bluuebunny/crossref_metadata_2025_split huggingface dataset:
2102 Crohn’s Disease With Rare Extra-Intestinal Manifestation and Unusual Great Outcome!!
Authors: Al Hillan Alsadiq , Hawa Fadi , Mohamed Mujtaba , Turtel Penny 
Published: October 2019

INTRODUCTION:
Crohn’s disease (CD) is a chronic relapsing inflammatory disorder that most commonly affects the small and large bowel. Prolonged diarrhea with abdominal pain, with or without gross bleeding, fatigue, and weight loss are the hallmarks of Crohn’s disease. Extraintestinal manifestations, such as joints, eye and skin disorders, biliary tract involvement, and kidney stones, may occur. Tonsillar involvement in CD has been very rarely described in the literature. CD is diagnosed with endoscopic and imaging studies of the bowel in a patient with a compatible clinical history. We present a 29-year-old female patient who had a rare extra-intentional manifestation of Crohn's disease which is granulomatous tonsillitis and had an unexpectedly favorable outcome post-tonsillectomy being off treatment for 9 years now without any complaints.

CASE DESCRIPTION/METHODS:
A 29-year-old with no past medical history presented with frequent episodes of tonsillitis followed by prolonged diarrhea with abdominal pain. Physical exam showed enlarged tonsils and generalized lower abdominal tenderness. Labs showed elevated C-reactive protein, Sedimentation rate, and fecal calprotectin. The patient underwent colonoscopy that showed scattered ileocolitis and biopsy results were compatible with Crohn’s disease. Patient’s tonsillitis failed multiple courses of antibiotic therapy. Accordingly, tonsillectomy was performed, and biopsy showed granulomatous lesion consistent with Crohn’s disease. The patient has been off treatment and never required maintenance therapy for 9 years now without any complaints.

DISCUSSION:
The first case of CD with granulomatous tonsillitis was reported in 1984. CD patients with an oropharyngeal manifestation of their disease are rare, with an estimation of only 0.5%–20% of patients, with a higher incidence in younger patients. A systematic review and meta-analysis did by Sun et al. demonstrated that tonsillectomy in healthy individuals is associated with an increased risk of developing Crohn’s Disease. Koutroubakis et al. did a case-control study that also showed the same results. Our case presented with recurrent tonsillar pain initially which is a rare extra-intestinal manifestation and underwent tonsillectomy with biopsy confirming Crohn’s Disease and had a remarkably unusual recovery from all Crohn’s Disease symptoms and never had any complaints in 9 years off medical treatment.
2103 Resolution of Infliximab-Induced Palmar Pustular Psoriasis (PPP) After Switching to Biosimilar Infliximab-DYYB
Authors: Abdulla Hafsa , Schairer Jason , Caines Allyce N. 
Published: October 2019

INTRODUCTION:
Biosimilars are designed to approximate the effectiveness and safety profile of the reference drugs they are based upon. A person who has a side effect to either the biosimilar or the reference drug would have a similar adverse event to the other medication. Infliximab is an anti-TNF drug used in a variety of autoimmune conditions including UC. While highly effective, it is associated with new onset psoriasis in 5-9% of patients with IBD. That is not typically an indication to abandon the medication if it is otherwise effective. We describe the case of a person with UC on infliximab with the adverse event of PPP who was changed to infliximab-dyyb for financial reasons and had resolution of their skin lesions.

CASE DESCRIPTION/METHODS:
A 68 year old F with history of pancolonic UC was started on Infliximab 5 mg/kg/8 weeks. After 8 months of therapy and due to unresolved inflammation and symptoms, infliximab was increased to 10 mg/kg/8 weeks resulting in clinical remission. She had no prior history of psoriasis or other skin disease but after one year on infliximab she developed a new rash, examination showed well demarcated, pruritic, tender raised erythematous plaques on bilateral palms with salmon colored papules and small pustules (Figures 1 and 2). Dermatology diagnosed her with PPP secondary to infliximab. She was treated for over a year with clobestasol ointment with only modest improvement. Due to infusion center policy, her infliximab was changed to infliximab-dyyb. On 3 month follow up it was noted that the rash had completely resolved since switching to the biosimilar (Figure 3).

