bluuebunny/crossref_metadata_2025_split huggingface dataset:
1828 CryoDilation: A Novel Treatment for Benign Esophageal Strictures Using Liquid Nitrogen Spray Cryotherapy
Authors: Roccato Mary Kathryn , Duh Erica , Mai Daniel , El Hage Chehade Nabil , Hashimoto Rintaro , Samarasena Jason 
Published: October 2019

INTRODUCTION:
Liquid nitrogen spray cryotherapy (SCT) was developed for endoscopic treatment of Esophageal Cancer and Barrett’s Esophagus. It has been shown to be a safe and effective therapy. Pulmonologists and thoracic surgeons have used SCT for treatment of benign tracheal strictures and stenoses with reduced severity of airway narrowing and symptomatic improvement. We describe the successful use of SCT in a recurrent, benign esophago-gastric anastomotic stricture, highlighting its potential as a new alternative treatment modality.

CASE DESCRIPTION/METHODS:
A 52-year-old female with stage T1 esophageal adenocarcinoma status-post laparoscopic thoracoscopic Ivor-Lewis esophagectomy presented to clinic 3 months following surgery for dysphagia. An esophagogastroduodenoscopy (EGD) revealed an esophago-gastric anastomotic stricture. Over the next 4 years, the stricture recurred despite monthly EGDs with dilations, steroid injections, and stent placement. Her course was complicated by dysphagia, food impactions, and severe protein-calorie malnutrition requiring total parenteral nutrition (TPN). The decision was made to perform Cryodilation. The patient then underwent seven EGDs with cryodilation over seven months. During the procedure, liquid nitrogen spray was administered for 20 seconds, followed by 60 seconds of thaw time, for a total of three freeze-thaw cycles and stricture then dilated up to 18mm. Prior to the first EGD with cryoablation, she recorded her lowest weight within 5 years at 49.4 kg (BMI 16.4). After initiating these procedures, the patient experienced marked functional and clinical improvement. After only three cycles, she began eating soft foods again. After five cycles, her weight peaked at 58.9 kg (BMI 19.7), which she maintained for 8 months. After six cycles of therapy she was able to discontinue TPN. Since cryodilation, she has had no further weight loss nor episodes of food impaction and the time between endoscopic dilation procedures has lengthened considerably.

DISCUSSION:
This case demonstrates a severe recurrent esophago-gastric anastomotic stricture which was unresponsive to aggressive, frequent traditional management. This novel and previously unreported method of serial cryotherapy with dilation greatly improved this patient’s symptoms and functional status. This method is a potential safe and effective primary treatment or adjunct modality for refractory benign esophageal strictures.
1902 Small Bowel Tumor: The Answer to Unexplained Overt Gastrointestinal Bleeding
Authors: De La Guerra Ramiro , Kulkarni Abhijit , Narula Arshjyot 
Published: October 2019

INTRODUCTION:
The rarity of small bowel tumors often makes diagnosis difficult due to nonspecific and variable presenting symptoms. This can result in a delay of diagnosis and consequent poor treatment outcome. Small bowel tumors can be either malignant (adenocarcinomas, lymphomas, sarcomas, and neuroendocrine tumors) or benign (adenomas, leiomyomas, and lipomas).

CASE DESCRIPTION/METHODS:
We present the case of a 58-year-old male, who presented to the hospital with dizziness, lightheadedness, and dyspnea on exertion for 3 days. History was significant for GERD, and iron deficiency anemia. Recent outpatient evaluation of weakness and fatigue revealed hemoglobin of 10 g/dL, decreased from 16.3 g/dL one year prior. An outpatient colonoscopy was scheduled for the following month but presented to the hospital because of multiple episodes of melenic stools. He denied any hematochezia, abdominal pain, weight loss, dysphagia, nausea, vomiting or hematemesis. He denied any family or personal history of malignancy or inflammatory bowel disease. He was tachycardic on examination. Initial lab work revealed hemoglobin of 8.2 g/dL. During his hospitalization, the patient experienced frank hematochezia and required transfusion of several units of blood due to acute blood loss. The patient underwent endoscopic evaluation, which revealed a small hiatal hernia with normal stomach and normal examined duodenum. A colonoscopy revealed red blood in the entire examined colon as well as the distal ileum. The patient then underwent video capsule endoscopy (VCE), which localized a source of bleeding in the proximal jejunum. A subsequent small bowel enteroscopy revealed a large infiltrative, polypoid, submucosal and ulcerated mass in the proximal jejunum. A CT scan revealed the location of the mass. The patient ultimately went to the operating room. Intraoperative visualization noted the mass to be exophytic, approximately 5 cm in diameter with mild purulence into the peritoneal cavity but without evidence of carcinomatosis.

