bluuebunny/crossref_metadata_2025_split huggingface dataset:
1207 Differences of Gastric Cancer Characteristics Between With and Without Helicobacter pylori Eradication
Authors: Kodama Masaaki , Okimoto Tadayoshi , Mizukami Kazuhiro , Ogawa Ryo , Okamoto Kazuhisa , Matsunari Osamu , Fukuda Kensuke , Murakami Kazunari 
Published: October 2019

INTRODUCTION:
Although the rate of gastric cancer (GC) after Helicobacter pylori (H. pylori) eradication has gradually increased over time, the features of GC following eradication remain to be examined. In this study, we investigate the clinicopathological features of GC following eradication in comparison with those of GC with H. pylori infection.

METHODS:
50 subjects with GC following eradication [HP(-) group] and 151 patients with GC with H. pylori infection [HP(+) group] were enrolled in this study. Clinicopathological features, such as age, gender, endoscopic atrophy, tumor form, location, depth of invasion, histology, were assessed. The manifestation of GC was further evaluated using immunohistochemistry of Ki-67, CDX22, p53, claudin18, E-cadherin, c-myc and In situ hybridization for detecting Epstein-Barr virus (EBV).

RESULTS:
Macroscopic analysis revealed a significantly higher ratio of depressed type/elevated type in HP(-) group compared with HP(+) group (30/19 vs. 61/77, P = 0.041). Tumor size was significantly greater in HP(-) group compared with the HP(+) group (13.02 ± 7.10 vs. 16.53 ± 11.12, P = 0.0019). The gastric mucin phenotype was more predominant in HP(-) group compared with HP(+) group, and the proportion of CDX2-positive cases was lower in HP(-) group (8 out of 18; 44.4%) compared with HP(+) group (18 out of 19; 94.7%) (P = 0.00082). Ki-67 labeling index was significantly lower in HP(-) group (32.03 ± 22.15) compared with the HP(+) group (79.20 ± 14.87, P < 0.0001). No patient in HP(-) group showed significant expression of EBV infection.

CONCLUSION:
The clinicopathological characteristics of GC following H. pylori eradication differ from those of GC in patients with H. pylori infection in morphology, mucin phenotype, and proliferation rate. It is necessary to be careful about these differences in GC screening.
1215 Helicobacter pylori Infection in Cancer Patients: MD Anderson Cancer Center Experience
Authors: Alasadi Mazen , Alasadi Mazen 
Published: October 2019

INTRODUCTION:
Helicobacter Pylori infection is prevalent worldwide. Up to 50% of the world population is affected, with or without symptoms. H. pylori infection can lead to gastritis, gastric or duodenal ulcers, gastric cancer, and rarely gastric mucosa-associated lymphoid-tissue lymphoma. Patients with cancer are exposed to several factors that can affect H. pylori behavior, such as chemotherapy, radiotherapy, and other treatment modalities. Also, the diminished immunity of cancer patients might be a risk factor for H. pylori or play a role in the responsiveness of H. pylori disease to treatment. Nonetheless, clinical features and outcomes of H. pylori in cancer patients are not well studied. We aimed to describe clinical symptoms, treatments, and outcomes of H. pylori in cancer patients.

METHODS:
We retrospectively collected information from adult cancer patients who had a diagnosis of H. Pylori after cancer diagnosis between January 2010 and November 2018. Descriptive statistics were used to summarize the data. T-tests and Pearson's Chi-Square were used to compare variables by cancer type.

RESULTS:
A total of 101 cancer patients diagnosed with H. Pylori by gastric biopsies were included, 61 males and 40 females with a mean age of 58.82 years. Asian was the most common race (n = 28), followed by Hispanic (n = 20) and White (n = 20). Reflux disease was present in 52 patients, hiatal hernia in 19, and Barrett's esophagus in 13. The most common cancer type was those of the gastrointestinal tract (n = 45), followed by lymphoma (n = 16) and breast (n = 14). Regarding cancer treatment, 15 patients had surgery, 51 had chemotherapy, and 35 had chemoradiation. The most common presenting symptom was abdominal pain (n = 45) then bloating (n = 30). Complications of H. pylori infection were manifested as gastric ulcer in 7 patients, duodenal ulcer in 3 and Gastrointestinal bleeding in 4. H. Pylori was treated with Prevpac in 45 patients and Pylera in 36. A 72 patients had response to treatment with the infection recurred in 14 patients.

