bluuebunny/crossref_metadata_2025_split huggingface dataset:
2033 Gastrointestinal Bleeding: A Rare Manifestation of Renal Cell Carcinoma
Authors: Kaimakliotis Pavlos , Thaker Sarang , Kang Jennifer , Ramadugu Ajit , Khan Ruben , Brown Russell D. 
Published: October 2019

INTRODUCTION:
We describe a rare cause of gastrointestinal bleeding in a patient with metastatic renal cell carcinoma (RCC) and discuss consideration and workup of this manifestation, as it is becoming more common given improved survival of this patient cohort.

CASE DESCRIPTION/METHODS:
A 65-year-old male with history of RCC treated with left nephrectomy complicated by local recurrence and pancreatic tail involvement, on nivolumab, presented with melena and dyspnea. Vitals were notable for orthostasis, melena on rectal exam, and labs revealed a Hgb of 5.6 gm/dL. After resuscitation, the patient underwent push enteroscopy and colonoscopy which did not reveal a source. The following day, the patient developed large volume hematochezia with lightheadedness, hypotension, and acute blood loss anemia requiring transfusion. Given his negative endoscopy and known metastatic RCC, CT angiogram was performed demonstrating an enhancing left upper quadrant soft tissue mass invading into the small bowel lumen. Interventional Radiology was consulted and recommended against embolization due to high risk of small bowel necrosis. Subsequently, Surgery was consulted and requested video capsule endoscopy, but the patient deteriorated requiring emergent surgery. An ileal mass, confirmed to be metastatic RCC, was resected. The patient had no further bleeding and was discharged home; he continues to follow closely with Oncology.

DISCUSSION:
Metastases to the small bowel are a rare cause of GI bleeding, but are often due to malignancies of the breast, cervix, lung, and melanoma. RCC metastatic to the small bowel has only been described in case reports thus far, but may become more common. Advances in targeted chemotherapeutics of the VEGF and mTOR pathways lead to improved survival and thus, more opportunities for metastases. Patients may present with intussusception, bowel obstruction, or GI bleeding alone, with bleeding favored by their vascular nature. Patients will undergo extensive upper and lower endoscopic evaluation without localizing the source, prompting cross-sectional imaging which is more sensitive for confirming the diagnosis. Surgery is often required, as tumors supplied by branches of the mesenteric arteries pose significant risk of small bowel infarction if embolized. In patients with known history of RCC who present with GI bleeding, small bowel metastases should be considered as an etiology if endocscopy is negative, and obtaining CT imaging urgently may lead to timely management of such lesions.
2076 Nasal Crohn’s: Rare but Real Possibility!
Authors: Vekaria Pratikkumar , Mao Johnnie , Patel Ravish , Vaishnani Devin , Raiyani Tejas 
Published: October 2019

INTRODUCTION:
Crohn’s disease(CD) is an autoimmune IBD that can occur anywhere along GI tract. Its pathology show transmural granulomatous inflammation that can include all layers of GI lining. Extra-intestinal manifestations can be seen in multiple organ systems like skin, joints, eyes, and mouth. These symptoms are common in patient involving large intestine compare to involving only small-intestine. Nasal involvement is rare with CD and very few cases have been reported so far.

CASE DESCRIPTION/METHODS:
32-year-old female with PMH of CD, pyoderma gangrenosum and rectovaginal fistula presented with bloody diarrhea and abdominal pain for week and a half. Her abdominal pain was located in RLQ and epigastric region. She denied chest pain, dyspnea. She had fever for 2 days. Physical exam was significant for RUQ, RLQ, and epigastric tenderness. CT abdomen showed mild transverse colitis and MRI of pelvis showed anal fistula with no abscess. Her stool was positive with WBCs. Gastroenterologist put her on wide-coverage empiric antibiotics. As her abdominal pain improved, she began to complain of severe headache and developed erythematous swelling on dorsum of nose. CT head showed paranasal sinus (PNS) mucosal thickening. Multiple IV pain medications didn’t help her pain. ENT was consulted and given her history, believed she might have CD. Trial of IV steroids was given and her symptoms improved. ENT subsequently obtained nasal biopsy. Report showed chronic inflammation, edema, and fibroplasia that was consistent with CD. Gastroenterologist began Adalimumab and her symptoms improved.