DISCUSSION:
Adequate diagnosis of small bowel tumors, which present with varied and nonspecific symptoms, can inform early and appropriate treatment. In this case, endoscopic evaluation with EGD, colonoscopy, and VCE, resulted in the localization of the tumor and facilitated its surgical excision. This case exemplifies a practical algorithmic approach to the evaluation of an unexplained overt gastrointestinal bleed in a patient with nonspecific symptoms.
1970 Spontaneous Page Kidney as a Cause of Gastric Variceal Bleed
Authors: Morales Alvarez Martha Catalina , Lio Jeffrey , Chuang Philip , Kheyfits Arkadiy , Dinani Amreen 
Published: October 2019

INTRODUCTION:
Gastric variceal bleeding occurs in 15–50% of patients with non-cirrhotic portal venous thrombosis but can also occur in cases of splenic vein thrombosis (SVT) due to the formation of isolated gastric varices (IGV). We present the first reported case of a page kidney causing splenic vein compression, thrombosis, and subsequent gastric variceal bleeding.

CASE DESCRIPTION/METHODS:
A 31-year-old stuntman presented with epigastric pain and worsening exertional dyspnea over 3 weeks. History was notable for melena and anemia with no reported ulcers on endoscopy. On admission, he had hemoglobin of 4.1 g/dl with severe iron deficiency and elevated reticulocyte count. There was no serologic evidence of hepatic or renal disease. A computed tomography (CT scan) of the abdomen revealed a large left-sided perirenal collection consistent with page kidney, splenomegaly and decreased caliber of the mid and distal splenic vein suggestive of nonocclusive SVT. His liver was normal. Initial endoscopy revealed an IGV type 1 and mild portal hypertensive gastropathy (Figure 1). CT angiography did not reveal a splenorenal shunt to pursue a balloon retrograde transvenous obliteration (BRTO). While admitted, he developed hematemesis and worsening anemia. Ultimately, underwent IR splenic vein stenting with a bare-metal stent and subsequent decompression of the gastric varices with brisk flow of the portal vasculature (Figure 2).

DISCUSSION:
Gastric varices are classified primarily by location with most involving the gastroesophageal junction due to portal hypertension. The incidence of bleeding is highest in IGV, typically associated with SVT. Common etiologies of SVT include pancreatitis, malignancy or trauma. Our case described an extrinsic splenic vein compression and subsequent thrombosis due to a sub-capsular renal hematoma possibly of unclear etiology. Treatment for GV often depends on local expertise, but commonly consists of cyanoacrylate injection, banding (especially in type 1 gastro-esophageal varices), transjugular intrahepatic portosystemic shunt (TIPS) placement, BRTO, and even splenectomy. More recently, in cases of IGV due to isolated SVT, splenic vein stenting has been increasingly utilized. In our case, TIPS would not address the pre-hepatic portal hypertension and cyanoacrylate was not available. Splenic vein stenting was thus chosen to decompress the IGV with excellent response seen on subsequent follow-up (Figure 1).
1973 Management of Duodenal NET With Significantly Low Hemoglobin Level on a Jehovah’s Witness Patient
Authors: Karim Syed S. , Jacob Bobby , Tackling Gary , Prasa Jarin , Rizvon Kaleem , Mustacchia Paul 
Published: October 2019

INTRODUCTION:
Neuroendocrine tumors (NETs), historically known as carcinoid tumors, can arise throughout the gastrointestinal tract. However, duodenal NETs are very rare; the incidence is only 0.19 / 100,000 in the US. We present a patient who identifies as a Jehovah’s witness presenting with acute on chronic anemia and occult gastrointestinal bleeding due to a bleeding mass which was biopsied and confirmed as a duodenal NET.

CASE DESCRIPTION/METHODS:
A 69 year-old African American female, Jehovah’s witness, with medical history of end stage renal disease on hemodialysis and anemia of chronic disease who was brought to the hospital for asymptomatic acute on chronic anemia with a hemoglobin of 5.6 g/dL (baseline 9–10 g/dL). Rectal exam revealed melena. Patient underwent upper endoscopy which revealed a 2 cm duodenal bulb mass which was biopsied and pathology revealed neuroendocrine tumor. Patient had elevated serum gastrin level of 250 pg/mL and chromogranin A level of 1963 ng/mL. Octreotide scan confirmed radiotracer uptake in the duodenum and in no other areas. The patient refused blood products adamantly and was managed with darbepoetin alfa. Her hemoglobin gradually trended up several months later to 10 g/dL. For her NET, she was referred to a tertiary center for EUS, for staging and surgical evaluation.

