bluuebunny/crossref_metadata_2025_split huggingface dataset:
2706 Ischemic Duodenal Ulcer: A Rare Complication of Embolization of the Gastroduodenal Artery in Yttrium-90 Radioembolization Therapy
Authors: Le Han N. , Chaaya Adib 
Published: October 2019

INTRODUCTION:
Selective internal radiation therapy (radioembolization) with yttrium-90 (Y-90) resin microspheres is an effective and increasingly popular treatment option for unresectable primary and metastatic liver malignancies. Gastric complications are detected in 4% to 27% of liver radioembolization cases. Most of these cases arise from non-targeted flow of microspheres with aberrant deposition into various non-selected organs. The gastroduodenal artery is routinely embolized prior to deposition Y-90 microspheres to decrease the risk of non-targeted dissemination of the microspheres. We present a rare case of duodenal ulcer which developed as a result of ischemia induced by embolization of the gastroduodenal artery.

CASE DESCRIPTION/METHODS:
A 68 year-old woman with a history of stage IV colon adenocarcinoma with metastasis to the liver presented to the hospital with a several week history of severe abdominal pain two months after receiving radioembolization therapy with Y-90 microspheres. She was found to have a duodenal ulcer and was treated with acid suppression therapy. She was re-evaluated six months later for severe abdominal pain. Repeat endoscopy showed a larger duodenal ulcer with multiple coils eroding through the center of the ulcer bed suggesting ischemic injury caused directly from the embolization coils. She was treated with acid suppressive therapy with resolution of her symptoms.

DISCUSSION:
Radioembolization with Y-90 microspheres is now a widely performed locoregional treatment for primary and metastatic liver lesions not amenable to resection. Our case is unique because the patient’s duodenal ulcer was likely ischemia-induced from mechanical occlusion of and direct injury to the gastroduodenal artery from the embolization coils. It is imperative that clinicians caring for patients who have received radioembolization therapy be familiar with the many gastrointestinal complications associated with this therapy. There is increasing awareness of radiation-induced mucosal injury in the literature. However, providers should also know that despite the presence of multiple collaterals in the gastroduodenal territory, chronic coil-induced ischemia can also form ulcers as a complication of selective embolization of the gastroduodenal artery.
2708 An Atypical Case of Lymphocytic Gastritis
Authors: Penmetsa Amulya , Santa Stephanie , Marino Danielle E. 
Published: October 2019

INTRODUCTION:
Lymphocytic Gastritis (LG) is an uncommon gastritis that is typically associated with Helicobacter Pylori (HP) and Celiac disease. We present the case of a patient with persistent LG on repeat biopsies without either aforementioned association, which improved with steroids.

CASE DESCRIPTION/METHODS:
A 48-year old woman with a history of Raynaud’s and Undifferentiated Connective Tissue Disorder (UCTD) presented with abdominal pain, early satiety, and weight loss of forty-five pounds over three years. She was taking Advil twice weekly for headaches. CT Abdomen/Pelvis was unremarkable. Esophagogastroduodenoscopy (EGD) showed diffuse nodular mucosa with normal rugae (Figure 1); biopsies showed LG. There was no HP and duodenal biopsies were normal. She was started on Prednisone 40 mg daily for one week and tapered by 10 mg weekly, which significantly improved her symptoms. EGD three months later demonstrated a nodular stomach and biopsies showed mild to moderate LG, similar to prior exam. Steroids were not restarted as the patient was asymptomatic with weight increase of five pounds. In follow up two years later, she continued to be asymptomatic and had total weight increase of eighty pounds. Repeat EGD showed erythema and edema throughout gastric body with nodular-like appearance; this was improved from the first endoscopy. Biopsies at this time were normal without LG.

