bluuebunny/crossref_metadata_2025_split huggingface dataset:
1843 A Rare Case of Large Cell Neuroendocrine Carcinoma of the Esophagus
Authors: Gioe Reed , Gioe Scott 
Published: October 2019

INTRODUCTION:
Neuroendocrine Tumors (NETs) are a rare form of esophageal malignancy with an incidence ranging from 0.4 and 2% of all malignant esophageal tumors (1). Among esophageal NETs, the vast majority are small cell esophageal carcinomas. A recent literature review found only 35 cases of large cell esophageal carcinoma have been reported since 1952 (2).

CASE DESCRIPTION/METHODS:
Patient is a 48-year-old male with past medical history of HTN, diabetes, and HLD who presented with 6 weeks of progressive dysphagia predominantly to solids. The dysphagia was initially infrequent, but eventually occurred every time he ate. ROS was pertinent for a 20 lb weight loss. Social history was pertinent for 1-2 drinks of alcohol per month and daily use of chewing tobacco. Family history revealed a mother with a brain mass and a grandmother with pancreatic CA. PE was normal. He underwent an EGD which showed a large, ulcerative distal esophageal mass extending into gastric cardia. Biopsies revealed a poorly differentiated carcinoma most compatible with large cell neuroendocrine carcinoma. CT imaging of chest, abdomen, and pelvis showed nonspecific lower esophageal mural thickening with no evidence of esophageal mass. PET scan showed hypermetabolic distal esophageal mass measuring 6 x 5 x 3 cm with peri gastric lymph node involvement. The patient underwent neoadjuvant treatment with radiation, cisplatin and etoposide followed by a distal esophagectomy with gastric pull-through. Surgical path revealed Stage III large cell neuroendocrine carcinoma involving the distal esophagus, proximal stomach, and peri gastric lymph nodes. Patient is currently recovering from the surgery with plans for postoperative chemotherapy.

DISCUSSION:
This case illustrates an rare form of a malignant esophageal neuroendocrine tumor. Esophageal NETs tend to be more aggressive than NETs found in other parts of the GI tract, so early diagnosis and treatment is critical in order to prolong survival. Due to a paucity of cases in the literature, there is a need for more cases to be presented in order to better understand the course of the disease and determine the best modalities for treatment.
1845 Rapidly Progressive Dysphagia as Presenting Symptom of Gastrointestinal Amyloidosis
Authors: Gandle Cassandra , Millien Valentine , Tasleem Syed , Bloomquist M. Suzanne , Choi Eunice , Hernaez Ruben , Cole Rhonda A. , Ketwaroo Gyanprakash Avinash 
Published: October 2019

INTRODUCTION:
Amyloidosis is a rare condition caused by the extracellular deposition of protein fibrils. The presence of these proteins in organs and tissues interferes with their ability to function normally. Amyloidosis commonly causes cardiomyopathy, neuropathy, and proteinuria. Gastrointestinal involvement in amyloidosis is less common and can either be isolated to the GI tract or systemic. When the GI tract is involved, patients typically present with symptoms such as bleeding, diarrhea, constipation, and steatorrhea. We present a case of gastrointestinal amyloidosis with rapidly progressive dysphagia as the presenting symptom.

CASE DESCRIPTION/METHODS:
A 70-year-old man presented with progressive dysphagia over one month. At first he noted difficulty swallowing meat. However, in the days leading up to admission he found that it took more effort to swallow liquids. He denied difficulty initiating swallow and endorsed a globus sensation after swallowing. Laryngoscopy was unremarkable. On EGD, the esophagus and duodenum appeared normal. Mild gastric erythema was present and biopsies were obtained of the esophagus and stomach. The esophageal biopsies were consistent with AL (lambda)-type amyloidosis. Congo red-positive amyloid deposits were present. Liquid chromatography tandem mass spectrometry (LC MS/MS) detected a peptide profile consistent with this diagnosis. Biopsies from the stomach and duodenum also had increased lamina propria fibrosis consistent with amyloidosis. Several weeks after this diagnosis was made, the patient expired due to an unrelated cause.

