she did not take any prescription or over-the-counter medications, herbal supplements, and had no history of alcohol use. Admission labs revealed AST of 37, ALT of 287, alkaline phosphatase of 522, total bilirubin 11.2, direct bilirubin 6.9, and indirect bilirubin of 4.3. A prompt liver biopsy revealed findings consistent with drug-related injury, including bile ductular reaction associated with portal inflammation consisting of lymphocytes, eosinophils, and neutrophils (Figure 2). She was stabilized and discharged with a plan for weekly outpatient monitoring. However, she presented two weeks later with complaints of right upper quadrant pain and melanotic stools for two days. Admission labs revealed a hemoglobin of 8.4, decreased from 12.0 on previous discharge. She was transfused appropriately and an upper endoscopy (EGD) revealed bleeding from the papillary orifice, indicative of hemobilia (Figure 3), warranting selective angiography and coil embolization for successful hemostasis. Jaundice resolved fully in four weeks and hemoglobin and liver function tests (LFTs) normalized in two months at follow-up.

DISCUSSION:
As noted in our case, gastroenterologists are bound to see an array of iatrogenic life-threatening complications from outpatient oral therapy for cosmetic lesions. Our case involved not only the hepatotoxic effects from Vismodegib, but a rare iatrogenic complication from the biopsy with bleeding requiring further interventions. Fatalities have been reported with this drug. Therefore, heightened awareness in medical community and mandated patient safety notifications by the manufacturer and the FDA are necessary to improve outcomes.
2026 Successful Hemostasis in Acute Gastric Variceal Hemorrhage With Hemospray (Hemostatic Powder)
Authors: Gohar Hamza , Massey Harper , Carlson Brian , Sharma Vishvinder , Mukherjee Ranadev 
Published: October 2019

INTRODUCTION:
Currently there are few effective therapies for acute gastric variceal hemorrhage: endoscopic variceal ligation (EVL), cyanoacrylate injection, and endoscopic sclerotherapy (ESL). For variceal hemorrhage that is not amenable to these therapies, Transjugular intrahepatic portosystemic shunt (TIPS) or Balloon-occluded retrograde transvenous obliteration (BRTO) are recommended. For patients with contraindications to these procedures there is no effective treatment. Here we present a case of acute gastric variceal hemorrhage, in which hemostasis was successfully achieved with the use of Hemospray (hemostatic powder).

CASE DESCRIPTION/METHODS:
A 63-year-old hispanic man with PMH of HCV and alcoholic cirrhosis presented with coffee-ground emesis and melena. Admission vitals: T-37.7, HR-117, RR-20, BP-139/72, O2 sat-100% on RA. Physical exam was significant for only mild jaundice. Hemoglobin was 6.3. We started Protonix IV BID, Octreotide drip and Ceftriaxone QD. CT abdomen showed multiple metastatic appearing liver lesions, cirrhosis, varices, and cavernous transformation of the portal vein. Overnight his hemoglobin decreased to 4.5. During EGD, multiple gastric varices were noted including a large, actively hemorrhaging, GOV-2 varix. Unfortunately, we were unable to perform EVL due to the sheer volume of bleeding present. IR was consulted for emergent TIPS. However the patient was not a candidate for TIPS or BRTO due to the cavernous transformation of his portal vein. The decision was made to utilize Hemospray. EGD was repeated and the large GOV-2 gastric varix was seen actively hemorrhaging. A large, obstructing clot was removed and the site of bleeding was visualized. Hemospray was applied and hemostasis was quickly and effectively achieved. After application, the patient did not have recurrent bleeding.

DISCUSSION:
Hemostasis in the setting of acute gastric variceal hemorrhage can be very challenging to achieve. Hemospray should be considered when traditional therapies fail. It becomes cohesive and adhesive when it comes into contact with moisture, forming a stable mechanical barrier. Although there are few studies investigating its use in acute variceal hemorrhage, it was very effective in this case. Hemospray can also be useful for providing temporary hemostasis in an emergent situation; giving physicians more time to organize more definite treatments. Hemospray is a powerful endoscopic tool and should be considered when standard bleeding therapies are inadequate.
2027 Upper GI Bleeding With Black Esophagus: Case Report of Acute Esophageal Necrosis
Authors: Hammami Muhammad B. , Aboushaar Reem , Musmar Ahmad , Azhar Mishah , Miller Stephen M. , Salomon Peter 
Published: October 2019

INTRODUCTION:
Acute esophageal necrosis, a very rare cause of upper GI bleeding, is seen mainly in elderly men. We report a new case in an elderly woman.

