bluuebunny/crossref_metadata_2025_split huggingface dataset:
2637 An Unusual Cause of Persistent Abdominal Pain and Hematochezia an Adult Male; Small Bowel Meckel’s Diverticulum Causing Intussusception
Authors: Dharmadhikari Neal D. , Fine Sean 
Published: October 2019

INTRODUCTION:
Symptomatic Meckel’s diverticulum (MD) in adults is extremely rare. The prevalence of MD in the entire population ranges from 0.3%–-2.9% with a lifetime incidence of symptoms at 4.2%. The common presentations of symptomatic MD are obstruction, gastrointestinal (GI) bleed, and inflammation; these complications are significantly more frequent in childhood. This case report highlights direct observation by traditional colonoscopy of small bowel MD as a lead point of intussusception in an adult.

CASE DESCRIPTION/METHODS:
A 25-year-old male presented to the hospital with acute on chronic periumbilical abdominal pain worsening over several days. He reported intermittent watery diarrhea and an episode of hematochezia. He was also hospitalized earlier in the year for bowel obstruction of unknown etiology, but found to have intussusception status-post diagnostic laparotomy and partial ileal resection. His vital signs were stable and the physical exam revealed peri-umbilical tenderness. Laboratory data resulted with fecal calprotectin 517.7 mg/kg, hemoglobin 10.2 g/DL, WBC 11.6 × 10exp9/L, ESR 33 mm/h, CRP 78.51 mg/L, and a negative Clostridium difficile PCR test. A CT abdomen/pelvis revealed mild thickening and mucosal hyperenhancement of the terminal ileum. A colonoscopy was performed due to concern for GI bleed and inflammatory bowel disease. On colonoscopy, the colon was normal, but a partially obstructing, mobile, villous mass was noted in the ileum. Subsequently, an exploratory laparotomy found recurrent small bowel intussusception. The ileal mass was resected and pathology showed ectopic gastric and pancreatic tissue confirming MD. An ulcer and acute inflammation were noted on the mass. His follow-up course was unremarkable and the patient’s symptoms have since improved.

DISCUSSION:
The symptoms of MD are significantly more common in other etiologies. In addition, symptomatic MD is rarely diagnosed in adulthood which makes the diagnosis of MD in adults a challenge. MD is often diagnosed by imaging modalities or direct observation during surgery. Balloon-assisted enteroscopy and capsule endoscopy are other diagnostic measures being explored. Endoscopy is indicated in patients presenting with GI bleed and was completed in this patient. A large portion of this patient’s distal ileum was previously resected and his altered anatomy allowed the direct observation of MD by colonoscopy. This case highlights a unique endoscopic finding that endoscopists should be aware as the etiology for GI bleed.
2639 A Curious Case of Abdominal Pain
Authors: Balarajah Sharmili , Martin Tracey , Wan David 
Published: October 2019

INTRODUCTION:
Median arcuate ligament syndrome (MALS) is a rare condition where compression of the coeliac artery and ganglia by the median arcuate ligament results in gastrointestinal symptoms. Whilst 13–15% of the population exhibit radiological features of celiac artery compression, only a fraction is symptomatic. We present a case of a frail patient investigated for chronic abdominal pain that was ultimately attributed to MALS.

CASE DESCRIPTION/METHODS:
An 86-year-old lady presented with a two-year history of post-prandial nausea, abdominal pain and unintentional weight loss. She was an ex-smoker and denied any alcohol intake or NSAID use. Clinical examination was unremarkable. Initial lab workup was within normal limits and H. pyloriserology negative. An EGD demonstrated duodenal erosions and superficial ulcerations. A gastric emptying study was unremarkable. CT enterography and an MR angiography demonstrated focal narrowing of the celiac artery by the median arcuate ligament (
Figures 1 and 2
). Vascular duplex demonstrated altered celiac artery velocities with respiration (
Figure 3
). A provisional diagnosis of MALS was made. The patient underwent celiac plexus block (CPB) with which her symptoms resolved. She later underwent celiac plexus neurolysis and remains symptom-free.