DISCUSSION:
Extra-intestinal involvement can be seen in almost 36% of cases of CD. Nasal manifestation occur rarely. Common presentation can be nasal obstruction, bleeding, mucosal inflammation and septal perforation. Our patient did not have these manifestations, but she presented with severe headache that even strong pain medication didn’t help much. This is unusual presentation of CD. Furthermore, there are various treatment options available in case of nasal CD from steroids to leukocytapharesis. In our case, new biologics therapy, TNF-α Inhibitor, worked better in combination with steroids. It would be interesting to know if nasal steroid has any role to play in local remission. From our and other case reports, we suggest that patient with CD, especially large intestinal involvement, when present with headache, fever or PNS symptoms, should warrants careful evaluation to rule out nasal CD.
2096 Leukocytoclastic Vasculitis Related to Ustekinumab in a Crohn’s Disease Patient
Authors: Costa-Moreira Pedro , Lopes Susana , Santos Ana Luísa , Pedrosa Ana Filipa , Andrade Patrícia , Portugal Raquel , Macedo Guilherme 
Published: October 2019

INTRODUCTION:
Leukocytoclastic vasculitis (LV) is a single-organ, skin-isolated small vessel vasculitis or angiitis, without systemic vasculitis or glomerulonephritis. This vasculitis is often mediated by immune complex deposition in the small vessels. Many drugs or inflammatory diseases may cause immune complex formation.

CASE DESCRIPTION/METHODS:
We report a case of a 28-year-old female patient followed in our outpatient clinic since the age of 20-years-old, with colonic Crohn's disease with perianal involvement (A2L2B1p). After the first pregnancy, she became steroid-dependent initiating immunomodulator and biologic therapy with partial response, with persistent perianal disease activity. Due to refractory disease, a diverting ostomy was made and ustekinumab 90 mg (every 8 weeks) was begun with no adverse events. Three years later, she presented painful and palpable purpura in the lower abdomen and both legs. The laboratory study performed to exclude a systemic disease as the cause of cutaneous vasculitis (liver and kidney function tests, serologies and immunological study with serum antibodies, cryoglobulins and serum complement levels) was normal. Ustekinumab was stopped until a diagnosed was achieved. A skin biopsy was performed that showed granulocytic dermatitis associated with the presence of fibrinoid material in the cutaneous small-vessels wall. Therapy with prednisone was started with symptomatic relief and resolution of cutaneous lesions. After this period, a new dose of ustekinumab was administered, with the reappearance of the same cutaneous lesions. The reappearance of cutaneous lesions following ustekinumab administration gave us a cause-effect relationship between the drug and cutaneous disease. Ustekinumab was permanently discontinued, with complete resolution of the cutaneous disease.

DISCUSSION:
In this report, we describe the first case of LV after a long term exposure to ustekinumab in a patient with IBD. When an adverse drug reaction occurs infrequently, it is unlikely to be detected in premarketing clinical trials. It is therefore important for the physician to recognize and report clinically significant adverse.
2109 Metastatic Crohn’s Disease: A Case of a Rare IBD-Related Entity at Initial Presentation
Authors: Kim Christopher , Guzik Paul , Kumbum Kavitha 
Published: October 2019

INTRODUCTION:
Metastatic Crohn’s disease (MCD) is a rare cutaneous entity of Crohn’s disease that mandates specific histopathologic findings and exclusion of other granulomatous diseases and infectious processes for a diagnosis. Due to its heterogeneous clinical presentation, MCD poses a diagnostic challenge for providers. We present a case of MCD in a woman with previously undiagnosed Crohn’s disease at initial presentation.

CASE DESCRIPTION/METHODS:
A 68-year-old woman presented to the Emergency Room with an acute onset of left-sided abdominal pain. She also noted a 6-month history of watery diarrhea with up to 8 bowel movements daily, describing them as bloody with a jelly consistency. On examination a painful 8 cm ulcer within her intergluteal fold extending to the anus was observed. Other “knife-like” ulcerations were noted of the left inframammary breast, under the pannus and bilaterally in the inguinal folds. She underwent a flexible sigmoidoscopy which demonstrated edematous and friable mucosa with a cobblestone appearance extending from the descending colon to the rectum. Mucosal biopsies and serologic testing were both diagnostic of Crohn’s disease. Punch biopsy of the pannus ulcer showed non-caseating granulomas and was negative for mycobacterial or fungal organisms, confirming the rare diagnosis of MCD. The patient was treated with systemic and topical steroids with subsequent symptomatic improvement of both her Crohn’s flare-up and cutaneous ulcerative lesions.