DISCUSSION:
LG is a rare subset of gastritis, seen in less than 1.5% of cases. Histologically, it is defined as a lymphocyte fraction of greater than twenty-five out of one hundred epithelial cells. Endoscopic appearance can include small, nodular erosions with enlarged rugae (an entity known as gastritis varioliformis), or it can present as giant fold gastritis. It has been described as a reaction to either HP infection or celiac sprue, which has been identified in up to 45% of cases. In this particular case, we describe a slightly different endoscopic appearance; HP and Celiac disease were both ruled out with negative biopsies. The literature has also identified a correlation of LG with Menetrier’s disease, autoimmune disorders, Crohn’s disease, viral (HIV) or parasitic infections. In this case, it is possible that she was predisposed to LG given her concurrent history of autoimmune disorders in the form of UCTD. NSAIDs may also have played a role, as they do in lymphocytic colitis. This case illustrates the successful treatment of LG with steroid therapy, which can lead to symptomatic and histologic remission.
2731 Duodenal Pressure Ulcer Secondary to Migratory PEG Tube
Authors: Nagirimadugu Ankita , Dong Ray , Weisberg Ilan 
Published: October 2019

INTRODUCTION:
Percutaneous endoscopic gastrostomy (PEG) tubes allow for long-term nutritional support in patients with preserved gastrointestinal function and dysphagia. The procedure and long-term presence of a PEG tube is well tolerated, with a complication rate of 0.4% to 4.4%. Adverse events include infection, skin breakdown, and aspiration. Upper GI bleeding, secondary to gastric or duodenal pressure ulcers is a rare complication. We present a case of duodenal pressure ulcers secondary to a PEG tube, along with a review of the literature and a proposed mechanism for this injury.

CASE DESCRIPTION/METHODS:
A 94-year-old non-verbal woman with a history of dementia and oral squamous cell carcinoma presented to the ED for RLQ abdominal pain. She was found to have leakage around the replacement PEG tube. Given comorbidities, patient was initially managed conservatively, but eventually underwent an endoscopy (EGD) due to persistent melena and down trending hemoglobin. The EGD demonstrated that the intragastric retention balloon had migrated beyond the pyloric channel resulting in a partial gastric outlet obstruction. The balloon was deflated revealing a large nonbleeding duodenal pressure ulcer. Since no stigmata of bleeding were identified, the replacement PEG was removed and new mushroom catheter and internal bumper was placed through the original tract. The patient was placed on an IV PPI to allow for adequate healing and melena resolved.

DISCUSSION:
Standard replacement PEG tubes are secured with an external bumper on the skin with an intragastric saline filled balloon. Ideal distance between the retainer and skin is 1-2 cm. If a PEG balloon is pulled too tightly there is a risk for pressure ulcer formation at the gastrostomy site. Conversely, if the PEG tube is too loose there is the risk of PEG balloon migration. With intense gastric peristalsis, the saline-filled balloon can migrate through the stomach, pylorus, and into the duodenum. While this is rare, case reports of gastric and duodenal outlet obstruction have been observed. In this case, the migration of the balloon into the duodenum led to a partial gastric outlet obstruction leading the patient to present with leakage, pain, melena, and anemia due to a large duodenal pressure ulcer. Proper PEG placement and care should be the main source of pressure ulcer prevention, and this rare complication should be considered in patients with melena and anemia.
2747 A Rare Case of Esophageal Squamous Cell Carcinoma With Intramural Gastric Metastasis
Authors: Kassim Gassan , Liu Yingheng , Smith Michael S. 
Published: October 2019

INTRODUCTION:
Esophageal cancer makes up about 1% of all cancers diagnosed in the United States . Gastric metastasis from esophageal cancer is relatively rare. Four different types of metastatic mechanisms were reported: 1) via peri-gastric lymph nodes; 2) gastric intramural metastasis; 3) direct invasion of the gastric wall, and 4) intra-epithelial spread to the gastric epithelium . Here we present a case with intramural gastric metastasis in a patient with esophageal squamous cell carcinoma.