DISCUSSION:
MALS is an uncommon diagnosis typically characterised by a triad of post-prandial abdominal pain, weight loss and abdominal bruit. There are currently no proven pathophysiological mechanisms though ischaemic and neuropathic mechanisms have been hypothesized. MALS is a diagnosis of exclusion and a difficult one to make given its rarity and lack of specific symptoms. The gold standard for diagnosis is with conventional angiography. Given our patient’s frailty, we opted for minimally-invasive radiological investigations and provocative physiological testing with CPB. The mainstay of management is with open surgical decompression but this is associated with high rates of post-operative complications and prolonged hospital stays. Celiac plexus neurolysis is an alternative option that could be considered in frail patients for both diagnosis and management. MALS is a rare but important diagnosis to consider in patients with chronic abdominal pain and proves to be a diagnostic challenge. Our case demonstrates the use of non-invasive investigations and provocative physiologic testing to diagnose MALS in a frail patient and highlights celiac plexus neurolysis as a treatment option.
2643 A Rare Presentation of Duodenal Adenocarcinoma Concealed by Membranous Nephropathy
Authors: Naser Jwan A. , Al Nimri Sarah M. , Mousa Omar Y. 
Published: October 2019

INTRODUCTION:
Duodenal adenocarcinoma is rare and often has a vague clinical presentation. Therefore most patients have advanced disease (stage III or IV) at the time of diagnosis, which heralds poor prognosis. Membranous nephropathy can be associated with solid tumors; however duodenal adenocarcinoma presenting as membranous nephropathy has not been reported in the literature.

CASE DESCRIPTION/METHODS:
A 78-year-old male presented with worsening dyspnea, nausea and anorexia over a period of several months. Further workup revealed proteinuria secondary to biopsy-proven membranous nephropathy. PLA2R antibodies were negative, which initiated an evaluation for secondary membranous nephropathy. Physical examination revealed anasarca. His creatinine was 3.4 mg/dL, and extensive workup for a secondary cause of membranous nephropathy, including ANA, C3, C4, and hepatitis B and C testing was negative. CT of the abdomen showed upper abdominal and mesenteric adenopathy. His presentation was complicated by gastrointestinal bleeding with a hemoglobin of 5.3 g/dL. Esophagogastroduodenoscopy revealed a large villous, infiltrative sessile mass in the third portion of the duodenum [Figure 1]. Biopsies showed moderately differentiated adenocarcinoma. Endosonographic ultrasound showed malignant-appearing lymph nodes and fine needle aspiration of the largest celiac lymph node confirmed metastatic adenocarcinoma. Therefore surgical resection was not recommended. The patient was started on 5-fluorouracil and oxaliplatin. Membranous nephropathy was due to a paraneoplastic syndrome and its resolution was dependent on the course of the duodenal adenocarcinoma. Unfortunately, his course was complicated by worsening renal failure and he required intensive care with continuous renal replacement therapy and non-invasive ventilation for respiratory failure. He recovered slowly and was discharged home on hemodialysis. Follow up imaging periodically over the following year revealed peritoneal, lung and liver metastasis. The patient eventually pursued palliative care and he passed away.

DISCUSSION:
The unusual presentation of duodenal adenocarcinoma in the form of membranous nephropathy led to a delayed diagnosis with poor candidacy for surgical resection. Age- and risk-appropriate assessment for malignancy is recommended in secondary membranous nephropathy without a clear etiology. Gastrointestinal malignancy should be in the differential especially when anemia is present.
2645 Small Bowel Bleeding Due to Solitary Metastatic Ovarian Clear Cell Carcinoma: A Case Report and Review of the Literature
Authors: Keihanian Tara , Pena Polanco Nathalie A. , Jordan Scott , Pearson Joseph M. , Barkin Jodie A. 
Published: October 2019

INTRODUCTION:
Small bowel bleeding (SBB) accounts for 5–10% of gastrointestinal bleeding cases. Common causes of SBB are inflammatory bowel disease, angioectasias, ulcers, & primary & metastatic neoplasms. The aim of this case report & literature review is to present ovarian clear cell carcinoma (CCC) as a rare cause of SBB.

CASE DESCRIPTION/METHODS:
A 51 year old woman with dual primary stage IIB CCC of bilateral ovaries & uterus, & stage IA, grade 1 endometrioid adenocarcinoma underwent total laparoscopic hysterectomy, bilateral salphingo-oophorectomy, bilateral pelvic lymph node dissection, & omentectomy. Pathology from the right pelvic side wall peritoneum was positive for CCC involving fibroadipose tissue. She completed 6 cycles of chemotherapy with paclitaxel & carboplatin. Following treatment, she achieved clinical remission for 14 months until computed tomography (CT) scan performed for new abdominal pain & constipation showed a 6.3 × 4.6 cm heterogeneously enhancing lobular mass lesion within the pelvis in close contact with the sigmoid colon without definite invasion. A month later, she was admitted with lower abdominal pain & bloody stools. Colonoscopy showed blood in the entire colon & terminal ileum (TI), without active source of bleeding identified. CT Angiography showed no evidence of active bleeding, but revealed increasing pelvic mass size (6.5 × 6.4 cm). No lymphadenopathy was noted on CT scan. Upper endoscopy was unrevealing. Video capsule endoscopy (VCE) showed an actively bleeding mass likely in the distal small bowel, without VCE passage beyond the mass or cecal intubation. Exploratory laparotomy revealed an 8cm mass arising from the distal TI adherent to the epiploica of the rectosigmoid, not involving the vaginal cuff or prior resection sites. A portion of distal TI was resected with a side-to-side ileo-ascending colon anastomosis. TI pathology was positive for CCC, with negative omental & lymph node pathology. Chemotherapy with carboplatin & doxorubicin was initiated without further bleeding.