CASE DESCRIPTION/METHODS:
A 90-year-old woman with a history of DM, HTN, and CHF presented with SOB and abdominal pain of 2-day duration. She didn’t vomit. Confusion, pallor, and large melanotic bowel movement were noted. Temperature was 36.1°C, BP 86/68 mmHg, HR 104 bpm, and RR 22 br/min. She had bilateral shallow coarse breath sounds and otherwise unremarkable abdominal and neurological exams. Urine ketones was negative, plasma glucose 98 mg/dL, WBC 40.8 K/mcL, hemoglobin 9.3 g/dL, platelet 437 K/mcL, GFR 18 mL/min/1.73 m2, lactate 15.5 mmol/L, and procalcitonin 1.49 ng/mL. Blood culture was negative. Chest CT showed small bilateral pleural effusions and ground glass opacities. Abdominal CT showed fecal impaction. Working diagnoses included septic/hypovolemic shock, pneumonia, encephalopathy, acute upper GI bleed, and acute hypoxic respiratory failure. Volume resuscitation, vasopressors (norepinephrine, phenylephrine, and vasopressin), mechanical ventilation, broad spectrum antibiotics (vancomycin, cefepime, and azithromycin), total parenteral nutrition, and proton pump inhibitor were started. EGD revealed friable, black, circumferential esophageal mucosal changes starting 25-30 cm from incisors and extending to GE junction without gastric outlet obstruction (Figure 1). Follow up EGD one week later showed slow healing with black and thin tissue, starting 4 cm proximal to GE junction without stricture (Figure 2). She continued to be encephalopathic, requiring mechanical ventilation and vasopressor support. She died upon intensive care withdrawal at family request.

DISCUSSION:
Our patient had endoscopic diagnosis of acute ischemic esophagitis, which was likely due to compromised esophageal perfusion secondary to septic/hypovolemic shock in the setting of chronic vascular compromise. Biopsy to differentiate ischemic esophageal necrosis from other etiologies, such as infection and malignancy, carries a high risk for perforation and was not performed. As seen in our patient, acute esophageal necrosis typically affects the relatively hypovascular distal esophagus down to GE junction and quickly resolves when blood flow is restored. Nevertheless, mortality remains high due to the underlying conditions. Unlike our case, acute esophageal necrosis affects mainly men, with a men/women ratio of 4/1.
2034 Upper GI Bleed in a Young Male: A Rare Presentation of Eosinophilic Gastroenteritis
Authors: Priyadarshni Shivani , Surapaneni Balarama K. , Dave Kairavee , Patel Nehal , Yella Prashanth Reddy , Cantave Rulz T. , Kaplan Steven R. 
Published: October 2019

INTRODUCTION:
Eosinophilic gastroenteritis (EGE) is a rare idiopathic disease affecting multiple organs (stomach and small intestine) of the gastrointestinal tract (GIT). It is characterized by eosinophilic infiltration of the bowel wall to a variable depth and symptoms associated with GIT. Klein et al classified EGE into 3 subtypes predominant mucosal, muscular or subserosal. The prevalence has been found to be ranging from 8.4 to 28 per 100,000.

CASE DESCRIPTION/METHODS:
Our patient is 28-year-old male with PMHx EGE, duodenal ulcers and stricture who presented to hospital with chief complaint of 3 episodes of dizziness and melena for one day. Allergies included food allergies to peanuts. Home medications included prednisone, montelukast and pantoprazole. On admission he was found to be tachycardic (150). Initial labs showed a hemoglobin (hgb) of 9.3. His hospital course included 1 episode of large volume hematemesis >1.5L and brief loss of consciousness followed up by a rapid response. Between day 1 and 2, hgb dropped to 5.7; patient received blood transfusion and managed conservatively with continuous vital monitoring in ICU. Emergent endoscopy (EGD) revealed high grade duodenal stenosis, severe pyloric-duodenal deformity with duodenal ulcer with visible vessel and 2 clips were deployed blindly. Epinephrine could not be injected due to hard and fibrotic tissue around duodenal stenosis. IR was consulted; angiography revealed active bleeding from gastric artery. Cool in and with a subsequent embolization was done. He received 5 unit RBCs total and continued on pantoprazole. For his known duodenal stricture, surgery was consulted with recommendation of no acute surgical intervention in the hospital. On discharge he was sent home with PO PPI, prednisone 40 daily, liquid diet, hydration and close follow up with GI, Surgery and PCP as soon as possible.