DISCUSSION:
Biosimilars of biologic therapies have become increasingly available. They are designed to recreate the effectiveness and safety of the reference medication. While some people develop side effects or loss of response when switching to a biosimilar from a reference medication, adverse events tend to happen at the same rate, suggesting that the event is not due to the biosimilar. Psoriasis caused by anti-TNF is a known adverse reaction. This may be due to a disruption in the balance from TNFα leading to increased production of IFN gamma. In studies infliximab led to psoriasis 5-9% compared to 5-12% in infliximab-dyyb. Even though it is believed that both the reference drug and biosimilar drug have similar efficacy and adverse reaction profiles, we hypothesize that our patient may have developed an immunogenic reaction to a part of the infliximab molecule that is not present in its biosimilar product infliximab-dyyb.
2107 A Case of Crohn’s Disease Complicated With Liver Abscess, Enterohepatic and Enterocutaneous Fistulas
Authors: Ajao Susanne , Lakkasani Saraswathi , Spira Etan , Adib Sami 
Published: October 2019

INTRODUCTION:
Crohn’s disease (CD) is a chronic inflammatory disease which can affect any part of the gastrointestinal tract. Liver abscesses and fistulas between a solid organ and intestine are rare. Here we present a unique case report of a CD patient who developed liver abscesses complicated by enterohepatic and enterocutaneous fistula.

CASE DESCRIPTION/METHODS:
48-year-old male with a longstanding history of CD presented with abdominal pain. A CT of the abdomen revealed multifocal hepatic abscesses (Figure 1). The abscesses were initially percutaneously drained and antibiotics were administered. Five weeks following discharge he presented with complains of worsened abdominal pain. He had developed a foul smelling pus-draining wound at site of the drainage. A repeated CT abdomen revealed persistent hepatic abscess with small bubbles of free air adjacent to the inferior hepatic edge with a thin enhancing tract suggesting an early enterohepatic fistula (Figure 2) and an enterocutaneous fistula in the lateral abdominal wall between the bowel and the skin (Figure 3). He underwent a right hemicolectomy with drainage of the hepatic abscesses and repair of the enterocutaneous and enterohepatic fistula. The biopsies from the ileo-cecal region showed extensive ulceration with underling transmural inflammation of mucosa and extensive active inflammation of visceral serosa with reactive fibrosis, suggestive of severe CD. His postoperative recovery was uneventful. Routine colonoscopy evaluation of the ileo-colonic anastomosis two months later showed erythema and inflammation at the anastomosis site with granular inflammation throughout the colon (Figure 4). He is currently doing well on Infliximab and has not reported further complications.

DISCUSSION:
Liver abscess and solid organ to intestinal fistulas are rare complications of CD. The incidence of liver abscess is higher in patients with CD compared with the general population. The diagnosis of liver abscesses is frequently delayed as patients present similar to a CD exacerbation. Unlike the patient in this report, intestinal symptoms may be absent leaving little to no evidence to suggest the presence of a liver abscess on clinical presentation. Imaging including CT scans and ultrasound help to facilitate the diagnosis of this rare condition. In this case, we have shown that surgical intervention, antibiotics and immunotherapy can help with successful outcomes in cases of liver abscesses, enterohepatic and enterocutaneous fistulas.
2110 A Case of IgA Vasculitis in Crohn’s Disease and Recurrent Clostridioides difficile Infection
Authors: Voth Elida , Olson Emily , Raffals Laura E. 
Published: October 2019

INTRODUCTION:
IgA vasculitis (IgAV) is an immune-mediated systemic vasculitis characterized by palpable purpura, arthralgias, abdominal pain, and renal disease. Approximately 90% of cases occur in children; however, adults are at increased risk for more severe disease. The pathogenesis of IgAV is associated with inflammatory, infectious, autoimmune, and medication triggers, including tumor necrosis factor (TNF) alpha inhibitors. We describe a case of a man with Crohn’s disease (CD) who developed IgAV in the setting of a perirectal abscess, recurrent Clostridioides difficile infection (CDI), and anti-TNF therapy.

CASE DESCRIPTION/METHODS:
A 20 year old man with ileocolonic Crohn’s disease and perianal involvement, inflammatory arthropathy, and recurrent CDI presented to an outside ED with increased abdominal pain and rash on the extremities, trunk, and soft palate. Medications included etanercept, vedolizumab, and prednisolone. In the ED, the patient was hypotensive and tachycardic. CT abdomen/pelvis noted multifocal active inflammatory disease and a 3.2 cm abscess in the left ischiorectal fossa. He was initiated on broad spectrum antibiotics for septic shock and underwent emergent perirectal drain placement; post-operatively, his shock resolved. He was transferred to our institution for further management. Upon arrival, the patient was hemodynamically stable and remained on broad spectrum antibiotics and high dose prednisolone. Review of systems was notable for worsening abdominal pain and hematuria. Biopsy of the rash demonstrated IgA vasculitis. C. difficile toxin PCR was positive. Repeat urinalysis demonstrated nephrotic range proteinuria and hematuria, consistent with IgA nephropathy. ACE-inhibitor therapy was initiated, and skin lesions gradually improved with topical triamcinolone.