DISCUSSION:
Ovarian cancer is thought to metastasize via direct invasion, lymphatic or hematogenous infiltration, or peritoneal dissemination. Solitary metastasis of ovarian CCC to the small bowel without peritoneal carcinomatosis or lymphatic involvement is a rare phenomenon. Our literature review revealed only one other published case report describing this entity. Solitary CCC metastases should be added to the list of potential neoplastic causes of SBB.
2646 Ischemic Colitis Secondary to Sumatriptan Overuse Along With Estrogen
Authors: Thyagaturu Harshith S. , Jha Samir , Demeria Dennis 
Published: October 2019

INTRODUCTION:
Sumatriptan, a 5-HT1B/1D (5-hydroxytryptamine-1B/1D) receptor agonist is the first line medication currently available for migraine and cluster headaches. The drug acts by selectively constricting the intracranial blood vessels. Also, studies have shown that estrogen modifies the levels of MAO-A (Monoamine oxidase-A) in the body thereby decreasing the metabolism of sumatriptan. In the past few decades, there has been a handful of reported cases of coronary vasospasm, myocardial infarction and ischemic colitis associated with sumatriptan use. We report a 57-year-old female who developed ischemic colitis in the setting of usage of increasing doses of sumatriptan along with estrogen.

CASE DESCRIPTION/METHODS:
A 57-year-old woman with a history of migraine headache, fibromyalgia, hypertension, diet-controlled diabetes mellitus, diverticulitis presented to the emergency room with sudden onset of left sided abdominal pain and 5 episodes of Bright red blood per rectum for one day. Medications included sumatriptan, estradiol, enalapril, venlafaxine, aspirin, and atorvastatin. On examination, left lumbar and left iliac quadrants tenderness was noted. Negative for peritoneal signs. Labs showed WBC 19.6 [3.7–10.6 cells/ul], Hb 15 [11.5–15.5 cells/ul], glucose 106 [70–139 mg/dL], lactic acid 3.2 [0.5–2.2 mmol/L], ESR 18 [<=30 mm/hr], CRP 10.2 [0.3–1.0 mg/dL]. CT abdomen and pelvis revealed findings suggestive of colitis extending from the hepatic flexure to sigmoid colon. Of note, she was using increasing doses of sumatriptan [100 mg tabs, at least 3 to 4 times a day] in the past few weeks for increased frequency of migraine headaches. Endoscopic findings are suggestive of ischemic colitis versus the others. Pathology of the mucosal biopsy showed hallmarks of ischemic colitis. Sumatriptan and estrogen were discontinued. The patient was followed up for a few weeks to months. She reported remarkable improvement of symptoms without any recurrence.

DISCUSSION:
Sumatriptan is a commonly prescribed abortive medicine for migraine, while ischemic colitis is one of its rare side effects. We aim to emphasize the synergistic effect of increasing doses of sumatriptan along with estrogen in causing ischemic colitis. Physicians should consider the diagnosis of sumatriptan-induced ischemic colitis in patients taking increased doses of this medication with concurrent estrogen usage, who develop severe abdominal pain, hematochezia and potentially counsel patient on cautious use of 5HT1 receptor agonist.
2653 Solitary Peutz-Jeghers Polyp Presenting as Iron Deficiency Anemia
Authors: Hamilton Daniel P. , Brown J. Andrew , Beyer Ryan J. 
Published: October 2019

INTRODUCTION:
A sporadic hamartomatous polyp in the duodenum is an uncommon finding, with occurrence of solitary Peutz-Jeghers polyps only reported in singular or small case series. Typical presentation of Peutz-Jeghers type polyps occurs in patients with Peutz-Jeghers syndrome (PJS), which is a rare, autosomal-dominant disorder consisting of the simultaneous presentation of multiple hamartomatous polyps in any part of the alimentary tract and mucocutaneous pigmentation deposits [1]. We present a case of a solitary Peutz-Jeghers type polyp causing anemia found in the duodenum of a patient without any other characteristic findings of PJS.