CONCLUSION:
In cancer patients with H. Pylori infection, Asian was the most common race, abdominal pain was the most common presenting symptom, GI cancer was the most common malignancy followed by lymphoma and breast cancer. 71% had responded to the treatment.
1288 Cystic Artery Pseudo-Aneurysm: A Rare Cause of Hemobilia and Jaundice
Authors: Rafiq Rehan , Rafiq Ariej S. 
Published: October 2019

INTRODUCTION:
Aneurysms of the hepatic artery or its branches are rare, representing 0.01-2% of all arterial aneurysms.1 Causes of cystic artery aneurysms include abdominal trauma and intra-abdominal inflammatory processes such as cholecystitis.2 We present a case of gastrointestinal bleeding, jaundice and colicky right upper quadrant abdominal pain (Quincke's clinical triad) as a result of a ruptured pseudo-aneurysm of cystic artery.

CASE DESCRIPTION/METHODS:
A 79-year-old white man with a past history of cholecystectomy presented with colicky right upper quadrant pain, jaundice and melena. Physical examination showed stable vital signs. He had icterus. He was mildly tender in the epigastrium and right upper quadrant on palpation. His CBC showed a white cell count of 16.5 K/UL, hemoglobin 13.8 GM/DL, and hematocrit 42%. LFTs showed total bilirubin of 7.50 MG/DL, direct bilirubin 5.30 MG/DL, AST of 379 IU/L, ALT of 798 IU/L, and alkaline phosphatase was 337 IU/L. An ERCP was performed. The ERCP showed blood clots at the ampulla. Cholangiogram showed multiple filling defects consistent with blood clots. This was treated with placement of biliary stent. CT showed hemorrhage next to a fusiform pseudo-aneurysm measuring 13 × 6 mm, which appeared to arise in the region of the cystic artery. Embolization of pseudo-aneurysm resolved the patient's symptoms.

DISCUSSION:
Pseudo-aneurysm of cystic artery after laparoscopic cholecystectomy is rare. One report identified 27 published cases.3 It can occur up to 120 days after surgery.4 Among the possible causes are the excessive use of electrocautery and erosion of the cystic artery caused by the metal clip used to occlude the cystic duct.5 Pseudo-aneurysm of the hepatic artery or its branches presents with hemobilia in about 20% of cases in the early postoperative period.4,6 The classic triad of upper gastrointestinal bleeding, pain in the right upper quadrant and obstructive jaundice described by Quincke is present in 32% of patients.7,8 In our patient, the possibility of a pseudo-aneurysm was only considered after imaging. Angiography established the diagnosis. Doppler ultrasound is an alternative means of detecting the aneurysm.9 In patients with gastrointestinal bleeding, EGD and ERCP may be performed before arteriography.10,11 Transarterial embolisation is the treatment of choice in the presence of hemorrhage.6,10,12 When there is compression of the bile duct or a fistula or failure of embolisation, surgery is needed to repair or ligate the artery involved.7
1294 Large Common Bile Duct Stones Creating a Rare Distal Choledochoduodenal Fistula Requiring Unusual Extraction Method
Authors: Dinh Brian , Chen Patrick , Beck Gregory 
Published: October 2019

INTRODUCTION:
Choledochoduodenal fistulas (CDF) are abnormal connections of the common bile duct to the duodenum separated into proximal and distal. Of the various enterobiliary fistula, the most common is cholecystoduodenal. The rare occurring distal CDF etiologies include cholecystolithiasis, malignancy, peptic ulcers and iatrogenic. In the case presented, common bile duct (CBD) stones were large enough to create a fistula from the common bile duct superior to the sphincter of Oddi requiring unique extraction.

CASE DESCRIPTION/METHODS:
A 75-year-old Caucasian female with past medical history significant for biliary colic status post cholecystectomy was found to have multiple large CBD stones on abdominal ultrasound outpatient. Physical exam and laboratory analysis was unremarkable. When the ERCP was performed, the papilla was identified and noted be abnormal. The papilla was downward facing. Shockingly, superior to the papilla was a CDF created by an impacted black CBD stone. Subsequently to this unexpected finding, selective deep cannulation of CDF, adjacent to the CBD stone, was done using a sphincterotome with a 0.035 wire. No attempts were made of cannulating the papilla. The cholangiogram showed multiple CBD stones throughout the distal CBD. A 13 mm sphincterotomy superiorly at the CDF, followed by balloon sweeps removing several large yellow cholesterol appearing stones.

