bluuebunny/crossref_metadata_2025_split huggingface dataset:
1870 Chest Tube Protrusion Into the Gastric Cavity Resulting in Biliary Drainage
Authors: Haddad Ibrahim , El Kurdi Bara , Aasen Tyler , El Iskandarani Mahmoud , Babar Sumbal , Alomari Mohammad , Al Momani Laith , Goenka Puneet 
Published: October 2019

INTRODUCTION:
Biliary drainage through a chest tube is a rare clinical finding that might be caused by Biliothorax or inadvertent penetration of the chest tube to the esophagus or the proximal stomach wall. We present a 63-year-old male patient who underwent Ivor Lewis esophagogastrectomy with his post procedural course complicated by chest tube migration and protrusion into the stomach cavity through gastropleural fistula.

CASE DESCRIPTION/METHODS:
A 63-year-old male patient who underwent Ivor Lewis esophagogastrectomy for distal esophageal adenocarcinoma, his clinical course was complicated by left sided pleural effusion and pneumothorax for which a chest tube was inserted. The patient clinical condition was stabilized and was discharged to an inpatient rehabilitation facility with the chest tube. Twenty days after discharge, the patient started to have bilious drainage through his chest tube again. He was admitted to hospital, imaging showed recurrent left pleural effusion. EGD was performed and showed chest tube protrusion into the stomach cavity through a gastropleural fistulas near the gastroesophageal junction. The chest tube was retracted and the gastropleural fistula was closed with over-the-scope clips. Bilious output stopped and the chest tube was removed with no further leakage.

DISCUSSION:
Biliary drainage through a chest tube is a rare clinical entity. It is highly suggestive of an esophageal leakage from a procedural complication. Gastropleural fistulae are rare and often occur as a complication of gastroesophageal surgery. When present, hardware, such as a chest tube, can be trapped into them resulting in various presentations. Endoscopic closure with over-the-scope clips may represent an effective and less invasive technique to close post procedural fistula tracts.
1883 A Surprising Biopsy Result: Primary GI Amyloidosis
Authors: Brindise Elizabeth , Tathineni Praveena , Venkataraman Subramanian 
Published: October 2019

INTRODUCTION:
Amyloidosis is the deposition of insoluble extracellular protein fragments. Gastrointestinal (GI) amyloidosis often presents with abdominal pain, weight loss, diarrhea and GI tract bleeding. Diagnosis is confirmed with congo red stain showing green birefringence under polarized light. Treatment differs for each type of amyloidosis; thus, accurate diagnosis is crucial for successful treatment. We present a case of primary GI amyloidosis presenting with new onset microcytic anemia.

CASE DESCRIPTION/METHODS:
A 73-year-old African American male with past medical history of hypertension, hyperlipidemia and erythrocytosis secondary to obstructive sleep apnea was being seen for a routine follow up by his hematologist. The erythrocytosis was previously evaluated with JAK2 and EPO testing; both negative. He was being treated with periodic phlebotomies, remaining asymptomatic. However, on this particular office visit he was found to have a new microcytic anemia, for which gastrointestinal workup was recommended. Upon evaluation by the gastroenterologist, esophagogastroduodenoscopy (EGD) and colonoscopy were performed. The EGD showed a non-obstructing Schatzki ring, erosive gastritis, a gastric ulcer at the pre-pyloric region, duodenitis and multiple superficial duodenal erosions. The colonoscopy showed a polyp in the cecum and descending colon and diverticulosis. Biopsies were taken during the procedures and returned with amyloid depositions, consistent with GI amyloidosis in the duodenum, stomach and descending colon. A few weeks later, the patient developed rectal bleeding and passage of clots. Repeat colonoscopy was done which showed diffuse large ulcerations in the sigmoid and descending colon. Again, pathology confirmed amyloid depositions in the GI mucosa. Given these surprising findings, his hematologist performed a bone marrow biopsy which showed normocellular marrow with trilineage hematopoiesis, negative for malignancy. Myeloma FISH panel was positive for 11.14 translocation. The patient was diagnosed with light chain myeloma with amyloidosis (AL subtype) involving the GI tract for which steroids and chemotherapy were initiated.