CASE DESCRIPTION/METHODS:
Our patient was a 37 yo female with h/o pulmonary embolus on anticoagulation who had undergone workup of iron deficiency anemia by an outside gastroenterologist. After negative EGD and colonoscopy, a capsule enteroscopy showed a polypoid lesion in the small bowel, and she was referred for push enteroscopy. Anticoagulation had been held for the procedure. The push confirmed a 2.5 cm pedunculated polyp in the third portion of the duodenum, which was resected with snare cautery, and removed using a Roth net. No bleeding was seen, but as the patient was to resume anticoagulation, 2 hemoclips were applied to the resection site. Pathology showed Peutz-Jeghers type polyp. On follow-up the patient’s hemoglobin had returned to normal levels, confirming the polyp as the cause of anemia.

DISCUSSION:
Solitary PJ polyps are extremely rare and are typically found in case reports with presentation on the spectrum from asymptomatic finding to dyspepsia, abdominal pain, intussusception and melena. To our knowledge, our patient’s case consists of the first reported case of a solitary PJ-type polyp presenting solely as iron deficiency anemia.
2658 Henoch-Schonlein Purpura Duodenitis
Authors: Kaila Vishal , Sudhekar Nivedita , Feldman Mark 
Published: October 2019

INTRODUCTION:
Henoch-Schonlein Purpura (HSP) is an IgA mediated systemic, small and medium vessel vasculitis that typically presents with palpable purpura, arthralgias, abdominal pain and hematuria. Gastrointestinal manifestations occur in about 20% of patients prior to skin involvement. We report a case of a 51-year-old woman that presented with HSP duodenitis.

CASE DESCRIPTION/METHODS:
A 51-year-old female presented with a several week history of nausea, vomiting and epigastric abdominal pain. In addition, she had been experiencing dysphagia, arthralgias, fever and, later on, a palpable, petechial and purpuric rash on her face, ears and all extremities. She had no previous medical history. Physical exam showed an extensive palpable, ecchymotic and purpuric rash involving her arms, face, right ear and purpura on plantar surface of her feet (See Figure 1). Her wrist, elbow, knee and ankle joints were tender to palpation, warm and swollen. She had epigastric tenderness to palpation with no rebound or guarding. Laboratory workup was notable for a white blood cell count of 18.32 M/μL (4.20–5.60 M/μL). Computed tomography of the abdomen showed bowel wall thickening at the junction of duodenum and jejunum with fat stranding in the central mesentery. Biopsy of the skin showed features of leukocytoclastic vasculitis with associated perivascular necrotizing inflammation and hemorrhage (See Figure 2). EGD showed diffuse circumferential erythema with boggy mucosa as well as friability with touch bleeding consistent with ischemic type changes from distal bulb to the second portion of the duodenum (See Figure 3). Biopsies of the duodenum showed evidence of intramucosal hemorrhage, a mixed inflammatory infiltrate of neutrophils, lymphocytes and some plasma cells within the lamina propria. There were also fragments of advanced necrosis with evidence of small vessel thrombosis and vasculitis. Her abdominal pain and oral intake improved after treatment with 1 g methylprednisone for three days. The patient was discharged from the hospital with an oral steroid taper.

DISCUSSION:
HSP is rare in adults with roughly 20-fold fewer cases than in children. The range of endoscopic findings includes gastritis, ulceration, duodenitis, and submucosal hemorrhage with the second portion of the duodenum being involved more than the duodenal bulb. The end capillaries of small intestinal villi are particularly susceptible to ischemic injury. HSP is a self-limiting disease and majority of the patients improve spontaneously.
2659 A Rare Occurrence: Anal Squamous Cell Carcinoma With Metastasis to Duodenum Causing Duodenal Stricture and Gastric Outlet Obstruction
Authors: Yuridullah Ruhin , Kaur Parminder , Estifan Elias , Sanchez Jessimar , Kapoor Ashima , Singhal Monisha 
Published: October 2019

INTRODUCTION:
Squamous cell carcinoma (SCC) of the anal canal is a rare entity encompassing only 2–4 percent of all colon, rectal, and anal cancers. SCC of the anal canal tends to be loco-regional and in the event of rare metastasis, most common sites of secondary seedlings are liver and lung. To our knowledge, metastatic spread from primary anal SCC to small bowel has been reported only once before. We report a rare case of SCC of anal canal with duodenal metastases in a 49-year-old female.