DISCUSSION:
Distal CDF is diagnosed via endoscopy and categorized based on location using the Ikeda classification. Type 1 (distal) fistulas occur along longitudinal fold adjacent to the papilla, often due to an impacted stone. Type 2 (proximal) occurs on the posterior wall of the duodenal bulb. The classification system further separates CDF into type A, opening greater than 2 cm from the papilla, type B, opening within 2 cm from the papilla, and type C, opening on the papillary fold. In this rare case of distal CDF, the diagnosis was likely type 1A (distal and greater than 2 cm from the papilla). Treatment is often based upon the etiology of CDF formation. Given the rare occurrence, it is important for gastroenterologist to be aware of the classifications as it may assist in treatment and safe stone removal.
1334 Malakoplakia Mimicking Pancreatic Cancer
Authors: Iriana Sentia , Voaklander Rebecca , Hubbard Lauren , Rogers Douglas , Sossenheimer Michael 
Published: October 2019

INTRODUCTION:
Malakoplakia is an indolent immune disorder of the urinary tract with isolated reports of skin, brain, and GI involvement. It may present as a mass, and is sometimes associated with malignancy. We report a patient on immunosuppression for heart transplantation who presented with a pancreatico-duodenal mass and biliary obstruction from malakoplakia.

CASE DESCRIPTION/METHODS:
A 67- year old heart transplant patient presented with fevers, malaise, leukocytosis and right upper quadrant pain. MRCP demonstrated a heterogeneously enhancing 10 cm pancreatic head mass. EUS with FNA for cytology, AFB, fungal, and aerobic/anaerobic cultures were obtained. Histology showed malakoplakia without malignancy. E.coli grew from one culture and was treated with ceftriaxone and metronidazole. He developed jaundice with worsening biliary and pancreatic duct obstruction and enlargement of the mass on repeat MRCP. ERCP showed a large periampullary ulcerated mass and distal common bile duct stricture. Histology, cultures, flow cytometry, and viral testing of the mass and brushings from the CBD showed histology consistent with malakoplakia. Cultures were positive for MAI complex, Candida guilliermondii, and staphylococcus epidermidis. Treatment with ampicillin-sulbactam, fluconazole, azithromycin, doxycycline, ethambutol, ganciclovir, and moxifloxacin resulted in clinical improvement and decreased size of the mass. Fluconazole, doxycycline and bethanechol as adjunctive therapy will be continued until imaging resolution of malacoplakia.

DISCUSSION:
Malakoplakia is a rare inflammatory reaction characterized by infiltration of large foamy macrophages, triggered by infections in immunosuppressed patients. While mostly found in the urogenital tract, the GI tract is the second most common site where malakoplakia may occur, and if mass forming may mimic malignancy. Antibiotics with intracellular penetration are required to treat the organisms that have been phagocytized by macrophages. In malakoplakia, decreased intracellular cyclic-guanosine monophosphate (cGMP) ratios alter microtubule function and decrease β-glucuronidase release, resulting in impaired phagolysosomal digestion. Bethanechol increases cGMP levels and ascorbic acid promotes phagosome bactericidal activity, theoretically resulting in more effective bacterial killing. This report highlights malakoplakia as a potential masquerade for pancreatic cancer, an important differential consideration in immunosuppressed patients.
1341 Not so Incidental: A Case of Incidentally Found Isolated Metastatic Melanoma of the Pancreas
Authors: Estepp Kayla , Meidinger Ross , Peng Hong Qi 
Published: October 2019

INTRODUCTION:
Metastatic lesions of the pancreas are uncommon, with reported frequencies of intrapancreatic metastases ranging from 4.5% to 11%, with isolated metastases around 2% of cases. Metastases from malignant melanoma is quite rare, with fewer then 200 cases reported in literature.