CASE DESCRIPTION/METHODS:
A 76-year-old Indian male with past medical history significant for idiopathic pulmonary fibrosis and coronary artery disease, recently started on aspirin and clopidogrel, presented with new onset fatigue and five days of black tarry stools. Hemoglobin (Hgb) on admission was 7.1 g/dL. Despite transfusion of one unit of packed red blood cells, repeat Hgb dropped to 6.6 g/dL. Emergent upper endoscopy was performed for suspected active gastrointestinal bleeding in the setting of blood thinner use. Endoscopy showed a 3 cm, non-bleeding, fungating and ulcerated mass in the middle third of the esophagus, as well as a 4-5 cm fungating, infiltrative and ulcerated gastric mass in the cardia with stigmata of recent bleeding (adherent clot) (see Figure 1). Removal of the clot revealed underlying oozing from the ulcer bed which was treated successfully with dilute epinephrine injection followed by hemostatic clip placement. Forceps biopsies of both the esophageal and cardia masses were obtained. Histopathology of both lesions revealed keratinized squamous cell carcinoma. CT of the chest, abdomen and pelvis showed no evidence of other metastatic disease. Oncology consultation was scheduled to discuss potential chemotherapy, radiation, and endoscopic interventions.

DISCUSSION:
Esophageal cancer with intramural gastric metastasis is very rare compared to other mechanisms of tumor spread. The prognosis is very poor with the mean survival time reported to be 8.6 months . Conventional chemotherapy or radiotherapy after surgery were ineffective in improving prognosis in current report, suggesting other techniques could provide a benefit when used adjunctively or in combination with more traditional approaches.
2751 Endoscopic Folie à Deux: Atypical Manifestations of Gastric Amyloid in Concurrent Cases
Authors: Ladhani Sanah , McCabe Patrick , Szmit Andrew , Bhuket Taft , Liu Benny , Wong Robert 
Published: October 2019

INTRODUCTION:
Gastrointestinal amyloidosis is rare with variable, nonspecific presentations, signs, and endoscopic findings. We describe two cases featuring unusual endoscopic findings produced by histologically confirmed gastric amyloid.

CASE DESCRIPTION/METHODS:

Case 1: A 60 year old man with Child B cirrhosis due to chronic hepatitis C virus (HCV) infection, hidradenitis suppurativa, and end-stage renal disease from biopsy-proven amyloidosis on hemodialysis presented with melena and severe anemia. EGD showed diffuse gastric hemorrhagic, fibrinous exudates (Figure 1). On biopsy, Congo red stain showed apple green birefringence with plane polarized light microscopy consistent with amyloid. Four months later, after recurrent melena and bloody diarrhea, along with severe hypotension due to newly diagnosed adrenal insufficiency, the patient died while on comfort care. Case 2: A 63 year old man with Child C cirrhosis from chronic HCV, end-stage renal disease on hemodialysis, and prior intravenous drug use presented with hyperkalemia after missing his scheduled dialysis session. During his hospitalization, he developed melena and underwent an EGD, which showed scattered patchy moderate submucosal hemorrhages in a partially ringed pattern throughout the gastric body (Figure 2). On biopsy, Congo red stain showed apple green birefringence with plane polarized light microscopy; protein identification showed AA-type amyloid (Figure 3). Three months later, and to-date, the patient is hospitalized in the ICU for altered mental status, septic shock, and respiratory failure, with his hospital course complicated by repeated episodes of GI bleeding.

DISCUSSION:
These two cases of melena had distinctive, initially puzzling endoscopic findings, with biopsy results indicating gastric amyloid, a rare and atypical presentation of systemic amyloidosis. It is interesting that both patients in these cases had HCV infection. While AA-type, secondary amyloid can be caused by a chronic infectious state, there are no studies thus far that establish a causal link between HCV and amyloidosis. The patients in these two cases also carry other risk factors for amyloidosis, including hidradenitis suppurativa, end-stage renal disease, and intravenous drug use. Thus, while gastric amyloid is rare, endoscopists should keep it in the differential and note its potential for causing GI bleeding, especially in patients with risk factors, as it is a difficult condition to treat and its endoscopic findings can be dramatic.
2810 Endoscopic Ultrasound in Diabetics: Is There a Protective Role of Metformin Therapy for Pancreatic Ductal Adenocarcinoma?
Authors: Schwartz Ingrid , Satiya Jinendra , Singh Harjit , Abraham Rtika , Girotra Mohit 
Published: October 2019

INTRODUCTION:
The relationship between diabetes mellitus (DM) and pancreatic ductal adenocarcinoma (PDAC) is a field of immense interest. Studies have proposed that metformin therapy (MT) could play a protective role in risk reduction for PDAC; however, the prevalence of pancreatic structural abnormalities in patients on MT is unknown. We aimed to identify the prevalence and distribution of pancreatic parenchymal and ductal changes during endoscopic ultrasound (EUS) of diabetic patients on MT, compared to patients non-MT.