DISCUSSION:
AL amyloid is the most common type of amyloidosis however it very rarely involves the GI tract. Biopsy proven disease is found in approximately 8% of cases with only 1% of patients experiencing symptoms at the time of diagnosis. AL amyloidosis is typically associated with systemic disease due to an underlying clonal plasma cell proliferation or B-cell lymphoma. The patient described expired before further work-up could be completed. Dysphagia is an uncommon symptom of gastrointestinal amyloidosis and very few cases have been reported in the literature to date. Our case demonstrates an unusual presentation of a rare illness.
1852 Acute Gastroparesis Syndrome After Percutaneous Atrial Fibrillation Ablation
Authors: Leung Marcia , Pan Dana , Terrado Cecilia 
Published: October 2019

INTRODUCTION:
Percutaneous radiofrequency ablation (RFA) is now a common minimally invasive procedure for the maintenance of sinus rhythm in drug-resistant atrial fibrillation. We present a rare case of acute delayed gastric emptying after an RFA procedure.

CASE DESCRIPTION/METHODS:
57-year-old male with a history significant only for paroxysmal atrial fibrillation, who presented for a planned RFA procedure. He has no other medical or surgical history. The patient tolerated the procedure well and was discharged the same day. That evening, 1-2 hours after he ate dinner, he experienced severe nausea, vomiting, and abdominal pain. He was hemodynamically stable on presentation to the emergency department with labs significant only for a mild leukocytosis. Computed tomography showed a severely dilated stomach and proximal duodenum, with a transition point identified at the third portion of the duodenum. The patient was managed conservatively as a case of proximal small bowel obstruction. As he had mild improvement in symptoms after five days, the decision was made for an exploratory laparotomy. An intra-operative push enteroscopy demonstrated large amounts of retained food in the stomach, but no gastroduodenal outlet obstruction. A diagnosis of acute gastroparesis syndrome was made, and surgical exploration was not done. The patient was discharged, managed conservatively, and on follow-up 4 weeks later his symptoms had significantly improved.

DISCUSSION:
Acute gastroparesis syndrome is a rare complication of RFA for atrial fibrillation, that occurs due to thermal injury to the peri-esophageal vagal nerves during ablation. Symptoms of nausea, bloating, vomiting, gastric pain occur within 72 hours after the procedure. Most patients fully recover within 1-2 months after the procedure with conservative management. However, a few reported cases with persistent symptoms required eventual esophagojejunal anastomosis or intra-pyloric botulinum injection. Due to wide variation in vagal plexus anatomy around the lower esophagus, and lack of visualization of the nervous system, nerve injury is hard to avoid. Higher BMI was noted to be a protective. Minimizing RF ablative power around the esophagus and/or esophageal temperature monitoring may be a strategy to lower the risk. As RFA ablation for atrial fibrillation becomes more common, gastroenterologists should be aware of this complication.
1854 Conservative Management of Pneumatosis Cystoides Intestinalis With Pneumoperitoneum in a Scleroderma-Related Illness
Authors: Nwaichi Chineme , Ajiboye Oyintayo , Randhawa Tejinder , Gevorgyan Ofelya , Attar Bashar M. 
Published: October 2019

INTRODUCTION:
Pneumatosis Cystoidea Intestinalis with pneumoperitoneum in scleroderma-related illness could mimic an acute abdomen, presenting with pseudo-obstruction and gas within and outside the intestinal wall in the absence of a true perforation of the intestinal wall. The recognition of the clinical presentation of pseudoobstruction with pneumoperitoneum, due to Pneumatosis Cystoidea Intestinalis is paramount for the clinical decision to manage conservatively and avoid a surgical intervention.

CASE DESCRIPTION/METHODS:
A 30-year-old female with a 3-year history of limited scleroderma and myositis overlap presented with worsening nausea, vomiting, abdominal pain and bloating for about a week. She had a similar episode about a month prior to presentation, with abdominal imaging showing intestinal wall blebs with pneumoperitoneum, and had undergone an exploratory laparotomy. There was no bowel perforation on exploratory laparotomy and biopsy results showed fibrous tissues lined by reactive mesothelial cells and chronic inflammation. On examination, her abdomen was distended with epigastric tenderness, without guarding or rebound tenderness. An abdominal x-ray and CT scan revealed small bowel obstruction with pneumoperitoneum, features characteristic of Pneumatosis Cystoidea Intestinalis. She was evaluated by gastroenterology, surgery and the rheumatology team, and managed conservatively with intravenous fluids, nasogastric tube decompression, and administration of proton pump inhibitor. Her vital signs were normal and abdominal distension subsided with a resolution of her symptoms after 24 hours of conservative management. She was subsequently able to tolerate diet and was discharged on day 2 of admission with a plan for outpatient follow up.