DISCUSSION:
We report a case of a patient with ileocolonic and perianal Crohn’s disease on TNF-alpha inhibitor therapy who developed IgA vasculitis in the setting of septic shock secondary to perirectal abscess and recurrent CDI. This case highlights anti-TNF therapy, infection and inflammatory bowel diseases as potential causes of systemic vasculitis. A high clinical suspicion is needed in order to obtain an early histopathologic diagnosis for IgAV and prompt evaluation of other organ system involvement.
2111 Antibiotic Dependent Pouchitis Successfully Managed With Vedolizumab in a Patient With a Prior History of Renal Malignancy
Authors: Farrakhan Kanhai , Fine Sean 
Published: October 2019

INTRODUCTION:
Pouchitis is a known complication of ileal pouch-anal anastomosis (IPAA). The mechanism is unknown but is felt to be due to altered bacterial flora and then a dysregulated immune response in the pouch. Although one of the mainstays of treatment is antibiotics, long-term use for patients with chronic pouchitis (CP) may not be addressing the underlying mechanism while also subjecting the patient to the risk of prolonged antibiotics. New limited data supports the use of biologics in the management of CP. We report a case of a man with a history of chronic antibiotic dependent pouchitis (CADP) and prior malignancy who was successfully managed with vedolizumab.

CASE DESCRIPTION/METHODS:
44 year-old male with past medical history of ulcerative colitis status-post IPAA, renal oncytoma status-post resection (2017), non-insulin dependent diabetes, and fatty liver disease presented with persistently increased bowel movements. He endorsed weeks of twenty bowel movements per day to the point that he was awoken from sleep. He presented to urgent care where he was started on ciprofloxacin and metronidazole yet he continued to be symptomatic. He then presented to gastroenterology clinic and was started on xifaxin. He subsequently underwent a pouchoscopy showing CP (confirmed by biopsy). After some discussion, the plan was to initiate a biologic as he was refractory to antibiotics. However he was concerned about starting systemic immunosuppression given his prior malignancy. As he was post resection with reported cure and no plan to undergo further treatment, he was started on vedolizumab. On vedolizumab he endorsed resolution of symptoms with a dramatic improvement in quality of life.

DISCUSSION:
The challenge in management of CP arises when there is dependence on antibiotics and continued symptoms. Recent studies support the use of biologics (i.e. vedolizumab). These papers document resolution of symptoms and endoscopic improvement of disease. However there has yet to be robust data evaluating the efficacy or safety of biologics for this indication in those with prior malignancy. In this case there was initial hesitation but given the remote nature and clinical stability of the malignancy as well as gut-specificity of vedolizumab the decision was made to pursue therapy. This case highlights the successful use of vedolizumab for the treatment of CADP. The use of biologics in CP needs to further be studied, especially in a cost-benefit analysis looking further into outcomes related to long-term antibiotic use.
2113 Biofeedback Therapy With the Rao Protocol for Dyssynergic Defecation Is Effective Among Patients With Inflammatory Bowel Disease
Authors: Spilman Samantha , Dulai Parambir , Kunkel David 
Published: October 2019

INTRODUCTION:
Dyssynergic defecation (DD) symptoms are common in patients with inflammatory bowel disease (IBD). Biofeedback (BFB) is a standard of care treatment for DD, however, few studies have evaluated its efficacy in IBD patients with DD.