METHODS:
We performed a retrospective chart review of diabetic patients who underwent EUS at the University of Miami Health System between 2010-2018. Patients with known history of chronic pancreatitis (CP), pancreatic mass/PDAC or pancreatic surgery were excluded.

RESULTS:
Seventy-eight patients were identified (mean age = 65 ± 13.6 years; M:F = 31:47): 18 (23%) African-American, 17 (22%) Caucasian and 43 (55%) Hispanic. Mean BMI was 31.55 ± 9.8. Four patients (5%) had DM type 1 and 74 (95%) had type 2, with mean hemoglobin A1c of 6.45 ± 2%. Diabetic complications were seen in 44 patients (56.4%): nephropathy = 25, neuropathy = 26 and retinopathy = 6. Forty-four (56.7%) patients were on MT and 34 (43.5%) patients were on either insulin (n = 20) or insulin secretagogue (n = 14), defined as non-MT group (Table 1) Indications for EUS included abdominal pain (24), submucosal esophageal (2), gastric (11) or duodenal (3) lesion, common biliary narrowing or dilation (18), abnormal hepatic panel (3), lymphadenopathy on imaging (5), suspected choledocholithiasis (3), jaundice (2), and elevated CA-19-9 (2). Parenchymal or ductal endosonographic findings were present in 34% (n = 15) of the patients on MT versus 53% (18) of patients non-MT (Table 2). Among the 44 patients on MT, 2 patients met criteria for chronic pancreatitis (CP), 1 was indeterminate and 41 (93.2%) were classified as normal pancreas, according to the Rosemont classification. In non-MT patients, 32 (94.11%) were classified as having normal pancreas, 2 were indeterminate and no patients met criteria for CP. Following EUS examination, PDAC was diagnosed in 1 (2.2%) patient in MT group, versus 3 patients (8.8%) in the non-MT group.

CONCLUSION:
Pancreatic structural abnormalities occurred equally in diabetic patients in MT (6.8%) versus non-MT (5.8%) groups (P = ns). Higher number of PDAC were diagnosed in non-MT group; however, whether or not this finding could explain the proposed protective role of MT on the risk of developing PDAC is yet unclear.
2825 Colorectal Cancer Is Not Associated With Obstructive Sleep Apnea: A Meta-Analysis and Systematic Review
Authors: Al Momani Laith , Alomari Mohammad , Kwak Hakyong Gloria , Sarmini Muhammad Talal , El Kurdi Bara , Thota Prashanthi N. , Young Mark , Sanaka Madhusudhan R. 
Published: October 2019

INTRODUCTION:
Multiple studies have attempted to evaluate the risk obstructive sleep apnea (OSA) imposes on certain malignancies. Particularly the association between OSA and colorectal cancer and cancer-related mortality have been scarcely studied with contradicting results. This study aims to review the literature on OSA and its association with colorectal cancer.

METHODS:
A systematic review was conducted in Pubmed, MEDLINE, EMBASE, and Cochrane databases from inception through May 2019 to identify the studies which explored the association between OSA and colorectal cancer. Effect estimates from the individual studies were extracted and combined using the random effect, generic inverse variance method of DerSimonian and Laird and a pooled odds ratio (OR) was calculated. Forest plots were generated, and publication bias was assessed for using conventional techniques.

RESULTS:
Three studies with a total of 1,705,003 patients with OSA were included in this analysis. Of them, 3,835 patients had an incident colorectal cancer diagnosis. The pooled OR for colorectal cancer in patients with OSA was 0.968 (95% CI: 0.940 - 0.997, P = 0.029) compared to the control group.