DISCUSSION:
MCD is a rare dermatologic manifestation characterized by its non-caseating granulomatous histopathology in non-contiguous areas from the gastrointestinal tract. Typically the GI disease precedes the skin disease for at least six months, however the skin manifestation can be the first sign of Crohn’s disease. The diagnosis should be suspected when “knife-like” ulcerations are seen on physical exam in a patient with known or suspected Crohn’s disease. Exclusion of other granulomatous diseases that could mimic MCD is required to confirm the diagnosis. Early recognition of this disease may ultimately spare unnecessary tests or treatments.
2128 Successful Treatment of Large Cavity Esophageal Disruptions With Transluminal Washout and Endoscopic Vacuum Therapy
Authors: Walsh Leonard , Manzo Carl , Loloi Justin , Mathew Abraham , Maranki Jennifer , Levenick John M. , Dye Charles , Taylor Matthew , Moyer Matthew 
Published: October 2019

INTRODUCTION:
Acute, high-grade esophageal perforation and postoperative leak after esophagogastrostomy are associated with high morbidity and mortality due to the development of mediastinitis and thoracic contamination. Endoscopic vacuum therapy (EVT) has proven to be a feasible, safe therapy for management of esophageal wall defects, but there is limited data on the effiacy of EVT for large and severe collections. We demonstrate that large and even multiple collections could be managed by EVT with serial endoscopic debridement and washout.

CASE DESCRIPTION/METHODS:
We describe a retrospective single-center analysis of two patients who underwent EVT for significant esophageal disruptions. Patient 1 developed esophageal perforation from Boerhaave Syndrome with a 2 cm disruption and 10.7 cm cavity, and Patient 2 developed postoperative anastomotic leak after Ivor-Lewis Esophagectomy with two separate disruptions: a 2 cm proximal disruption with a 4 cm mediastinal cavity and 14 cm gastric pull up disruption with a cavity encompassing the entire central and lower right thorax. EVT was accomplished with the use of a standard upper video endoscope, nasogastric (NG) tube and vacuum-assisted closure dressing kit, with endoscopic placement of a polyurethane sponge and nasogastric tube assembly into the mediastinal/ thoracic cavity. Serial washout and debridement were performed prior to each sponge insertion. Data were collected on indication, size of the cavities, time to intervention, number of procedures, time to resolution, outcomes, and adverse events.

DISCUSSION:
Two patients underwent therapy with a mean age of 69.5. The median size of the collections via longest cross sectional diameter was 10.7 cm. The average number of EVT procedures performed was six and average duration of therapy was 49 days. Complete resolution was achieved in both patients. In conclusion, endoscopic washout and debridement followed by EVT can be effective for large, even multiple, thoracic and/or mediastinal contaminations following esophageal perforation and gastroesopagheal anastamotic dehiscence and leaks in appropriately-selected patients. Our technique involving EVT coupled with serial washout and debridement has the potential to change the current approach to the management of severe mediastinal or thoracic contamination from anastomotic dehiscence and other types of esophageal disruptions.
2141 “Knock Out” Pancreas: An Unusual Case of Isolated Pancreatic Duct Laceration in a Mixed Martial Arts Fighter
Authors: Makar Ranjit , Maklad Muthena , Aziz Hamza , Lankarani Daisy S. , Mubder Mohamad I. , Wahid Shahid , Ohning Gordon , Saud Bipin 
Published: October 2019

INTRODUCTION:
Isolated Pancreatic duct laceration due to blunt trauma to the abdomen is very rare. Diagnosis requires a high level of suspicion as delay in diagnosis can lead to complications such as pseudocyst, abscess and duct stricture. We present an unusual case of pancreatic duct laceration complicated with pseudocyst formation due to blunt trauma to the abdomen during a Mixed Martial Arts fight.

