bluuebunny/crossref_metadata_2025_split huggingface dataset:
1378 Diagnostic Dilemma: Evaluation of an Exophytic Paragastric Mass
Authors: Dalal Ishita , Andalib Iman , Cristelli Ryan , Barnard Nicola , Shahid Haroon , Patel Anish V. 
Published: October 2019

INTRODUCTION:
Ectopic pancreas is rare congenital entity that is usually asymptomatic, appearing as an upper gastrointestinal (UGI) mass and difficult to diagnose. Our case describes a presentation of ectopic pancreas with atypical imaging and endoscopic findings.

CASE DESCRIPTION/METHODS:
A 28 year old male with asthma presented with hematemesis and epigastric pain. Laboratory studies included normal lipase level. Computerized Tomography (CT) of the abdomen revealed a hypervascular soft tissue mass between the pylorus and gallbladder, possibly arising from the pylorus (Figure 1). The mass was noted on prior imaging but had increased in size with a new surrounding complex fluid collection. Magnetic Resonance Angiogram (MRA) showed the mass to be contiguous with the gastric antrum and more suggestive of a vascular mass. Upper endoscopy showed esophagitis but no gastric or duodenal lesions. Hypervascularity and increase in size raised concern for malignancy. A subsequent endoscopic ultrasound (EUS) revealed abnormal tissue between the gallbladder and stomach (Figure 2). Fine need aspirate (FNA) demonstrated pancreatic acini consistent with pancreatic tissue (Figure 3). This established the diagnosis of ectopic pancreas. Patient was discharged with plans for surveillance imaging in three months.

DISCUSSION:
We present a case of an exophytic paragastric ectopic pancreas. Ectopic pancreas is a rare anatomical abnormality where pancreatic tissue originates outside its typical location with no anatomical or vascular connection to the pancreas. It has been reported most commonly as a submucosal lesion in the gastric antrum, duodenum or proximal jejunum. It is difficult to identify because patients are usually asymptomatic. For our patient, location near the gastric antrum was typical of ectopic pancreas. However, the exophytic appearance, lack of submucosal gastric lesion on endoscopy, paragastric location between the gallbladder and stomach, and lack of gastric invasion was atypical which made the diagnosis challenging. There are limited reports of ectopic pancreas, and it can be difficult to differentiate from malignancy. Our case highlights an atypical presentation of ectopic pancreas and the diagnostic challenges in its identification. A combination of imaging with contrast CT or MRI, and EUS with FNA will help differentiate from other lesions such as GIST. Though a rare entity, clinicians and gastroenterologists should consider ectopic pancreas in the differential diagnosis of extra-luminal UGI lesions.
1397 Intrahepatic Bile Duct Adenoma: A Diagnostic Dilemma
Authors: Park Ji Seok , Ayyagari Sravanthi , Tismenetsky Mikhail , Brower Steven , Jhawer Minaxi 
Published: October 2019

INTRODUCTION:
Intrahepatic bile duct adenoma (BDA) is a rare tumor arising from the epithelial cells of the bile ducts. BDA has been usually found incidentally by intra-abdominal surgery and autopsy. BDA is clinically significant because of its benign prognosis but also its difficulty differentiating from malignant neoplasms of the liver by imaging studies.

CASE DESCRIPTION/METHODS:
A 52-year-old male presented with hematuria. A CT abdomen and pelvis showed an incidental, 1.5 cm lesion in the right hepatic lobe. Following fine needle aspiration biopsy of the lesion, the tissue demonstrated a slightly irregular hepatic duct proliferation, for which a differential diagnosis of bile duct adenoma and well-differentiated cholangiocarcinoma was considered. Alpha-fetoprotein, carbohydrate antigen 19-9, and carcinoembryonic antigen were normal. An MRI was obtained to better ascertain the lesion, which demonstrated a 1.1 × 1.1 cm lesion within the right hepatic lobe, segment 6. The decision was made to pursue a hepatic resection. On gross examination, the specimen revealed an ovoid, well-circumscribed, white-tan, firm lesion measuring 1.4 cm in greatest dimension, and located 0.5 cm from the hepatic capsule. Microscopically, there was a well-circumscribed lesion composed of small biliary-type glands in tubular and branching trabecular patterns with a mild nuclear enlargement and inconspicuous mitotic activity. The lesion was well-delineated and the interphase with hepatocytes was regular without infiltrative growth (Figure 2). Immunohistochemically, CD56 stain was focally positive in the tumor.