CASE DESCRIPTION/METHODS:
79-year-old female who presented to ED in June 2018 with fever, dysuria, and dyspnea. Past medical history significant for prednisone dependent sarcoidosis, atrial fibrillation, and basal cell carcinoma. Labs showed elevated WBC and UA concern for UTI. She was admitted for treatment. CT scan was done due to dyspnea showing LLL consolidation. Incidentally, a new 2.6 × 1.8 cm mass within the pancreas neck was seen. At discharge she was referred to our facility for EUS and FNA. EUS showed a pancreatic mass abutting the superior mesenteric vein without invasion. Cytological analysis obtained by EUS-FNA (Figure 1) showed malignant melanoma with abundant melanin pigments (Figure 2). Positive for Sox-10, Melan A and HMB-45. Referral to medical oncology was made for further work-up. PET scan was preformed due to lack of previous melanoma history, showing no evidence of disease outside the pancreatic area (Figure 3). With no primary lesion identified further referrals to Dermatology and Ophthalmology, however these evaluations were negative for overt cutaneous or ocular melanoma. Colonoscopy was performed and showed no lesions. Due to the isolated lesion, deemed an appropriate candidate for resection. September 2018, partial pancreatectomy and regional lymph node resection completed. Pathology of the 4.5 cm pancreatic neck mass, in addition to celiac and portal lymph node, consistent with malignant melanoma. October 2018 started immunotherapy of Opdivo and Ipilumimab. Repeat PET scan showed nodule along right flank, superior to iliac crest, FDG avid, suspicious for melanoma and thought to be the sight of primary lesion. Tolerated immunotherapy well, but in December 2018, was admitted due to respiratory distress secondary to aspiration pneumonia, was transitioned to comfort cares due to worsening clinical status, passing away.

DISCUSSION:
This case is a unique presentation of an isolated metastatic pancreatic melanoma, found incidentally in an otherwise asymptomatic patient. With the widespread use of imaging, clinicians can expect an increasing number of “incidentalomas” being found, stressing the role of EUS-FNA in gaining a precise diagnosis which is critical in the overall prognosis and management of patients.
1359 A Case of Pancreatic Pseudoaneurysm
Authors: Gurala Dhineshreddy , Idiculla Pretty Sara , Polavarapu Abhishek , Daoud Magda , Gumaste Vivek 
Published: October 2019

INTRODUCTION:
Pancreatic Pseudoaneurysm is a rare vascular complication of chronic pancreatitis. It may lead to fatal complications if left untreated. Here we report a case of pseudoaneurysm from a gastroduodenal artery in a patient with chronic pancreatitis which was managed successfully with coil embolization.

CASE DESCRIPTION/METHODS:
30-year old male with history of alcohol abuse, chronic pancreatitis, and splenic vein thrombosis on Xarelto presented to emergency department with epigastric pain. He was recently discharged from the hospital after an episode of acute pancreatitis. On admission, the pain was dull, radiating to the back with nausea but no vomiting, hematemesis or melena. Physical examination was grossly unremarkable. He was hemodynamically stable and blood work was unremarkable except for lipase 318 U/L. Computerized tomography of abdomen showed development of a pseudoaneurysm branching from the gastroduodenal artery with pancreatic inflammatory changes and fluid collections (Figure 1). Interventional Radiology were consulted, angiography was performed with coil embolization of inflow, outflow vessels, and the pseudo aneurysmal sac (Figures 2 and 3). His hemoglobin remained stable, and his symptoms resolved. Diet was advanced and Xarelto was resumed. He was discharged on the third day to follow up as outpatient.

DISCUSSION:
Pancreatic pseudoaneurysms are formed by erosion of the pancreatic or peripancreatic artery into a pseudocyst. These may occur after pancreatitis, as well as after pancreaticobiliary surgery, pancreatic transplantation, trauma, and motor vehicle accident. They are classified according to the artery they originate from, communication with gastrointestinal tract and exposure to pancreatic juice. Most commonly involved is splenic artery due to its proximity to the pancreas, followed by gastroduodenal artery, pancreaticoduodenal arteries, then superior mesenteric, left gastric, hepatic and small intrapancreatic arteries. Gastro-Duodenal Pseudoaneurysm commonly presents as gastrointestinal bleeding secondary to rupture. It can also present as abdominal pain, asymptomatic, rarely as retroperitoneal bleed or bleeding into pancreatic duct or common bile duct, which can cause obstructive jaundice. Treatment modalities include either embolization or surgery. Surgery is necessary when embolization is unsuccessful. Prompt diagnosis and early treatment of pancreatic pseudoaneurysm is mandatory because of potentially life-threatening consequences and increased mortality if left untreated.
1363 A Rare Case of Heterozygous Hemochromatosis Presenting as Recurrent Pancreatitis
Authors: Alomari Mohammad , Patel Ankit , Al Momani Laith , El Kurdi Bara , Khazaaleh Shrouq , Young Mark 
Published: October 2019

INTRODUCTION:
Hemochromatosis induced pancreatitis is a relatively rare cause of acute pancreatitis that may complicate further into chronic or recurrent pancreatitis. However, heterozygous hemochromatosis is an exceptionally rare cause of overt disease with only a few cases reported to date. Herein we describe a case of heterozygous hemochromatosis solely presenting as recurrent pancreatitis.