DISCUSSION:
Duodenal NETs can be divided upon proliferative activity, (well differentiated and poorly differentiated) as well as upon hormonal capabilities (gastrinoma, somatostatinoma, nonfunctional, and paragangliomas). Most patients are incidentally diagnosed during endoscopy or present with late complications of an indolent tumor. Carcinoid syndrome only occurs in less than 10 % cases, when there is metastasis to the liver. Diagnosis is based upon histological staining for neuroendocrine tissue, such as chromogranin and synaptophysin along with checking for proliferative activity with Ki-67 staining. Our patient’s biopsy confirmed well differentiated neuroendocrine tumor, positive for the above markers and low Ki-67 staining. Serum chromogranin A is elevated in 80% of NETs, as in this case. Gastrin level was below 1000 pg/mL, ruling out a functional tumor. CT and octreotide scan excluded any metastasis. NETs which are nonfunctional, without metastasis, and are less than 1 cm can be endoscopically resected. Our patient’s mass was 2 cm, and therefore she was sent for surgical evaluation. Her hemoglobin improved gradually with erythropoietin therapy and her outcome did not change despite her beliefs.
1996 Rectal Syphilis Presenting as Painless Hematochezia
Authors: Ching Patrick R. , Rubin Jonah N. , Twaddell William S. , Kim Raymond E. 
Published: October 2019

INTRODUCTION:
Diagnosing syphilis is challenging and rectal syphilis is a rare presentation. Patients with rectal syphilis can be asymptomatic or have anal pruritus, tenesmus, urgency of defecation, or anal discharge. We describe a case of rectal syphilis presenting with painless hematochezia.

CASE DESCRIPTION/METHODS:
A 40-year-old man with a history of HIV not on antiretroviral therapy and multiple sexually transmitted diseases presented with 7 days of painless hematochezia. He reported that 17 years ago he was infected with Chlamydia, gonorrhea and syphilis, which were all treated. He last had anal intercourse one-year prior. Starting 8 months ago, the patient had daily 7–10 non-bloody formed bowel movements that decreased the week prior to presentation to 3–5 bowel movements daily when his hematochezia began. Over the past month he has had progressive fatigue limiting his functional capacity and a 10-lb weight loss. He did not have nausea, vomiting, abdominal pain, constipation, or fever. Upon presentation, vital signs were within normal limits. He was well-developed and well-nourished with unremarkable abdominal, perianal and digital rectal examinations. CBC showed normocytic anemia. CD4 count was 204 with HIV viral load of 1.5 million copies/mL. CMV viral load was undetectable. Testing for Chlamydia and gonorrhea were negative. Notably his rapid plasma regain (RPR) was non-reactive. Stool studies including culture, ova and parasites were unremarkable. CT scan of the abdomen and pelvis showed mild asymmetric rectal thickening. A colonoscopy was performed which was significant for a 4-mm rectal submucosal nodule with ulceration and surrounding erythematous tissue. Hematoxylin and eosin stain of the biopsy was negative for malignancy, but Warthin-Steiner (silver) stain was positive for spirochetes. There was concern for rectal syphilis and the patient was referred for treatment.

DISCUSSION:
The differential diagnosis of spirochetes in the intestines include Treponema and Brachyspira. Patients with successfully treated syphilis can have reactive non-treponemal and treponema serum testing, but the titers wane over time. In HIV and syphilis co-infected patients serum testing has a lower sensitivity and specificity. Therefore despite the findings of blood testing, direct visualization helps with diagnosis. If there is any concern for syphilis, such as in this patient, treatment with penicillin is used to prevent sequelae of the disease (e.g. neurosyphilis or gummas).
2055 A Case Report of Rectal Mesalamine-Induced Myopericarditis
Authors: Luft Suzannah , Siegel Corey A. 
Published: October 2019

INTRODUCTION:
Inflammation of the pericardium, myocardium or both is a rare but known side effect of 5-aminosalicyclic acid (5-ASA) containing medications. While most reports in the literature of this side effect have occurred with oral mesalamine, our patient developed myopericarditis approximately 3 weeks after initiation of rectal mesalamine suppositories.