DISCUSSION:
The main characteristics of BDA are as follows: the lesion is small-sized, with a diameter ranges between 1 to 20 mm; the lesion is always detected under the hepatic capsule, with clear borders but without capsule; the majority of the proliferated bile ducts are observed in the lesion, accompanied by plenty of chronic inflammatory cell infiltration; immunohistochemical stain for CK7, CK19, and CD56 are positive, whereas Ki67 and p53 are negative. Gütgemann et al. suggested that CD56 expression can aid the differential diagnosis of cholangiocarcinoma and a benign lesion such as BDA. Since our case showed positive CD56 stain along with other aforementioned features, the appropriate diagnosis was BDA. Since there are no definite imaging characteristics or tumor markers that allow a preoperative diagnosis, surgical resection followed by microscopic and immunohistochemical findings is crucial for the diagnosis of BDA.
1400 Thrombotic Thrombocytopenic Purpura as an Unusual Complication of Alcoholic Pancreatitis
Authors: Ridout Nicholas , Rai Puja 
Published: October 2019

INTRODUCTION:
Thrombotic thrombocytopenic purpura (TTP) is a non-immune-mediated thrombocytopenic disorder with a high mortality rate if mistreated and usually presents with microangiopathic hemolytic anemia and end-organ damage, commonly as kidney injury. There are only a handful of cases featuring TTP induced by acute pancreatitis in literature, some of them succeeding alcoholic pancreatitis. None of these patients had any initial clinical or laboratory signs of TTP on admission and the median time to developing TTP after admission was 3 days.

CASE DESCRIPTION/METHODS:
A 22-year-old male without significant medical history presented with epigastric abdominal pain two days after significant alcohol consumption. Serum lipase was elevated to 15,000 IU/liter. Given a strong family history of pancreatitis, computed tomography (CT) revealing borderline prominent pancreas, and recent alcohol binge, a diagnosis of alcoholic pancreatitis was made. Within the first 36 hours, he developed increased indirect bilirubin, marked thrombocytopenia to 34 K/uL, and an increase in creatinine from 1.29 on admission to 2.30. Peripheral blood smear was remarkable for many schistocytes (Figure 1). Normal coagulation studies excluded a diagnosis of disseminated intravascular coagulation. The presumed diagnosis of TTP was made, and the patient was treated with 9 cycles of plasma exchange, while his pancreatitis resolved with bowel rest and intravenous fluids. ADAMTS13 activity eventually returned at 61% (normal value >67%).

DISCUSSION:
Pancreatitis preceding a TTP picture has been scarcely described in the literature, but few reports have shown TTP to present itself at a median of 3 days after initial admission for pancreatitis. Our patient is unique in the sense that he presented with laboratory signs within the first 36 hours and was found to have schistocytes present on his blood smear within two days of his presentation, representing a rapid time-course compared to prior documented cases. Similar to prior reports, our patient was diagnosed based on his clinical presentation as his ADAMTS13 activity was only moderately reduced. Although exceptionally rare, it is crucial to consider imminent TTP in patients presenting with acute pancreatitis who are found to have acute hemolysis and significant kidney injury. If clinical suspicion is high, patients should receive prompt treatment with plasma exchange to ensure adequate platelet and end organ recovery.
1419 Extramedullary Plasmacytoma of the Pancreas
Authors: Fazeli Cameron , Hopp Grace , Rosenkranz Laura , Malik Mishel S. 
Published: October 2019

INTRODUCTION:
Multiple Myeloma (MM) is a hematologic malignancy that most commonly presents with anemia and lytic bone lesions. MM is considered more aggressive if extramedullary involvement in either bone or solid organs is present. Review of literature reveals there are only a few documented extramedullary plasmacytomas that have occurred in the pancreas. We present a case of MM relapse manifested by a pancreatic plasmacytoma without recurrent bone marrow involvement.