CONCLUSION:
Our meta-analysis found that OSA is not associated with an increase incidence of colorectal cancer. Further studies might be needed to explore this association and its effect on the disease course mortality.
2877 Electronic APP vs. Paper Form Stool Diary for Fecal Incontinence
Authors: Yan Yun , Karunaratne Tennekoon , Jimenez Enoe , Sharma Amol , Parr Rachael , Herekar Anam , Eubanks Audrey , Sanku Amalesh , Rao Satish 
Published: October 2019

INTRODUCTION:
The irregular and unpredictable bowel movements (BM) and leakage events makes it challenging for patients with fecal incontinence (FI) to accurately recall, describe or quantify stool habit. Although paper stool diary has been used in clinical trials, patients find these diary entries cumbersome or embarrassing and has not gained popular use. Cell phone apps provides a unique opportunity to instantly record BM and FI events and protect privacy. We developed an electronic FI stool diary app and assessed its reliability/reproducibility and psychometrics and compared this with paper stool diary.

METHODS:
In a randomized cross-over study, FI patients (≥1 FI episode/week), completed both a paper and app diary for 2 weeks each. The 10-item diary recorded number of bowel movements (BM), FI leakage events, severity and associated symptoms. Also, we assessed functionality and ease of use. Data was assessed and compared for reliability, reproducibility, validity and separately for ease of use (Visual analogue scale, VAS scores 0-10). Intraclass correlation coefficients (ICC) assessed equivalence.

RESULTS:
Ten patients (18.7 ± 5.9 years, F/M = 9/1) completed assessments for this analysis. The app showed significant correlation between pad use, stool frequency and percentage of BM with urgency (ICC >0.703) between week 1 and week 2, and demonstrated high reliability and test-retest reproducibility (Table 1). The weekly FI episodes trended towards significant correlation between week 1 and week 2 (ICC = 0.676, P = 0.054). The mean stool consistency (ICC = 0.944, P < 0.0001), number of normal (Bristol Stool Form Scale, BSFS type 3-5) and loose stools (BSFS type 6-7) were significantly correlated between week 1 and week 2. The number of FI episodes and use of pads over 2 weeks in app were significantly correlated with paper stool diary (ICC >0.812). Also, stool frequency, percentage of BM with urgency, stool consistency, number of normal and loose stools were significantly correlated with paper diary. The psychometrics parameters were significantly better (P < 0.01) compared to paper diary, but other parameters although better were not significant (Table 3).

CONCLUSION:
The App is a reliable and reproducible instrument for documenting and assessing FI symptoms, and demonstrates comparable accuracy against paper diary. This user-friendly diary could improve our ability to provide optimal care for FI patients by accurately characterizing their symptoms.
2884 How Delay in Colonoscopy Impacts Diagnosis of Significant Medical Conditions
Authors: Borecky Thomas , Borecky Michael , Chang Lauren , Chang Alexander , Sheikh Akber , Chang Andrew , Godil Aslam , Foliente Roy , Hill Kevin , Brichler Benjamin 
Published: October 2019

INTRODUCTION:
Colonoscopy cancellations will lead to delaying diagnosis of medical conditions that may be found at colonoscopy. The delay in diagnosing a treatable medical condition can lead to unnecessary increases in patient morbidity and mortality. This study evaluates the impact of a delayed colonoscopy on diagnosing significant medical conditions and the risk factors that may predict significant findings at colonoscopy.

METHODS:
Retrospective study done at Sierra Nevada Gastroenterology Medical Associates and Sierra Endoscopy Center, both located in Grass Valley, California. Electronic medical records of 421 patients were reviewed from January 2016 through December 2017. Demographics, insurance, reasons for cancellations, timing of rescheduled colonoscopy, indications and significant findings of colonoscopy were recorded.

RESULTS:
421 patients cancelled their colonoscopy and 223 (53%) rescheduled. 157 (70%) rescheduled their colonoscopy within 3 months. Demographics, insurance, rescheduled timing.
Reasons for cancellations, indications, and findings of colonoscopy.

CONCLUSION:
Most patients cancel their colonoscopy without realizing the impact that may have on their health. This study shows that significant findings were diagnosed in 98 (44%) of patients, including polyps, colitis and colon cancers. Delaying the diagnosis of these conditions can lead to increased morbidity and mortality. Symptoms, indications or demographic characteristics did not consistently predict significant colon pathology. Therefore, all patients should be encouraged to follow through on their colonoscopy as quickly as possible.