DISCUSSION:
The presence of pneumoperitoneum portends a sinister finding in a patient with intestinal obstruction, often requiring surgical intervention. Pneumatosis Cystoides Intestinalis is characterized by micro-perforations of intestinal wall blebs which give rise to pneumoperitoneum, without a true perforation of the intestinal wall. The bacterial overgrowth and mechanical theory are both highlighted as mechanisms for the loss of integrity of the intestinal intimal layer, resulting in leakage and formation of gas within the intestinal wall. However, in the absence of acute peritonitis, abdominal abscess, and a worsening clinical status, Pneumatosis Cysotiodea Intestinalis can be managed conservatively in spite of a pseudo-obstruction with pneumoperitoneum.
1855 An Unusual Mimicker of Irritable Bowel Disease
Authors: Hodgeman Nicholas , Horn Christian L. , Paredes Angelo 
Published: October 2019

INTRODUCTION:
Delayed anaphylactic reaction to red meat is a rare phenomenon that was first recognized during clinical trials for cetuximab. Through careful retrospective study of the patients afflicted, it was discovered there was a geographic overlap with the Amblyomma americanum tick, also known as the lone star tick. These patients were also found to have IgE antibodies to the peptide galactose-alpha-1,3-galactose (α-gal), commonly found in non-primate mammalian meat. Since the trials with cetuximab, allergic reactions to red meat has been documented in patients who have not been exposed to cetuximab, believed to be caused by the bite of the lone star tick. We present the case of a 46-year-old male who was evaluated for 6 months of progressive gastrointestinal symptoms and was ultimately found to have elevated α-gal IgE levels.

CASE DESCRIPTION/METHODS:
A 46-year-old male was evaluated for 6 months of progressive abdominal distress following consumption of red meat. He reported severe nausea, vomiting and diarrhea that persisted for hours after consumption of red meat. He had not experienced anaphylaxis, but had a 40 pound weight loss since symptom onset. He had recently moved to Texas from Maryland and denied any outdoor recreation, to include camping, hiking, or known tick bites. Initial work up was unrevealing for infectious or inflammatory cause of his symptoms, and cross-sectional imaging was noncontributory. EGD and colonoscopy were notable only for mild esophagitis and duodenitis. Due to concern for α-gal syndrome and at the prompting of the patient and his wife, total serum IgE and α-gal IgE were drawn, both noted to be elevated at 6215 IU/mL and 0.2 kU/L (ULN < 0.10 kU/L) respectively. A presumptive diagnosis of α-Gal syndrome was made and he was referred to nutrition for dietary counseling. Following removal of red meat from his diet, he reported his gastrointestinal symptoms had markedly improved.

DISCUSSION:
This case demonstrates the unique and uncommon condition known as α-gal syndrome. Our presentation’s presentation was not as dramatic as other documented cases, which likely led to a delay in his initial diagnosis. Diagnosis is made by first noting an elevated serum IgE. Specific α-gal IgE levels can then be drawn, which if elevated has high sensitivity and specificity for this syndrome. Improvement on a red meat restricted diet is ultimately diagnostic. As was seen in this case, improvement is often drastic and long lasting if red meat products are avoided.
1856 Immediate Air-Tight Seal With a Padlock Clip Defect Closure System for Iatrogenic Colonic Perforation
Authors: O'Keefe Ryan , Pathirana Induruwa 
Published: October 2019

INTRODUCTION:
Iatrogenic colonic perforations are an infrequent complication of endoscopy that often require immediate surgical repair. However, endoscopic suturing devices or endoscopic clips are increasingly being utilized for closure. Through-the-scope clips can have high rates of failure and often require multiple clips per closure to achieve a similar level success to over-the-scope clips. Ovesco over-the-scope clips (OTSC®) have been studied in small prospective studies with 89% successful closures of acute iatrogenic gastrointestinal perforations without adverse events1. More recently, the Padlock Clip® defect closure system has emerged as a newer over-the-scope clip with case reports showing high levels of efficacy and safety in a variety of uses. We present a case of iatrogenic colonic perforation repaired with the Padlock Clip with a concurrent laparoscopic air-leak test confirming immediate complete closure.