CASE DESCRIPTION/METHODS:
33-year-old MMA fighter with no past medical history sustained a blunt trauma to the abdomen during a fight resulting in a knockout. Patient was emergently transferred to the hospital for evaluation. Lab work revealed elevated lipase >2000 IU consistent with acute traumatic pancreatitis. CT of the abdomen revealed diffuse edema of the pancreas with suspicion for possible laceration of the pancreatic duct. Patient was conservatively managed and later discharged once pain improved. Patient continued to have abdominal pain and returned to the emergency room 3 months later with abdominal distention associated with nausea and vomiting. Repeat CT of the abdomen revealed a 13 cm × 12.5 cm cystic lesion around the body of the pancreas with communication with the pancreatic duct (Image 1,2). MRI revealed a large cystic lesion with potential communication with the pancreatic duct seen on T2 images (Image 3).An ERCP was attempted but due to the mechanical compression caused by the cyst, the ampulla could not be accessed. An Endoscopic Ultrasound guided placement of a 10 × 10 mm cyst gastrostomy stent resulted in successful drainage of the pancreatic pseudocyst. Patient was later discharged and followed up in 1 month with repeat imaging showing complete resolution of the cyst. Endoscopy was repeated 4 weeks later with removal of the cystgastrostomy stent. Patient has since been doing well and awaits ERCP to evaluate the anatomy of the pancreatic duct.

DISCUSSION:
Isolated laceration of the pancreatic duct due to blunt trauma to the abdomen is very rare. Sudden severe impact to the abdomen, such as a punch, compresses the pancreas against the vertebral column resulting in pancreatic laceration. Diagnosis requires a high degree of suspicion and imaging confirmation. Management can be challenging as most pancreatic duct lacerations are often missed resulting in complications such as in our patient. There have been case reports of successful management with early endoscopic pancreatic duct stent placement. Refractory cases often require complex abdominal surgeries such as pancreatico - jejunostomy.
2160 Transpapillary Drainage of Persistent Pseudocyst Causing Dysphagia
Authors: Kim Grace E. , Lo David 
Published: October 2019

INTRODUCTION:
Pseudocysts (PC) are well-known complications of acute and chronic pancreatitis. Symptoms can include abdominal pain, early satiety and weight loss. We present a unique case of a PC presenting with dysphagia.

CASE DESCRIPTION/METHODS:
A 47-year-old female with history of acute on chronic pancreatitis due to alcoholism complicated by a persistent PC presented with weight loss and progressively worsening dysphagia for one year. Prior attempted surgical cystgastrostomy and percutaneous aspiration of her PC were unsuccessful. Esophagram showed a stricture of the distal esophagus, without passage of a barium tablet, and computed tomography and magnetic resonance imaging demonstrated a 6 × 5.3 cm PC compressing the distal esophagus (Figure 1). Esophagogastroduodenoscopy with balloon dilation was not efficacious. Endoscopic ultrasound cystgastrostomy was attempted but not feasible due to the proximal location of the PC. Endoscopic retrograde cholangiopancreatography (ERCP) was consistent with severe chronic pancreatitis by Cambridge classification; there was a high-grade stricture at the genu with upstream pancreatic duct (PD) dilation and communication with the PC. The stricture would only allow dilation initially with a 5-4-3 cannula, which allowed placement of a 5-French PD stent to bridge the stricture, and a 10-French double pigtail stent for transpapillary drainage of the pseudocyst (Figure 2). Stricture brushings were negative for malignancy. Her dysphagia resolved with resulting weight gain, and subsequent ERCPs (with serial PD stenting to 10-French) demonstrated resolution of her PC and PD stricture.

DISCUSSION:
Dysphagia due to PC has been rarely reported. It is usually due to mediastinal extension of a PC, which has been treated by endoscopic (e.g. transpapillary and transmural drainage), radiologic, and surgical means with good technical success1,2. In our case, due to the proximal position of the PC which prohibited transmural drainage, along with failure of prior surgery and percutaneous aspiration, transpapillary drainage was necessary and effective. Resolution of the inciting PD stricture by stenting was of paramount importance for the prevention of PC recurrence.
2188 Off-label Use of Lumen-Apposing Metal Stent for Gastro-Jejunal Anastomotic Stricture Following Roux-en-y Gastric Bypass
Authors: Dellatore Peter , Tawadros Augustine , Reja Debashis , Sarkar Avik , Tyberg Amy , Kahaleh Michel , Shahid Haroon 
Published: October 2019

INTRODUCTION:
Roux-en-y gastric bypass (RYGB) is the second most common bariatric surgery performed after sleeve gastrectomy. A complication of this procedure is a gastrojejunal (GJ) anastomotic stricture. A lumen apposing metal stent (LAMS), which was initially used for draining pancreatic fluid collections/cystogastrostomy, is now being used in various locations throughout the gastrointestinal tract due to its novel dumbbell shaped design. In this case report we present a case of GJ anastomotic stricture successfully managed with LAMS after failure of serial balloon dilations.