CASE DESCRIPTION/METHODS:
This is a case series that looks at 5 patients with IBD who were enrolled in BFB for DD between 2015 to 2018 at a tertiary referral motility program. All patients had greater than two sessions, survey and high resolution anorectal manometry (HR-ARM) data were collected at baseline and during each DD BFB visit. The Rao protocol for BFB is a physician-led program that consists of an active phase with the number of sessions tailored to each patient’s progress, followed by refresher sessions. A solid state HR-ARM catheter is utilized with sensors in the rectum/pouch and anal canal. Stool retention simulation consists of inflation of a rectal balloon during manometry based BFB. A total of 5 patients were identified for this case series. The average age of the patients was 46 years. Of these 5 patients, 3 had Crohn’s disease and 2 had ulcerative colitis. After completion of BFB, IBD patients experienced a significant improvement in stool form (Bristol stool scale type 2 to 6, P = 0.01), rise in the defecation index (intrarectal/pouch pressure divided by intra-anal pressure during simulated defecation; 0.39 to 0.81, P = 0.04), and complete resolution of DD with a rectal balloon inflated to simulate stool present in the rectum/pouch on final BFB session (P < 0.01). IBD patients did not report a significant improvement in global bowel satisfaction rating on a 10-point Likert scale (2.2 to 3.6, P = 0.22).

DISCUSSION:
Biofeedback with the Rao protocol in conjunction with use of HR-ARM catheters shows efficacy in the correction of dyssynergia pattern, leading to improvement in objective measures such as defecation index and stool form on diary in IBD patients. Subjective improvement in global bowel satisfaction rating was less than the non-IBD cohort. In conclusion, patients with IBD who are found to have DD should be given consideration for enrollment in a BFB program, which is a labor-intensive approach but has no adverse effects.
2114 Pharyngo-esophageal Perforation During Endoscopic Ultrasound: Case Report and Literature Review
Authors: Tariq Raseen , Enslin Sarah , Kaul Vivek 
Published: October 2019

INTRODUCTION:
EUS related serious complications such as luminal perforation, pancreatitis and bleeding are rare. We report a case of EUS-related pharyngo-esophageal perforation, successfully managed conservatively and brief literature review.

CASE DESCRIPTION/METHODS:
A 75-year-old male presented with elevated LFTs without jaundice. CA 19-9 was elevated (112 U/mL). CT revealed a double duct sign and a 3 cm pancreatic head mass (Figure 1). Decision was made to proceed with EUS with FNA. Diagnostic EGD noted no luminal esophageal narrowing. The linear array echoendoscope was inserted into the oropharynx but was difficult to pass into the esophagus secondary to cervical osteophytes. The gastroscope was reinserted into the esophagus. Minimal pharyngeal mucosal trauma was noted. A savary guidewire was passed into the stomach; the gastroscope was removed. The echoendoscope was backloaded onto the wire and reinsertion attempted. Despite gentle maneuvers and multiple attempts, resistance to passage was encountered, esophageal intubation was not possible; the echoendoscope was removed. Repeat EGD revealed a 2 cm deep mucosal tear extending from the posterior pharynx to the esophageal inlet without full-thickness perforation or significant bleeding (Figure 2). The gastroscope and the guidewire were removed and the procedure was terminated. Patient complained of throat pain, especially with swallows. CT showed pneumomediastinum and extraluminal air and edema adjacent to the right aspect of the pharynx & esophagus (Figure 3), consistent with a pharyngo-esophageal microperforation. Thoracic surgery was consulted, antibiotics started, patient kept NPO. The patient remained hemodynamically stable with improved pain and no need for surgical intervention, discharged home on post-procedure day 4.

DISCUSSION:
EUS is a safe procedure with complication rates comparable to EGD. The rate of esophageal perforation is very low, ranging from 0.03-0.04%. The treatment for pharyngo-esophageal perforation depends upon the degree, location, timing of diagnosis, hemodynamic status and clinical status of the patient. In a case series of 16 cervical esophageal perforations, 44% of patients had history of difficult intubation with endoscopic procedures. 81% were managed conservatively.1 Early recognition and timely management is critical for ensuring an excellent outcome with conservative management.

JOURNAL/ajgast/04.03/00000434-201910001-02115/figure1/v/2024-02-04T204205Z/r/image-tiff

JOURNAL/ajgast/04.03/00000434-201910001-02115/figure2/v/2024-02-04T204205Z/r/image-tiff

JOURNAL/ajgast/04.03/00000434-201910001-02115/figure3/v/2024-02-04T204205Z/r/image-tiff
2116 Salvage Therapy for Recurrent Gastrojejunal Anastomotic Stricture Using a Lumen-Apposing Metal Stent
Authors: Oldfield Edward C. , Parekh Parth J. 
Published: October 2019

INTRODUCTION:
Gastrojejunal (GJ) anastomotic stricture following Roux-en-Y gastric bypass is a well-known complication of the surgery with reported ranges varying from 2.9-23%.1 Unfortunately, prior endoscopic interventions for these strictures have had limited durability of treatment response.