CASE DESCRIPTION/METHODS:
A 49-years-old female with 8-month history of anal SCC Stage IIIA, status post chemo-radiation therapy and loop ileostomy creation, was seen for complaints of vague abdominal pain, nausea, vomiting, and anorexia. Physical examination was significant for mild periumbilical tenderness. Computed tomography (CT) of the abdomen and pelvis with contrast revealed distended stomach with food contents and distended proximal duodenum. Esophagogastroduodenoscopy (EGD) showed moderate gastritis with duodenal edema resulting in narrowing of the second portion of the duodenum. An upper gastrointestinal series revealed distended stomach with air-fluid level and marked narrowing at the junction of the distal descending and transverse duodenum with "U-shaped" appearance and normal appearing jejunum. Colonoscopy via the stoma revealed normal colon proximal to diverting colostomy, normal terminal ileum, narrowed and scarred rectal vault. Biopsy from the duodenal stricture revealed duodenal mucosa with scattered malignant cells and malignant cell clusters within lymphatic spaces. Immunohistological staining demonstrated malignant cells positive for CK7, p16, p63 and negative for CK20, CDX2, GATA-3, CA19.9, TTF-1, Napsin A and PAX-8 favoring a metastatic anal SCC.

DISCUSSION:
Primary rectal squamous cell carcinomas (SCC) are very rare tumors. Additionally, either primary or metastatic SCC of the gastrointestinal tract is extremely rare with very few cases reported in the literature. In our case, the patient with established 8-month history of anal SCC stage IIIA, status post chemotherapy, radiation, and status post loop ileostomy creation presented with a rare duodenal metastasis, which has only been reported once before. The possibility of primary SCC of the small bowel was excluded with duodenal stricture biopsy showing scattered malignant cells and malignant cell clusters within lymphatic spaces and positive immunohistological staining favoring a metastatic lesion.
2665 Choledochoduodenal Fistula as the First Sign of Metastatic Ovarian Cancer
Authors: Mirza Muhammad U. , Misra Deeksha , Vangimalla Shiva S. , Waleed Muhammad , Mukhtar Kashif 
Published: October 2019

INTRODUCTION:
Choledochoduodenal fistulas (CDF) account for 5–25% of all internal biliary fistulas. They arise from duodenal ulcers or choledocholithiasis. Clinical presentation is non specific, therefore diagnosis necessitates use of imaging modalities. Most tumors that cause obstructive jaundice originate in the biliary tree, however there have been reports of biliary metastasis arising from distant cancer sites. We present the first case of CDF as the initial presentation of metastatic ovarian cancer after years in remission.

CASE DESCRIPTION/METHODS:
An 83 year old African American female with untreated Hepatitis C, chronic kidney disease, and high grade ovarian serous carcinoma status post exploratory laparotomy and chemotherapy 10 years ago, was admitted to the hospital with undocumented fever and abdominal pain for 4 days. She had right upper quadrant tenderness. Total bilirubin (TB) was 1.3 mg/dl and direct bilirubin (DB) was 0.5 mg/dl. CT scan abdomen showed dilation of the intra and extra hepatic bile ducts. ERCP showed a 13 mm duodenal ulcer superior to the duodenal major papilla with a common bile duct (CBD) stricture. Sphincterotomy and plastic stent placement in CBD was done after which she was discharged home. One month later, she was readmitted with melena for 3 days. Heart rate was 120 beats per minutes with hemoglobin of 5.6 mg/dl from a baseline of 9–10 mg/dl. CA 125 was 162.2 U/ml and alpha-fetoprotein was 7.6 ng/ml. EGD showed a 2 cm necrotic ulcer in the first part of duodenum with a fistulous tract. MRI abdomen showed a fluid collection around the duodenum with a choledochoduodenal fistula. Due to concerns about cancer, a repeat EGD was done for biopsy of the ulcer that showed a poorly differentiated carcinoma with immunoprofile positive for CK7, PAX8, ER and P53, consistent with ovarian cancer. PET scan was negative for any other metastasis. After discussion with the family, no further therapy was planned after which she was discharged home with palliative treatment.

DISCUSSION:
There have been cases of CDF arising from metastatic cancer invading the biliary tree. Colon adenocarcinoma and other neoplasms of the bile duct have been shown to cause CDF. Ovarian cancer has not been known to metastasize to the duodenum. Our patient was the first ever case of ovarian cancer metastasis to the duodenum that caused a CDF years after remission. Hence, we strongly recommend keeping a high index of suspicion when treating rare conditions like CDF in patients with a history of malignancy.