CASE DESCRIPTION/METHODS:
A 37-year-old man with a history of hypertension, GERD, irritable bowel syndrome and proctitis on rectal mesalamine suppositories presented to the emergency department with acute onset pleuritic chest pain and was found to have elevated troponin and non-specific ST segment changes on electrocardiogram. Initially he was evaluated for possible acute coronary syndrome; however given positional and respirophasic nature of the pain, his symptoms were felt to be more consistent with myopericarditis. Transthoracic echocardiogram showed a small pericardial effusion without tamponade and no significant wall motion abnormities. Cardiac MRI was consistent with myocarditis. Evaluation for infectious or autoimmune etiologies of myopericarditis was unrevealing, including negative ANA and Lyme antibody. He had been started on rectal mesalamine suppositories 3 weeks prior to presentation after colonoscopy showed proctitis concerning for possible ulcerative colitis. Later review of his colonoscopy findings and chronic gastrointestinal symptoms was more consistent with irritable bowel syndrome than ulcerative colitis. The rectal mesalamine was felt to be the most likely etiology of his myopericarditis and was stopped during the hospitalization. He was treated with a course of naproxen and colchicine with rapid resolution of chest pain.

DISCUSSION:
Myocarditis and pericarditis are well-described and potentially lethal side effects of drugs containing 5-ASA, although the mechanism for cardiac toxicity is not clear. Symptoms usually manifest within 28 days of drug initiation and may resolve with drug cessation alone. While the absorption of oral mesalamine is estimated to be around 20-45%, rectal mesalamine absorption is variable and likely depends of a variety of factors including retention time and degree of underlying rectal disease. Our case suggests that rectal absorption alone may be sufficient to cause cardiac toxicity and that rectal mesalamine may not be safe in patients who have previously had cardiac or other toxicity on oral 5-aminosalicyclic acid containing drugs.
2063 A Stellar Case of Stelara in the Treatment of Lymphocytic Colitis
Authors: Abughazaleh Shaadi , Glassner Kerri , Wilhite Amanda , Abraham Bincy 
Published: October 2019

INTRODUCTION:
Lymphocytic colitis is a chronic inflammatory disease manifesting with chronic, watery, non-bloody diarrhea. Patients have a normal appearing colon with biopsies showing histological changes. Medications are believed to be typical culprits, however data on causality is lacking. Treatment is focused on symptom management, however in refractory cases budesonide has been shown to provide both clinical and histological remission. There is limited data to guide practitioners for patients who fail to have improvement on budesonide. We present a case of a female who failed budesonide and was treated with ustekinumab for her lymphocytic colitis.

CASE DESCRIPTION/METHODS:
A 54-year-old woman with a history of indeterminate colitis presented with diarrhea, severe fatigue, and abdominal pain in January 2019. She was presumably diagnosed with ulcerative colitis (UC) in 2000 but without evidence of endoscopic or histologic findings. Her diagnosis was subsequently changed to Crohn’s disease (CD) in 2008 based on serologic markers alone again without evidence of endoscopic inflammation. Previous colonoscopy in 2015 showed endoscopically normal mucosa with biopsies suggestive of lymphocytic colitis (Figure 1). Due to her symptoms, she was started on ustekinumab. At that time, ustekinumab levels were found to be 9.9 (Inform Tx). At presentation, she was on ustekinumab q8 weeks, budesonide, and methotrexate. She was started on azathioprine while continuing budesonide and stopping methotrexate. After 3 months (March, 2019), her symptoms persisted, so her ustekinumab level was checked and was found to be low at 2.2. Therefore, she received a booster 90 mg SQ dose of ustekinumab. Budesonide was discontinued. Colonoscopy in May 2019 revealed endoscopic and histologic remission of the lymphocytic colitis.

DISCUSSION:
First line treatment options for lymphocytic colitis include avoidance of culprit medications and symptomatic treatment. In patients with persistent symptoms, budesonide has been effective in inducing clinical and histological remission in 6 weeks. In cases refractory to budesonide, there is very limited data on alternative treatment options. Although immunomodulators and biologics have been used for CD and UC, their utility in microscopic colitis remains unknown. Case reports have described varying success using agents such as azathioprine, infliximab, adalimumab, and mercaptopurine. We present a case of lymphocytic colitis successfully treated with a combination of ustekinumab and azathioprine.
2185 69-Year-Old Male After Gastric Bypass With Choledocholithiasis Treated With EDGE Procedure Complicated by LAMS Dislocation
Authors: Kloska Michal , Vaze Reema , Buckshaw Ricky , Shah Hiral 
Published: October 2019

INTRODUCTION:
With the alarming increase in the prevalence of obesity, more people are undergoing bariatric surgeries of which most common is Roux-en-Y gastric bypass (RYGB). This altered anatomy poses challenges in accessing the papilla for ERCP in the setting of biliary pathology. Until recently enteroscopy or surgery assisted ERCP were the two main treatment options. Today, EUS-directed trans-gastric ERCP (EDGE) procedures have emerged as a promising treatment option in such circumstances.