DISCUSSION:
Our case discusses a rare diagnosis of primary GI amyloidosis. This patient is unique because GI amyloidosis was his primary presentation without any cardiovascular or renal manifestation. Although amyloidosis is rare, it is important to have a high index of suspicion when evaluating new onset anemia of unknown origin.
1884 Migration of Embolization Coil in a Crohn’s Patient With NSAID-Induced Peptic Ulcer Disease
Authors: Mandiga Pujyitha , Patel Kruti , Miller Justin 
Published: October 2019

INTRODUCTION:
Peptic ulcer-related bleeding has a high mortality rate if not controlled. If endoscopic interventions fail, interventional radiology or surgical intervention is often considered. We report a case of rare complication of Transcatheter Arterial Embolization (TAE) for bleeding duodenal ulcer in a patient with Crohn’s Disease.

CASE DESCRIPTION/METHODS:
A 69-year-old female with a previous medical history of Crohn's colitis (on prednisone taper for active Crohn’s disease/pending initiation of biologic therapy) presented to the emergency department for generalized weakness, nausea, non-bloody, non-bilious emesis and melena. No prior history of gastrointestinal bleeding, antiplatelet or anticoagulation use was reported. Medications includes: Prednisone 20mg and Naproxen 400mg (BID or TID). Hemoglobin was 6.0 (11.0-16.2 g/dL), BUN 46 (8-26mg/dL), Cr 1.54 (0.44 – 1.00 mg/dL). Upper GI bleed was suspected with the initiation of Pantoprazole 80mg IV, 3 units of pRBC and Intravenous fluids. Endoscopy performed post-resuscitation revealed LA Grade D esophagitis, large non-bleeding duodenal bulb ulcer with extension into the sweep. No endoscopic therapy was performed. Twenty hours later, the patient became hemodynamically unstable requiring massive transfusion. As ulcer was not amenable to endoscopic therapy, Interventional radiology was consulted who TAE with the placement of two coils in the gastroduodenal artery (GDA). The patient tolerated the procedure well without any recurrence of bleeding. A follow-up endoscopy four weeks later, showed improvement in ulceration with only a 3-4 mm area of non-bleeding, healing ulcer with a coil protruding from ulcer site. The coil was left in place without any manipulation to the area. The patient was advised to discontinue NSAIDs and continue Pantoprazole 40 mg BID. In the interim, the patient was started on Vedolizumab (Entyvio) with improvement in CRP and abdominal pain.

DISCUSSION:
Embolization of GDA is safe and effective in patients with high surgical risk. Complications such as duodenal ischemia, hepatic artery embolization, duodenal stenosis do exist. Migration/Erosion of coil into lumen can occur, especially in a patient with active Crohn’s disease. Ulceration surrounding the coil can occur with a consequence of bleeding, which would require surgical intervention if endoscopic hemostasis is unable to be achieved.
1887 Don’t Stop at the Colon! A Rare Case of Strongyloides Hyperinfection Diagnosed on Esophagogastroduodenoscopy
Authors: Dalal Shaman , Sheth Niyati , Jain Alok 
Published: October 2019

INTRODUCTION:
Strongyloides stercoralis (SS) endemic to the tropics, is uncommon in the US. Symptoms from SS infection can mimic Irritable Bowel Syndrome (IBS). Immunocompromised individuals may present with fatal systemic ‘hyperinfections’ where SS larvae enter the bloodstream and bring enteral bacteria with it. Current literature recommends the use of endoscopy with biopsy to confirm diagnosis and begin prompt treatment to prevent further complications.

CASE DESCRIPTION/METHODS:
A 46-year-old woman with Rheumatoid Arthritis managed with prednisone and Rituximab presented for chronic abdominal pain and diarrhea reportedly from IBS. Past medical history was significant for recurrent hospital admissions for gram negative meningitis attributed to her immunocompromised state. She was treated with Ceftriaxone empirically each time. As part of her IBS workup, she underwent out-patient diagnostic Esophagogastroduodenoscopy (EGD) and Colonoscopy. The Colonoscopy was unremarkable. The EGD showed diffuse white villi in the second part of the duodenum. Biopsy revealed inflammation with presence of many SS larvae and eosinophils. A unifying diagnosis of SS hyperinfection causing recurrent gram negative meningitis was thus made. The patient was treated with Ivermectin and Albendazole. Surveillance EGD and Colonoscopy with random biopsies showed absence of SS. She reported complete resolution of her symptoms.