CASE DESCRIPTION/METHODS:
A 66-year-old male was diagnosed with stage 1 MM in 2014 after a bone marrow biopsy demonstrated clonal plasma cells. He underwent radiation, chemotherapy and received an autologous stem cell transplant with high dose melphalan. His M spike has remained undetectable, and he has had stable lytic lesions seen on surveillance imaging. He was considered to be in remission. He presented for a surveillance PET/CT scan which demonstrated a hypermetabolic lesion in the head of the pancreas. A follow up MRI pancreas confirmed the presence of a well circumscribed 2.7 cm structure in the proximal pancreatic body. The differential diagnosis was fairly broad, based on imaging. He underwent an endoscopic ultrasound with fine needle aspiration. Flow cytometry demonstrated monoclonal plasma cells consistent with plasmacytoma, confirming relapse of his MM. The patient is now undergoing systemic chemotherapy and local radiation.

DISCUSSION:
MM presents with diffuse myelomatosis and can have associated solitary myeloma of the bone or involve other organs as extramedullary plasmacytomas. Extramedullary plasmacytomas are extremely rare, occurring in 5% of cases of MM and indicate a more aggressive form of disease. Of these 5%, most extramedullary plasmacytomas involve the submucosal lymphoid tissue of the upper respiratory tract, spleen, lymph nodes and liver. There have been only 50 cases of pancreatic plasmacytomas documented in the literature, making this a rare occurrence. Most of these cases had active bone marrow disease. Of these 50, only 5 documented cases of MM relapse manifested as a solitary pancreatic plasmacytoma. Similarly, our patient had no active bone marrow involvement at the time of diagnosis. Additionally, pancreatic plasmacytomas comprise less than 0.1% of all pancreatic masses. This case demonstrates that, although rare, an extramedullary plasmacytoma should be high on the differential if a pancreatic mass is visualized in the setting of previously treated MM.
1429 Choledocholithiasis in Primary Hepatic Lymphoma (PHL): An Additional Hurdle to PHL Diagnosis?
Authors: Kumar Kishore , Essrani Rajesh Kumar , Sun Haozhe , Chime Chukwunonso U. , Tariq Hassan , Patel Harish , Nayudu Suresh 
Published: October 2019

INTRODUCTION:
Primary hepatic lymphoma (PHL) is a rare disorder involving solely liver at the time of initial presentation. Diffuse large B-cell lymphoma (DLBCL) variant in PHL is scarce. Patients with Immune suppression and HIV infection are at increased risk for the PHL-DLBCL variant. We present an individual, whose initial clinical presentation is masked my choledocholithiasis, subsequently diagnosed with PHL-DLBCL by histopathology.

CASE DESCRIPTION/METHODS:
A 59-year-old-man with prostate cancer (Gleason score of 7) managed conservatively for the last two years presented to the ED with intermittent epigastric pain of one-week duration associated with subjective fever and night sweats. On examination, he was afebrile and hemodynamically stable. The liver was palpable below the right costal margin and found to have inguinal lymphadenopathy. The laboratory data revealed obstructive jaundice with a cholestatic pattern (Table 1). Abdominal U/S and MRCP revealed cholelithiasis with normal biliary anatomy. Viral hepatitis, autoimmune and metabolic markers of liver disease were normal. Given the worsening of the obstructive pattern of liver tests, the patient underwent ERCP which showed two small stones in the distal CBD. Cholestasis improved, and the patient was discharged home in stable condition. Three weeks later he was readmitted with significant weight loss, malaise and night sweats. The laboratory investigation showed worsening of cholestasis with no imaging evidence of biliary stent obstruction. Hence, liver biopsy was performed to evaluate infiltrative liver disease. His hospital course was complicated by multiple organ failure requiring mechanical ventilator support and renal replacement therapy. Despite all resuscitative efforts, patient's general condition deteriorated and expired. His liver biopsy was reported with findings suggestive of DLBCL. Extrahepatic involvement was ruled out by negative lymph node biopsy.

DISCUSSION:
PHL is very rare primary hepatic malignancy and, DLBCL variant is extremely rare. As laboratory and imaging findings in PHL are non-specific, it is difficult to distinguish from infiltrative, granulomatous and other malignant liver diseases. Liver biopsy is essential for diagnosis and identifying the immunophenotype. It is vital to consider this condition as outcomes in PHL vary from other liver diseases. Our patient is a unique example where coexistent choledocholithiasis posed a diagnostic challenge like prior reported cases in literature.
1441 Beyond Pseudocysts: When Acute Pancreatitis Involves the Colon
Authors: Hashmi Irma , Shor Julia , Mahmoud Mohamed , Singh Anupam 
Published: October 2019

INTRODUCTION:
While common complications of acute pancreatitis can include pseudocysts, necrosis and infection, colonic involvement, leading to stenosis and necrosis, is a rare sequela of severe acute pancreatitis. We present the case of an unfortunate gentleman with severe pancreatitis complicated by sigmoid stricture and large bowel obstruction requiring hemicolectomy.