CASE DESCRIPTION/METHODS:
A 69-year-old male with history of RYGB, cholecystectomy, Barret’s esophagus, CAD and CKD was admitted with one day history of vomiting and RUQ abdominal pain. On initial evaluation the patient was afebrile, normotensive with scleral icterus. Labs were significant for leukocytosis (14.2 10^3/µL), elevated transaminases (AST 254 U/L; ALT 231 U/L) and signs of biliary obstruction (ALP 252 U/L; bilirubin 3.3 mg/dl). Abdominal imaging (CT, US) revealed dilated intra and extra hepatic biliary ducts with the CBD measuring 1.4cm. For further evaluation, an EDGE procedure was performed within 24 hours. After injecting water to form a fluid collection in the stomach and confirming no blood flow in the path, a 20mm Hot Axios LAMS was successfully deployed under EUS guidance. The gastric lumen was confirmed after dilatation to 18mm. The duodenoscope was advanced and subsequent cholangiogram revealed several large stone filling defects along with dilated hepatic ducts. A sphincterotomy was performed, 9-12mm followed by 12-15mm extraction balloons were advanced over the wire and after multiple sweeps, 5 large stones were removed with resolution of biliary obstruction. During the ERCP, the LAMS dislodged into the native stomach over the scope but was able to be successfully removed by rat-tooth forceps. Finally, the fistula was closed using endo-clips and the patient reported resolution of his symptoms and LFTs normalized.

DISCUSSION:
Choledocholithiasis after RYGB is not unusual as nearly 50% of patients develop biliary stones within two years after surgery. The most common complications after EDGE procedure are bleeding from the fistula site, persistent fistula formation, perforation or adverse events related to ERCP. We present a rare case of LAMS dislocation into the stomach during EDGE which was successfully removed with the snare. Being able to recognize and immediately treat this potential complication may help providers anticipate it during EDGE procedures.
2198 Not an Ordinary Cause of a Biliary Stricture: The Case of a Surgical Clip Migration After Open Cholecystectomy
Authors: Poola Shiva , Jampala Nannaya , Mudireddy Prashant 
Published: October 2019

INTRODUCTION:
Cholecystectomy is the mainstay treatment for gallstone disease. Post-operative complications include bile leaks, duct injury, abscess, and retained stones. Migration of surgical clips are a rare complication of cholecystectomy which is rarer in open cholecystectomy. Migrated clips may be asymptomatic to cholangitis. This case highlights a biliary stricture from a surgical clip after an open cholecystectomy that was endoscopically treated.

CASE DESCRIPTION/METHODS:
A 77-year-old Male presented with a 2-year h/o progressive abdominal fullness, lethargy and fatigue. He denied fevers, nausea, vomiting, or appetite changes. Initial work up found an elevated bili of 2.3 and an intrahepatic gallbladder (Figure 1). He was referred to surgery for concerns of gallbladder cancer and underwent a lap converted to open cholecystectomy with IOC. Pathology showed chronic cholecystitis with fibrosis and no malignancy. After two weeks he represented with worsening fatigue, low grade fevers, and dark urine. He had a leukocytosis, transaminitis, direct hyperbilirubinemia, and on imaging a hepatic abscess and intrahepatic biliary ductal distention. An ERCP demonstrated a dilatation of the upper third of the main bile duct with a single severe stenosis at the location of surgical clips on fluoroscopy. Spyglass cholangioscopy was performed and a clip with surrounding inflammation and stenosis was noted (Figure 2). The clip was removed with spybite forceps. A 10 F × 9 cm transpapillary plastic stent was placed through the left hepatic duct. The patient had downtrending LFTs and was discharged. Repeat ERCP at 6 weeks showed persistence of the stricture. The stricture was dilated and a 10 mm × 8 cm fully covered metal stent was placed. Repeat ERCP at 4 months showed resolution of the stricture with good biliary drainage (Figure 3). Patient continues to do well 2 months post procedure with improving LFTs.

DISCUSSION:
This is a case of a biliary stricture caused by a surgical clip post cholecystectomy that was managed endoscopically with clip removal and serial biliary ductal stenting. Intrabiliary foreign body is rarely described in the literature. Studies have described clip migration after cholecyestomy with the median time of presentation at 26 months. This patient presented at 14 days after cholecystectomy. One study found 70% of post-cholecystectomy clip migration was managed with ERCP. This patient had complete resolution of his biliary stricture after clip removal, balloon dilation, and stent placement.