CASE DESCRIPTION/METHODS:
A 64-year-old female with a history of severe diverticulosis presented for routine colonoscopy for polyp surveillance. The patient became significantly uncomfortable with water irrigation and a perforation was identified approximately 20cm from the anal verge, likely consistent with a perforated diverticulum. The procedure was aborted with subsequent imaging confirming a sigmoid colon perforation. In the operating room, a Padlock Clip defect closure device was endoscopically deployed with subsequent laparoscopic leak test confirming immediate air-tight seal. A diet was subsequently initiated without evidence of a leak.

DISCUSSION:
This case illustrates the efficacy of an alternative over-the-scope clip in closure of an acute colonic perforation. Compared to prior over-the-scope clips, the Padlock Clip is easier to deploy with potentially similar rates of efficacy and safety. The design of the Padlock Clip better facilitates two-person deployment as opposed to the Ovesco OTSC®. The deeper cap length makes acquisition of tissue easier and obviates the need for additional graspers. This patient demonstrates the Padlock Clip system as a viable option for the management acute iatrogenic colonic perforations. Reference: 1Voermans RP, Le moine O, Von renteln D, et al. Efficacy of endoscopic closure of acute perforations of the gastrointestinal tract. Clin Gastroenterol Hepatol. 2012;10(6):603-8.
1857 Not the Average Pseudopolyp
Authors: Pathirana Induruwa , O'Keefe Ryan 
Published: October 2019

INTRODUCTION:
Polyposis syndromes are rare and often undiagnosed or misdiagnosed in clinical practice. Presented here is a case of Cowden syndrome initially misdiagnosed as an atypical presentation of ulcerative colitis.

CASE DESCRIPTION/METHODS:
A 62-year-old male presented to the gastroenterology clinic for routine annual surveillance colonoscopy. He had undergone numerous colonoscopies for the past decade demonstrating pseudopolyps throughout the colon. Pathology revealed normal colonic mucosa, hyperplastic features, and inflammatory polyps. He denied a history of diarrhea or hematochezia, or a family history of inflammatory bowel disease. The patient was ultimately diagnosed with ulcerative colitis, placed on oral mesalamine treatment, and advised to undergo annual colonoscopy for dysplasia surveillance. On the date of encounter a thyroidectomy scar was noted on physical exam. The patient had undergone total thyroidectomy in the 1990’s for an unknown reason. Chronic lesions resembling papillomas were present on his buccal mucosa. Although he did not have a formal diagnosis of autism, the patient displayed several characteristics of the disorder throughout the encounter. The patient’s son had also been diagnosed with numerous non-adenomatous colon polyps and his father had passed from renal cell carcinoma. Given clinical suspicion for Cowden syndrome, an upper endoscopy was added to the annual colonoscopy demonstrating significant esophageal glycogenic acanthosis and extensive duodenal hamartomas. Colonoscopy again demonstrated numerous hamartomas throughout the colon. Genetic sequencing demonstrating a frame shift mutation in the PTEN gene was performed by Athena Diagnostics, diagnostic of Cowden syndrome. Subsequently his mesalamine was discontinued, his colonoscopy surveillance interval was increased to every five years, and annual screening for renal cell carcinoma screening was initiated. His son was advised to undergo genetic testing as well due to the syndrome’s autosomal dominant inheritance pattern.

DISCUSSION:
This case showcases the utility of highlighting rare clinical entities. The prevalence of Cowden syndrome is estimated to be only 1 in 200,000 to 250,000 individuals. Clinicians are proficient at diagnosing more common disease presentations; however, rare disorders such as polyposis syndromes can be unrecognized unless they are consistently reviewed outside of daily practice.
1859 Paperclip or Inferior Vena Cava Filter Probe? The Case of an Unusual Foreign Body
Authors: Ghosh Soumojit , Ghoulam Elie , Clarrett Danisa M. , Qureshi Kamran 
Published: October 2019

INTRODUCTION:
Inferior vena cava (IVC) filters are mechanical devices used to prevent pulmonary embolism, often used in patients with recurrent venous thromboembolism while on anticoagulation, or who have a contraindication to anticoagulation. Despite its increasing popularity over the last two decades, they do not come without complications such as migration of the filter or its parts, perforation or protrusion into surrounding structures such as the small or large bowel, vasculature, diaphragm, or the retroperitoneal space. We herein present a case of duodenal perforation caused by a migrating IVC filter, of which there have only been a few reported cases.