CASE DESCRIPTION/METHODS:
The patient is a 46-year-old man with history of necrotizing pancreatitis secondary to familial hypertriglyceridemia, complicated by pseudocyst formation, requiring cyst gastrostomy and stent placement, who presented with subacute nausea, vomiting and diffuse abdominal pain. Laboratory findings, including complete metabolic panel, complete blood cell count and lipase were unremarkable. Computed tomography, however, revealed interval development of large bowel obstruction, with transition point within the proximal descending colon. The patient was managed conservatively initially but required colonic decompression with colonic stent placement of the descending colon. Colonoscopy did not reveal any mucosal lesion and biopsy confirmed the absence of malignant cells. Due to persistent large bowel obstruction, the patient underwent an exploratory laparotomy and removal of fibrosis bowel with left hemicolectomy. His course was complicated by post-operative hypotension and an increase in peripancreatic fluid collection requiring endoscopic retrograde cholangiopancreatography with sphincterotomy and pancreatic duct stent placement. A drain was subsequently placed for infected intrabdominal fluid collection and the patient was discharged on a 10-day course of antibiotics.

DISCUSSION:
Cited only a few times in the literature, colonic involvement as a complication of acute pancreatitis is a rare and interesting finding. Inflammatory pancreatic enzymes precipitate necrosis, leading to fibrosis with stricture formation, perforation or peritonitis. The colon is affected due to its anatomic proximity with the pancreas. The splenic flexure, which abuts the pancreatic tail, is most commonly involved. While aggressive debridement of necrotic pancreatic tissue and drainage of retroperitoneal collections can help prevent colonic pathology, once involved, large bowel necrosis carries a mortality rate as high as 50% and 95%. Management is with early colon resection. Interestingly, compression by a pancreatic pseudocyst can cause colon involvement and may have been the etiology for our patient's sigmoid stricture.
1449 The “Runaway” Gallstone: Cholecystoduodenal Fistula Presenting as Gallstone Ileus
Authors: Ramrakhiani Hannah , Simpson Nicole , Strichartz Seth , Shetler Katerina , Triadafilopoulos George 
Published: October 2019

INTRODUCTION:
Gallstone ileus is a rare condition caused by impaction of a gallstone in the ileum after its passage through a biliary-enteric fistula. Diagnosis can often be delayed since symptoms may be intermittent. We present a case of gallstone ileus diagnosed with endoscopic ultrasound and computed tomography.

CASE DESCRIPTION/METHODS:
A 91-year-old female presented to the Emergency Department with symptoms of left flank pain, nausea, and vomiting. Laboratory studies including liver panel and complete blood count were unremarkable. Initial CT scan of the abdomen showed pericholecystic edema and possible gallstones with pneumobilia. Upper endoscopy revealed an ulcerated area with a fistulous opening containing pigment stone in the first portion of the duodenum. Endoscopic ultrasound findings included thickened gallbladder wall with a fistulous opening in the duodenum consistent with cholecystoduodenal fistula. Over the course of the next couple of days, the patient's symptoms of nausea and vomiting worsened. A repeat CT scan demonstrated signs of small bowel obstruction, pneumobilia, and an impacted stone in the jejunum - findings consistent with Rigler's triad. Patient underwent a laparoscopic-assisted enterotomy with removal of the obstructing intraluminal gallstone. She did well and was discharged home five days later. We postulate that the patient's intermittent obstruction was a result of the stone “tumbling” through the bowel lumen.