DISCUSSION:
‘Auto-infected’ SS larvae in the duodenum can transform into adult worms which reside in the colon and are known to mimic IBS. In immunocompromised hosts larvae can also enter bloodstream by transmural migration of the duodenum causing hyperinfection. Literature from regions endemic to SS suggest that enteral bacteria may accompany the larvae during this migration causing gram-negative septicemia and meningitis. Diagnosing SS can be challenging. Stool studies have poor diagnostic sensitivity. Endoscopy with biopsy confirming presence of SS larvae as seen in our patient continues to give the highest yield for diagnosis and prompt treatment to prevent fatal outcomes. A variety of endoscopic findings including duodenal white villi are documented but no pathognomonic finding is established for which more cases need to be reported. While a large burden of the adult worms reside in the colon causing IBS like symptoms, SS larvae reside in the crypts of duodenal mucosa. If SS hyperinfection is suspected, we strongly recommend to not stop the investigation at a diagnostic Colonoscopy but also perform an EGD.
1894 Gastrointestinal Post-Transplant Lymphoproliferative Disorder (PTLD) With Rapidly Forming Characteristic Lesions After Heart Transplantation: A Case Report
Authors: Azab Mohamed , Mosier Evan , Lewis Terence D. , Wright Andrew P. 
Published: October 2019

INTRODUCTION:
Post-transplantation lymphoproliferative disorders (PTLDs) are the second most common neoplasms in adult transplant recipients. Epstein-Barr virus infection in the setting of immunosuppressive therapy is implicated etiologically in most cases. More than half of PTLD cases present with extra-nodal involvement including the GI tract. Few reports have described the endoscopic findings. We present a case of rapidly progressive PTLD involving the GI tract with gross lesions that developed less than 2 months after a macroscopically normal upper and lower endoscopy.

CASE DESCRIPTION/METHODS:
A 37-year-old female with history of orthotopic heart transplant 3 months prior for transposition of the great arteries was admitted to the hospital with 3 weeks of non-bloody diarrhea. Her immunosuppressive regimen included tacrolimus, mycophenolate and prednisone. Extensive serologic and fecal testing was performed with no evidence of systemic CMV, EBV, HSV (serum PCR), clostridium difficile, or other bacterial intestinal infection. She underwent diagnostic upper and lower endoscopy with no grossly visible lesions. Random colon biopsies demonstrated increased lamina propria eosinophils and eosinophilic crypt abscesses suggestive of drug-effect. A presumptive diagnosis of mycophenolate induced colitis was made. Symptoms resolved however during her hospitalization and she was continued on mycophenolate. She presented 6 weeks later with 3 weeks of recurrent non-bloody diarrhea. Repeat serologic and fecal testing revealed EBV and CMV viremia. CT abdomen and pelvis with IV contrast was unremarkable. Repeat upper and lower endoscopy revealed multiple new ulcerated nodular lesions 1 cm in size (Figures 1 and 2) in the stomach, duodenum, terminal ileum and entire colon. Biopsies showed monomorphic PTLD, diffuse large B-cell type, with EBV positive staining.

DISCUSSION:
PTLD can be isolated to the gastrointestinal tract in immunocompromised post-transplant patients. Endoscopy with biopsy is required to establish the diagnosis. When there is high suspicion for PTLD, consideration should be given for repeat endoscopy even with recent normal examination as macroscopic and microscopic findings may develop rapidly.
1899 Bronchial Aspiration of Capsule Endoscopy: A Rare but Potentially Fatal Complication
Authors: Rutazaana Darius , Nawaz Arif 
Published: October 2019

INTRODUCTION:
Video capsule endoscopy (VCE) is increasingly being used in the diagnosis of small bowel disorders and the evaluation of suspected small bowel bleeding in adults. VCE is considered a safe procedure with no attributable deaths. Clinically significant complications include symptomatic capsule retention and aspiration that occur in less than 2% of examinations.