CASE DESCRIPTION/METHODS:
The patient is a 61-year-old female with HTN, GERD, iron-deficiency anemia, and a history of DVT while on anticoagulation (s/p IVC filter placement in October 2011) who initially presented with complaints of dizziness. Her workup revealed a new anemia with no overt GI bleeding for which she underwent endoscopic evaluation. She was found to have a thin piece of metal in the second portion of her duodenum, thought to be a swallowed foreign body, possibly a paperclip, which was later denied by the patient. Several attempts at retrieval were unsuccessful. One week later, she developed sudden-onset, severe, epigastric pain with guarding. She presented to our emergency department where a CT abdomen/pelvis with contrast revealed an infrarenal IVC filter with protrusion of a prong through the lateral wall of the IVC into the duodenum, as well as protrusion of a prong through the posterior wall of the IVC into the superior aspect of the right iliopsoas muscle. Given the pain, she was ultimately taken for successful percutaneous removal via the right internal jugular vein by Vascular Surgery with endoscopic assistance by Gastroenterology. There was no involvement of the ampulla and the duodenum maintained insufflation following removal.

DISCUSSION:
With the advent of contemporary IVC filters, the migration rates are less than 1%. However, because of new prong hooks to prevent migration, they can lead to perforation of surrounding structures. Retrievable filters have been found to have higher rates of perforation than the permanent form, particularly when the retrievable filters are left in place longer than anticipated. As seen in this case, the importance of IVC filters are paramount to prevent pulmonary embolism, but in a patient with sudden onset abdominal pain, one must rule out IVC filter perforation into surrounding structures.
1860 Use of NBT Gastrostomy Tubes as Replacement Jejunal Feeding Tubes
Authors: Moore Ryan , Evans J. Robert 
Published: October 2019

INTRODUCTION:
For severely neurologically impaired patients, feeding tubes are a life-sustaining measure. While most patients can tolerate direct feeding into the stomach via nasogastric feeding tubes or gastrostomy feeding tubes, these options may be unhelpful or dangerous for patients with gastric retention or severe gastroesophageal reflux. For such patients, feeding through a jejunostomy may offer a safe alternative. However, when the tube needs to be replaced there are limited options. We review our experience of using non-balloon tip (NBT) gastrostomy replacement tubes as replacement jejunostomy tubes.

CASE DESCRIPTION/METHODS:
We searched procedure and follow-up reports from an individual gastroenterologist (JRE) from 03/2015 to 11/2018 for patients with jejunostomy feeding tubes at a single sub-acute nursing facility. All four jejunostomy patients on record had received 20 French NBT gastrostomy replacement tubes as replacement jejunostomy feeding tubes. The NBT tubes have a collapsible mushroom-shaped tip which is placed in the stoma with an obturator. We reviewed the patient records to determine if NBT replacement tubes effectively delivered nutrition and medication, whether they resulted in complications, and with what frequency the tubes needed replacement.

DISCUSSION:
The patients’ records show that the improvised replacement jejunal feeding tubes performed quite well. Available records show that the patients were fed jejunally for periods ranging from 47 to 168 weeks. Replacement NBT tubes lasted from 28 to 609 days. During this period, the only complication suffered was internal detachment of the mushroom tip, which occurred 5 times (4 of which in a single patient). In each of these cases however, the bowel remained unobstructed and the tips passed through the alimentary canal. Patients retained overall good health in spite of neurological impairment. For patients requiring feeding interventions, but lacking adequate gastric function, jejunostomy feeding is often needed if enteral feeding is to be maintained. While there is at present a dearth of equipment designed specifically for jejunal feeding tube replacement, our experience suggests that NBT gastrostomy tubes may constitute a viable option for patients with jejunostomy tubes. These mushroom-tip tubes remain in place without occluding the jejunum, they clog infrequently due to the wide lumen, and they represent a readily available and easy to place option for patients who need jejunostomy tube replacement.