CASE DESCRIPTION/METHODS:
A 32-year-old female patient with a past medical history of hypertension presented to our emergency department with epigastric pain of one-day duration. Her only medications were labetalol 300 mg and lorazepam 0.5 mg with reported alcohol use of two glasses of wine up to two to three times a week. On arrival, blood pressure was 177/116 mmHg. All vital signs were otherwise within normal limits. Physical examination was significant for mild epigastric and left upper quadrant tenderness. Initial laboratory workup was remarkable for elevated AST at 197 U/L, ALT of 63 U/L, alkaline phosphatase 124 U/L, and total Bilirubin 1.5 µmol/L. Lipase was within normal limits at 69 U/L. Urine toxicology screen was negative. IgG-4 level was within normal limits as well as triglycerides at 67 mg/dL. Magnetic resonance imaging of the abdomen (Figure 1) showed mild hepatomegaly and hepatic steatosis. The pancreas and gallbladder showed no acute changes. Hepatobiliary iminodiacetic acid (HIDA) scan showed a decreased ejection fraction at 6% (Figure 2). Magnetic resonance cholangiopancreatography (Figure 3) showed signs of chronic pancreatitis and a dilated pancreatic duct proximally. Signal characteristics in the spleen and marrow compartment suggested iron deposition leading to a more thorough investigation for hemochromatosis and hence transferrin saturation level returned elevated at 86% and ferritin at 800. She tested heterozygous for the C282Y mutation. The patient was managed conservatively and discharged home with plans for initiation of phlebotomy. The patient's transferrin saturation and ferritin normalized and reported no recurrent episodes of pancreatitis on follow up at 7 months.

DISCUSSION:
Hemochromatosis is a condition of iron overload and deposition leading to various organ dysfunction. On that spectrum, pancreatitis is considered an extremely rare manifestation, never mention, the sole presenting manifestation of this disease. Clinicians should be cognizant of the variety of medical conditions that can cause pancreatitis and investigate them when clinically indicated.
1371 Iatrogenic Lingual Hematoma Resulted in Impending Airway Compromise
Authors: Alnabulsi Rawaa , Ahmad Dina , Wong Richard C. , Smith Zachary L. 
Published: October 2019

INTRODUCTION:
Rapidly expanding lingual hematoma can result in life-threatening airway compromise. We describe a rare case of iatrogenic large tongue hematoma in a patient on Rivaroxaban after securing the endotracheal tube tightly with a thread for an ERCP.

CASE DESCRIPTION/METHODS:
An 82-year-old male with history of atrial fibrillation on rivaroxaban, and newly-diagnosed adenocarcinoma of the pancreatic head. He had recently undergone endoscopic placement of an uncovered self-expanding metal metal stent (SEMS), and after deployment, a very tight waist was noted. He presented to the emergency department 5 days after ERCP with vomiting and fever. Laboratory data were significant for AST 3075 IU/L, ALT 1311 IU/L, ALP 1432 IU/L, and total bilirubin of 10.4 mg/dL. CT abdomen and pelvis showed evidence of possible biliary stent occlusion versus incomplete expansion. An ERCP was performed during which a plastic stent was inserted through the SEMS. The day after the procedure, the patient developed tongue swelling and speech difficulty. IV diphenhydramine was administered with no improvement. An emergent flexible nasolaryngoscopy was performed demonstrating tongue edema with dark red/black discoloration extending to the floor of the mouth and swelling of the aryepiglottic folds (Figure 1a). He was treated with IV dexamethasone, famotidine, and diphenhydramine, and was transferred to the ICU for closer observation. The hematoma was thought to have resulted from tightly securing the endotracheal tube with a thread during the ERCP (Figure 2b). The patient was observed for 24 hours in the ICU after which he improved clinically and tongue swelling subsided without need for further intervention.

DISCUSSION:
This case illustrates a rare and a serious iatrogenic injury to the tongue as a result of securing the endotracheal tube too tightly with a thread. Lingual hematoma should be identified early to avoid impending airway compromise. Recognition of this potential complication by anesthesiologists and interventional endoscopists is necessary to prevent it.