DISCUSSION:
EGE is more common in pediatric population and affects adults between the 3rd and 5th decade of life with a female predominance in USA. The risk factors include: genetic factors observed in familial cases, higher socioeconomic status, Caucasian race and excess weight. EGE is seen in patients with various allergies, asthma and elevated serum IgE levels, suggesting an association with hypersensitivity involved in the pathophysiology of EGE. 3 clinical criteria used to diagnose EGE: Presence of gastrointestinal symptoms; Gastrointestinal eosinophilic infiltrates; Exclusion of causes of tissue eosinophilia such as drug reactions or parasitic infections.
2038 Jejunal Lymphangioma: A Rare Cause of Gastrointestinal Bleeding
Authors: Chaudhari Rahul B. , Shirodkar Manoj A. , Syed Rifat Mannan Abu Ala 
Published: October 2019

INTRODUCTION:
Lymphangioma is a rare benign vascular tumor in adults. The etiology is not clear but is proposed to be from the anomalous development of the lymphatics or inflammation and obstruction of developed lymphatics (1). Although most cases are asymptomatic and thus detected incidentally, non-specific symptoms, including abdominal pain, nausea, vomiting and weight loss may be present (2). Here we present a case of such tumor presenting as obscure overt GI bleed.

CASE DESCRIPTION/METHODS:
A 76-year-old female with past medical history of DM, ESRD, CHF, AFib presented with SOB and hypotension. Three weeks prior, she had a cardiac arrest during dialysis and was found to be anemic on admission to outside hospital (Hb 5.9). She was diagnosed with PE and anticoagulation was started. This resulted in multiple episodes of melena. She was deemed clinically unstable for EGD/colonoscopy and was discharged (Hb 8.6). A week later, she was again found to be anemic (Hb 5.8) and continued to have multiple episodes of melena. Colonoscopy and EGD were unremarkable and she was eventually discharged again. Her symptoms recurred following discharge and she was hospitalized now with SOB and hypotension (Hb 6.4). She continued to have melena. Diagnostic tagged RBC scan showed possible focus of luminal hemorrhage in small bowel in left abdomen. A capsule endoscopy showed a jejunal mass with active bleeding. Subsequent single balloon enteroscopy revealed a 2.5 cm polypoid mass with active bleeding in the mid-jejunum. Biopsies were taken and hemostasis was achieved with argon plasma laser. Histology revealed this mass to be a lymphangioma. She was discharged with no further bleeding. At 2 months follow up, she still did not have any further bleeding. She elected not to pursue any further management.

DISCUSSION:
A lymphangioma is a rare benign tumor. For lymphangioma, intestinal tract involvement is very uncommon. GI bleeding, intestinal obstruction, intussusception and protein-losing enteropathy are very rare manifestations(5). Diagnostic tests include barium enema, CT scan and endoscopic evaluation (7-9). Surgical resection may be required to provide definitive diagnosis and treatment. The upper and lower GI endoscopies can sometimes miss the mass, as in our patient. In such cases, capsule endoscopy and push enteroscopy play an important role. In our case, conservative measure was chosen due to the surgical risks of the patient from multiple comorbidities.
2043 A Case of Optic Neuritis in Setting of Starting Infliximab-dyyb in Ulcerative Colitis Patient
Authors: Alameri Aws , Hughston Adam , Lorio Eric , Parker Allan L. 
Published: October 2019

INTRODUCTION:
Evidence supports an association between CNS demyelination disorders and use of with Tumor Necrosis Factor-α (TNF-α) inhibitors. Here we present a case of optic neuritis onset after initiating therapy with infliximab-dyyb and describe subsequent treatment response.