CASE DESCRIPTION/METHODS:
A 67-year-old male with history of developmental delay and with no history of swallowing disorder or stroke was initially admitted to the hospital with severe symptomatic anemia. His hemoglobin was 7.1g/dl. Anemia work up revealed serum iron level of <10g/dl and a ferritin level of 4.30. He underwent upper GI endoscopy and colonoscopy with findings of a short segment Barrett’s esophagus and small non-bleeding hemorrhoids. He was then scheduled an outpatient VCE. He was given the capsule and asked to swallow it. He initially had some difficulty in swallowing it but then took a big gulp and apparently swallowed it. Immediately upon swallowing, he started experiencing difficulty breathing. Nursing staff present immediately checked his oxygen saturation and noted a transient drop which corrected with minimal oxygen supplementation. An X-ray was immediately ordered and the monitor activated. Images suggested ingestion into the bronchus and a chest X-ray confirmed presence of a pill camera overlying the right main stem bronchus. He underwent an emergent flexible bronchoscopy with successful extraction of the capsule. This was followed by endoscopy assisted capsule insertion into his duodenum.He tolerated the procedure well.

DISCUSSION:
VCE is increasingly being used to provide diagnostic imaging of the small intestines, an anatomic site that is peculiarly difficult to visualize. Suspected small bowel bleeding and tumors of the small bowel are some of the common indications of VCE.Capsule aspiration although a rare complication with VCE can be life threatening. Early detection with emergent timely retrieval of the capsule is recommended. In order to prevent such complications and to be able to intervene expeditiously, it is recommended that VCE should be administered in an office with oxygen and where other resuscitative facilities are available. In conclusion, though rare, capsule aspiration is a serious complication of VCE and physicians should pay attention to patients who have any delay in capsule ingestion and if possible confirm passage of the capsule endoscope into the stomach before the patient leaves the clinic.
1906 Double Pylorus: Case Report of Atypical Presentation
Authors: Orpiano Christopher L. , Kang Gurjeet , Quinn Michael , Venu Lakshminarasimhan , Staffetti Joseph 
Published: October 2019

INTRODUCTION:
Double pylorus is a rare endoscopic finding that has been reported in 0.001% to 0.4% of upper gastrointestinal endoscopies, consisting of a gastroduodenal fistula extending from the prepyloric gastric antrum to the duodenal bulb through an accessory channel. In the majority of cases, it is a complication when peptic ulcers erode and create a fistula between the duodenal bulb and the distal stomach. It usually presents on the lessor curvature of the gastric antrum and on a superior wall of the duodenal bulb. It is commonly an endoscopic finding, since clinical presentation is similar to other peptic diseases.

CASE DESCRIPTION/METHODS:
The patient was a 62-year-old female presented to the emergency room for evaluation of intractable nausea and vomiting. The patient reported sudden onset of symptoms day prior, with multiple episodes of brown-colored liquid emesis. Patient denied any associated abdominal pain, no postprandial association with food. CT showed significant mucosal thickening of the gastric antrum to proximal duodenum, resulting in severe dilation of the stomach with air fluid level. Nasogastric tube was then placed for decompression and serial KUB showed adequate position and non-obstructive bowel gas pattern. An esophagogastroduodenoscopy revealed moderate gastritis and antral duodenal fistula, an accessory channel was noted on the lesser curvature side and once engaged was able to be passed with the endoscope. Pathology returned reactive mucosal changes suggestive of focal erosions, Helicobacter Pylori returned negative.

DISCUSSION:
The majority of reported cases of double pylorus are acquired and are attributed to complications of ulcers at the antrum-pyloric area or at the duodenal bulb. Acquired double pylorus typically present symptomatic with chronic upper abdominal pain, vomiting, dyspepsia, or upper gastrointestinal bleeding. Patients often have a long history of treatment with NSAIDs or corticosteroids, which should prompt an investigation for Helicobacter pylori and eventual treatment if found positive. Medications for the reduction of peptic acid should be taken and ulcerogenic medications should be avoided. The majority of patients respond well to medical treatment, according to a retrospective follow-up study in patients treated with H2 receptor antagonist or proton pump inhibitor after the diagnosis of acquired double pylorus, the fistula remained open in the majority of patients (64%), fused with normal pylorus in 27% of patients and closed only in 9% of cases.
1907 Methemoglobinemia: A Life-Threatening Complication of Topical Pharyngeal Anesthetics
Authors: Riaz Sana , Kudaravalli Pujitha , Saleem Sheikh A. , Heisig David 
Published: October 2019

INTRODUCTION:
Topical pharyngeal anesthetics such as benzocaine are used in conjunction with moderate sedation to increase patient comfort during esophagogastroduodenoscopy (EGD). Topical pharyngeal anesthetics can cause methemoglobinemia, which is a rare and life-threatening complication. We want to highlight the potential complication with the use of topical pharyngeal benzocaine through this case presentation.