DISCUSSION:
Cholecystoduodenal fistula can be associated with obstruction either in the duodenum (Bouveret's syndrome), or more distally (gallstone ileus). Gallstone ileus can present with vague, intermittent symptoms that evolve over several days. A high index of suspicion is necessary for timely diagnosis. Our case highlights the role of upper endoscopy and endoscopic ultrasound in making an early diagnosis that may allow for expeditious treatment. If initial imaging is not diagnostic, repeat imaging may be helpful in confirming gallstone ileus.
1453 Cholecystocolic Fistula: An Unusual Cause of Abdominal Pain
Authors: Hamed Amira , Lambert Karissa , Hamed Ahmed Said , Ali Eslam 
Published: October 2019

INTRODUCTION:
Biliary-enteric fistula is a rare but a pertinent complication of gallbladder disease. It is usually a complication of acute cholecystitis. It occurs in 0.06%-0.14% of patients with biliary disease. Cholecystoduodenal (70%) is the most common site of communication of the fistula, followed by cholecystocolic (10-20%), and then cholecystogastric fistula (10-20%). Failure to identify these fistulas during cholecystectomy can have catastrophic complications as it may result in division of the fistula, perforation of the colon that can result in fecal peritonitis which ultimately can lead to sepsis and death. We are reporting a 57-year-old female presenting with diffuse sharp abdominal pain, nausea, vomiting who was found to have a cholecystocolic fistula and a 1.7 cm gallstone in the proximal sigmoid colon.

CASE DESCRIPTION/METHODS:
A 57-year-old Caucasian Female with a history of diverticulosis presented with diffuse sharp worsening abdominal pain, nausea, vomiting and diarrhea. Her physical exam was normal except for diffuse abdominal tenderness. Her Laboratory findings were unremarkable including her liver function tests. An abdominal CT scan showed a non obstructing 1.7 cm gallstone in the proximal sigmoid colon and a fistula between the hepatic flexure and the gallbladder (Figures 1 and 2). It also showed evidence of colitis in in the distal left colon and proximal sigmoid colon. Patient was scheduled for a cholecystectomy with fistula repair.

DISCUSSION:
Cholecystocolic fistula is a rare but a pertinent complication of gallbladder disease. Although a diagnosis of cholecystocolic fistula is rarely suspected clinically, Clinicians should be aware of it given that it can have catastrophic complications.
1454 Recurrent Isolated Colon Ischemia Secondary to Kayexlate. Kayexelate Helps History to Repeat Itself
Authors: Florian Rosemarie , Jackson Christian 
Published: October 2019

INTRODUCTION:
Kayexalate, sodium polystyrene sulfonate, is often used for treatment of hyperkalemia. This resin based medication has been associated with colon ischemia.

CASE DESCRIPTION/METHODS:
69 y/o male with extensive past medical history of end stage renal disease (ESRD) on hemodialysis (HD), atrial fibrillation not on anticoagulation, stroke with right hemiparesis s/p trach and PEG dependent, and left colostomy for diversion. He was transferred from the HD clinic to the ED for acute anemia, hypotension and hematochezia from ostomy. He was admitted for hemorrhagic shock, received intravenous fluid resuscitation, blood transfusions and was started on inotropic support. Infectious workup was negative. Computed tomography angiography was negative for acute bleed. EGD was unremarkable. Colonoscopy revealed extensive circumferential ulceration and pseudomembrane in the cecum and proximal ascending colon. Biopsies were consistent with colon ischemia. He improved clinically with supportive care and discharged. Three months later he was admitted for parotitis and hyperkalemia. He was started on Kayexalate and then developed hematochezia from ostomy with hemodynamic stability a few days later. He underwent repeat colonoscopy revealing persistent ulcerations with erythematous friability in the same area previously seen in prior colonoscopy. Biopsies this time revealed acute reactive epithelial atypia with embedded polystyrene sulfonate crystals.

DISCUSSION:
It is well known patients with renal failure on dialysis have a higher risk of developing colon ischemia. Kayexalate has been seen to cause colitis, which can progress to necrosis in 1% and perforation. This is hypothesized to be due to the release of prostaglandins and mesenteric vasoconstriction, thus causing mucosal damage. This may explain why this patient with recent history of right colon ischemia had Kayexalate induced injury in the same area. Symptoms of this damage can be seen within days to weeks after administration of medication, as in this case. In conclusion, patients with ESRD presenting with hematochezia, careful review of medications should be done as Kayexalate may induce colon ischemia. ESRD patients with previous colon ischemia, urgent HD rather than Kayexalate may be preferred, as the latter may recur as colon ischemia in the setting of previously injured tissue.