CASE DESCRIPTION/METHODS:
A 51-year-old woman with a history of RYGB in 2008, complicated by recurrent stricture of her GJ anastomosis, presented for treatment options of her stricture. She had undergone dilations in the past with no change in her symptoms of daily vomiting. The patient requested a more definitive treatment. The patient was taken for placement of a LAMS endoscopically. Her stricture at the GJ anastomosis measured 7mm in diameter and <1 cm in length. A hydrophilic wire was inserted into the jejunum under fluoroscopic guidance. A 15mm LAMS was advanced over the wire into the jejunal lumen. Placement was confirmed with endoscope and fluoroscopic image. Finally, a 12-13.5-15 mm CRE balloon was advanced over the wire and used to dilate the lumen of the stent. The patient returned to the clinic 5 weeks later with complete resolution of her symptoms. She will have the stent removed in 2 weeks.

DISCUSSION:
GJ anastomoses can initially be managed with pneumatic dilations. However, this requires repeat interventions with limited success. A common alternative is the fully covered self-expanding metal stent (FCSEMS). The FCSEMS has a high rate of adverse events including stent migration, perforation, and recurrence of strictures after removal. A LAMS has a novel dumbbell shape design that prevents leakage and migration due to 24 mm anchoring flanges, while also being shorter and smaller than FCSEMS. Additionally, because of the dumbbell shape, when inflated with a CRE balloon, the risk of migration is very low. For these reasons, in addition to its expanding use within the GI tract, it was used in our patient with success. This case demonstrates another use for LAMS that is safe and effective in an expanding population.
2190 A Unique Case Demonstrating the Endoscopic Management of a Duodenal Stump Fistula
Authors: Davis Sarah , Owen S. Craig , Magulick John 
Published: October 2019

INTRODUCTION:
Medical procedures continue to evolve towards being more minimally invasive leading to significant advances in the endoscopic management of transmural defects of the gastrointestinal (GI) tract. These are typically divided into three primary types; anastomotic leaks, perforations and fistulas. Once the site of injury has been identified, basic management involves surgical debridement and drainage with subsequent closure, diversion or both. We present a case of a complicated fistula and a novel approach to closing it.

CASE DESCRIPTION/METHODS:
A 35 year old female presented to the emergency room following blunt abdominal trauma from a horse kick. She sustained significant injuries to the small bowel requiring emergent surgical intervention and ultimately a duodenectomy with gastrojejunostomy. She was left with a 6cm blind limb of native post pyloric duodenum that was drained percutaneously with a 32Fr Malecot catheter. Gastroenterology was consulted to assist with endoscopic drain removal and management of the residual fistula tract. The Malecot was replaced with a 24Fr percutaneous gastrostomy tube with subsequent downsizing procedures every 2-3 weeks. The end result was a 3-4mm duodenal-cutaneous fistula with persistent output. After fulguration of the surrounding area with Argon plasma coagulation a single running suture of 5 stitches was placed using the OverStitchTM device and the external opening was allowed to close by secondary intention. At a 2 week clinic follow up she had returned to her usual activities and a barium upper GI series at 4 weeks post closure confirmed no stump leak.

DISCUSSION:
There is a paucity of data to guide the gastroenterologist on duodenal stump defects. In the setting of a planned surgical fistula such as in our patient, the most appropriate treatment option was successive downsizing of the tract with definitive closure via endoscopic suturing. The unique location of the fistula in a blind pouch precluded the use of a self-expanding metal stent, the defect was too large to close with a through-the-scope clip, and there was a theoretical concern of retention in the stump if a larger over-the-scope clip was employed. The high volume of bilious output through the fistula precluded the use of tissue adhesives as a monotherapy. Despite the desired outcome being achieved in our case we suspect this method of closure would be less successful in fistulas complicated by chronic inflammation, infection, or malignancy.