CASE DESCRIPTION/METHODS:
A 22-year-old female presented with odynophagia after swallowing a piece of meat. She underwent inpatient EGD and received topical pharyngeal benzocaine spray along with moderate sedation. EGD was unremarkable, but during recovery, the patient became dyspneic, cyanotic, and her oxygen saturation (SaO2) dropped to 85% on room air. On chest examination, she had no wheezing, rhonchi, or crackles. Arterial blood gas showed pH 7.50, partial pressure of carbon dioxide 21 mmHg, partial pressure of oxygen 409 mmHg, and SaO2 99%. Blood work showed a methemoglobin level of 27.8%. She was transferred to the Intensive Care Unit and was given supplemental oxygen through facemask and IV ascorbic acid, which resolved her cyanosis and hypoxemia. Repeat methemoglobin level was 8.3% with normal oxygen saturation on room air. Upon stabilization, she was discharged home 48 hours after her initial presentation.

DISCUSSION:
Methemoglobinemia is the oxidation of ferrous to ferric iron within hemoglobin, impairing its ability to transport oxygen, leading to tissue hypoxemia and death. The etiologies of methemoglobinemia are hemoglobinopathy (hemoglobin M), hereditary nicotinamide adenine dinucleotide reductase (NADH) enzyme deficiency and drug induced. Drug-induced methemoglobinemia should be considered in patients with cyanosis and hypoxemia following topical pharyngeal anesthetic use. Despite the rare incidence, most cases of topical-anesthesia-induced methemoglobinemia are secondary to benzocaine. If the use of topical pharyngeal anesthetics is deemed necessary during an EGD, topical viscous lidocaine should be preferred over benzocaine to avoid this potentially life-threatening complication. There is insufficient evidence for methemoglobinemia caused by topical pharyngeal lidocaine alone and reported cases of lidocaine associated methemoglobinemia occurred in patients with either cardiorespiratory diseases or with the use of other anesthetic agents.
1910 Listeriosis in an Immunocompetent Patient After Diagnostic Colonoscopy
Authors: Jacob Burch , Kandola Samanjit , Enofe Ikponmwosa 
Published: October 2019

INTRODUCTION:
Although considered safe, colonoscopy, like all other procedures, involves inherent risks, including that of infection. Although rare, there are documented cases of patients with systemic infections caused by Listeria monocytogenes following mechanical disturbance of the GI tract. These systemic infections with Listeria are referred to as listeriosis. Previous cases describe patients with underlying risks for systemic infection, often patients with inflammatory bowel disease on chronic immunosuppressive medication. In this report, we examine the case of an immunocompetent patient with listeriosis following colonoscopy with biopsy.

CASE DESCRIPTION/METHODS:
An 80 year-old female with well controlled diabetes, who was sent to the ED for hemoglobin (Hgb) of 6.5 mg/dL. In the ED, her vitals were stable and physical exam was unremarkable. Labs revealed iron deficiency. Colonoscopy revealed three polyps along with a mass occupying 50% of the circumference of the descending colon. Snare cautery was performed to remove the smaller polyps. Polyp biopsies demonstrated tubular adenoma, with biopsies from the mass representing high-grade dysplasia. Thirty-six hours after colonoscopy she developed a fever of 38.3C (101oF). IV vancomycin and metronidazole were started for the empiric treatment of sepsis. Multiple blood cultures grew Listeria monocytogenes. Additional infectious workup ruled out other sources of infection. Following return of cultures and sensitivities, she was discharged home with three weeks of IV penicillin. Six weeks later, she underwent transverse colectomy with surgical pathology of the lesion showing intramucosal adenocarcinoma.

DISCUSSION:
Symptomatic infection following colonoscopy remains a rare occurrence and is most commonly found in immunocompromised patients. Prior reported cases of listeriosis following colonoscopy have been predisposed with underlying risks, including: cirrhosis, systemic malignancy, HIV, or chronic immunosuppression. In this case, the patient did not display convincing evidence of immunocompromise. The patient’s diabetes was well controlled and had been for over a year prior to her presentation based on two previous A1Cs of 5.9 and 6.5%. The patient’s colon mass found on colonoscopy was found to be intramucosal on surgical pathology and did not represent invasive malignancy. Considering this patient’s risk factors, this case represents a unique presentation of a patient with listeriosis following colonoscopy in an immunocompetent patient.