CASE DESCRIPTION/METHODS:
A 71-year-old male with previous Roux-en-Y gastric bypass presented to our hospital with 2 weeks of nausea, vomiting, weight loss, and severe hypoglycemia. Initial imaging with CT abdomen showed a fluid-filled and distended gastric pouch with likely stenosis of the GJ anastomosis. An upper GI series was performed which confirmed significant stenosis at the GJ anastomosis (Figure 1a). An EGD was performed at which time the stricture was successfully dilated using a through-the-scope (TTS) 6-7-8 mm and then an 8-9-10 mm balloon dilator (Figure 2). Unfortunately, the patient did not clinically respond to dilation and was unable to advance diet beyond liquids, requiring initiation of total parenteral nutrition. Subsequently, the patient underwent a repeat EGD with placement of a 20 mm × 10 mm lumen apposing metal stent (LAMS) (Axios, Boston Scientific) under fluoroscopic guidance. The stent was successfully dilated with a TTS 12-13.5-15 mm balloon dilator to a maximal size of 13.5 mm with obliteration of the waist. The LAMS was then sutured into place with the endoscopic suturing device (OverStitch, Apollo Endosurgery, Inc) using 2.0 polypropylene suture and placing 2 interrupted sutures with cinches on both ends (Figure 3). An upper GI series was repeated 24 hours after LAMS, which showed excellent functioning of the stent without leak or obstruction (Figure 1b). Over the next five days, the patient’s symptoms abated, diet was gradually advanced to low residue diet, TPN was discontinued, and the patient was discharged home.

DISCUSSION:
Management of these strictures has primarily been pneumatic balloon dilation or fully covered self-expanding stents; however, dilation is unlikely to achieve durable response and other stents are associated with complications of stent migration and recurrence of symptoms after removal. Previous case reports have documented successful treatment of GJ anastomotic strictures using LAMS with excellent response given its novel shape and anchoring phalanges.
1
We further show the successful endoscopic suturing of the LAMS, which will allow for prolonged time for stent placement with enhanced risk-mitigation for stent migration.
2121 A Combined Antegrade/retrograde Dilation Procedure With Gastroenterology and Interventional Radiology: A Case Report
Authors: Chaudhari Rahul B. , Attalla Sarah , Schwartz Stephen 
Published: October 2019

INTRODUCTION:
Endoscopic recanalization techniques for complete esophageal obstructions are not very well established. Dilatations of esophageal strictures causing complete obstruction by conventional bougienage techniques are not very successful. We present a case where complete esophageal stricture was treated with endoscopic recanalization by combine efforts of GI and IR team with endoscopy and guidewire by IR.

CASE DESCRIPTION/METHODS:
A 78-year-old male with a past medical history of HTN, HLD, DVT, prostate cancer, esophageal cancer s/p esophagectomy with gastric pull-up c/b anastomotic stricture s/p esophageal stent placement s/p removal in 1/2019 c/b recurrent stricture progressing to apparently complete obstruction. He had gastrostomy tube placed by interventional radiology. During endoscopy, one severe stenosis was found at the esophageal anastomosis with surrounding staples. A lumen was not visualized and Gentle probing using a Savary guidewire, fluoroscopic guidance or a Glot tip catheter did not help to visualize the lumen. Patient had a J tube which precludes retrograde approach. Procedure was aborted. Subsequently with IR guidance, a catheter with a metal wire was passed in retrograde fashion from gastrostomy site to the stenosed lumen. A puncture was carefully made and a guidewire was advanced out the mouth. Site of recanalization was dilated to 6 mm. Using the guidewire, an 18 mm × 10.3 cm WallFlex fully covered stent was loaded over it and passed into the esophagus. The stent was then deployed. Patient improved clinically. Subsequent Endoscopy showed mild tissue hyperplasia just proximal to the stent. Patient was followed up closely and still needed regular endoscopies and dilatations but is clinically stable and his dysphagia and quality of life has improved significantly.

DISCUSSION:
Patients with advanced malignancy and limited life expectancy who develop complete esophageal stricture and cannot tolerate surgical reconstruction benefit significantly from the endoscopic recanalization. New endoscopic techniques include rendezvous recanalization and CARD(combined antegrade‐retrograde dilation). In our case, combined efforts of GI and Interventional radiology helped to recanalize the complete obstruction of the esophagus by GI guided endoscopy and IR guided guidewire. Such novel techniques bring a significant improvement in the overall quality of life of patients with terminal diseases and high surgical risk.