CASE DESCRIPTION/METHODS:
A 31-year-old female with a history of Ulcerative Colitis, presented with new left periorbital heaviness 2 weeks after receiving the first dose of infliximab-dyyb. The pain eventually progressed to darkening and blurring of vision. The physical examination was positive for reduced visual acuity, color desaturation, and positive relative afferent pupillary reflex on the left eye only. CSF studies were remarkable for positive Oligoclonal bands and increased IgG Index. Orbital and brain MRI were suggestive of optic neuritis. Infliximab-dyyb was discontinued and she was treated with a course of IV Methylprednisolone and discharged home on Glatiramir acetate. On follow up visits, eye pain and blurry vision dramatically improved. In order to avoid extra-colonic side effects, she was switched to vedolizumab which she has tolerated well.

DISCUSSION:
It has been described that IBD patients can present with CNS demyelination, which can be explained by both conditions sharing epidemiological and immunological characteristics. However, this association can be confounded by the use of TNF-α inhibitors, which are commonly used in treating IBD and have been themselves associated with CNS demyelination. Though mechanism is unclear, blocking TNF-α receptors in the CNS has been found to result in neuroinflammation and long-term neural damage. The average time from exposure to the onset of symptoms has been described as seventeen months in one case series on infliximab. However, in our patient she started experiencing symptoms after the initial dose. This rapid reaction may be due to infliximab-dyyb being used. To our knowledge this is the first reported reaction related to a bio-similar. This demonstrates that further studies are needed to estimate the true incidence of demyelinating disorders in patients with IBD and to elucidate if bio-similar may be subject to stronger demyelinating reactions.
2046 Peristomal B-Cell Lymphoma in a Patient With Complicated Ulcerative Colitis
Authors: Hafiz Nazar , Ghildiyal Naomi , Jogimahanti Anusha , Rashid Shazia , Maruvada Smita , Jordan Paul , Manas Kenneth J. , Morris James D. , Mendoza Mardeli Saire , Chaudoir Catherine , Palmer Thomas , Singh Tejinder 
Published: October 2019

INTRODUCTION:
Ulcerative colitis (UC) is an inflammatory disease that predominantly involves the colon and rectum often requiring treatment with corticosteroids and immunomodulators. However chronic use of immunomodulators is usually associated with increased risk for lymphoma. Extranodal involvement of GI tract is typically seen however primary GI lymphoma is very rare. Here we present a unique case of B-cell lymphoma diagnosed from stomal biopsies.

CASE DESCRIPTION/METHODS:
A 76-year-old caucasian male with history of Ulcerative Colitis for almost 28 years, status post multiple abdominal surgeries including ventral hernia repair, ileostomy and colostomy presented with ongoing stoma complications for about 6 months. These complications included new fistula formation around the colostomy and ileostomy sites. Despite aggressive wound care, lesions did not regress, and continued to grow producing sharp, burning type of pain. There was ongoing purulent discharge from new fistula formation. Peri-ostomal biopsy from both ileostomy and colostomy was positive for B-cell lymphoma. On further history, patient endorsed fever, night sweats, and 30-lb weight loss over 5 months. PET scan showed increased uptake in both the stomas as well as liver. Chemotherapy options were discussed with Oncology, however patient opted for hospice as the prognosis was deemed poor.

DISCUSSION:
Primary GI lymphoma is common in stomach. Small intestine and colonic lymphoma account for 9% and 1% respectively. There have been multiple reports published citing association of lymphoma in IBD patients treated with immunomodulators. Our patient had two stomas (ileostomy and colostomy). Both periostomal biopsies were positive for B cell lymphoma. Periostomal lymphoma has been rarely reported. Parnesh et al (Case 1) reported a similar case of stomal lymphoma in a patient with history of Ulcerative Colitis. Levecq et al (Case 2) reported a stromal lymphoma in a patient with transfusion related AIDS who underwent total colectomy and ileostomy for indeterminate colitis. The lymphoma was diagnosed at 20 years (Case 1) and 2 years (Case 2) post stoma formation. Lymphoma should be in the differential of stoma being complicated by peristomal tissue proliferation, fistula and infection.