bluuebunny/crossref_metadata_2025_split huggingface dataset:
2693 Gastric Emphysema: A Complication of Intractable Vomiting
Authors: Kelts Andrew , Steimle Cassandra , Jeng Jennifer , Kochik Michael , Golikov Edwin , Ali Farhan , Raborn Eric 
Published: October 2019

INTRODUCTION:
Gastric pneumatosis is a term used to describe gas within the wall of the stomach. It is due to either one of two causes: emphysematous gastritis or gastric emphysema. The latter carries a better prognosis and is generally characterized by hemodynamic stability and spontaneous resolution with conservative management8.

CASE DESCRIPTION/METHODS:
A 58 year old female presented to the hospital with dyspnea and vomiting. Past medical history included coronary artery disease and diabetes mellitus type II. She was found to have a non-ST elevation myocardial infarction which was treated medically. Because of persistent vomiting, a gastroenterology consultation was requested. Physical examination at the time of consultation revealed an obese female with stable vital signs and a moderately distended abdomen. Laboratory tests revealed white blood cell count: 13.7 10 × 3/uL, hemoglobin 12.4 g/dL, lactic acid 1.0 mmol/L, lipase 30 U/L, and amylase 52 U/L. Computed tomography (CT) scan of the abdomen/pelvis was performed and revealed diffuse wall thickening of the stomach and a large amount of intramural air, particularly involving the fundus. Based on her symptoms and radiological findings, the diagnosis of gastric emphysema was made and she was treated with conservative measures. Her symptoms improved and a repeat CT scan of the abdomen ten days later failed to reveal any gastric pneumatosis.

DISCUSSION:
Gastric emphysema is benign and managed with observation and conservative treatment. Patients are hemodynamically stable without any associated infection3,8 The cause of either gastric emphysema or emphysematous gastritis can be due to an increase in intraluminal pressure or a mucosal injury that leads to intramural gas formation. Mucosa may be compromised in patients who are on immunosuppressive/cytotoxic therapy or in those patients who suffer from autoimmune and inflammatory diseases7. Diagnosis of gastric pneumatosis is made using CT imaging6 which can detect small amounts of gas in the stomach wall.3,5 Treatment for gastric pneumatosis includes supportive care. This includes adequate bowel rest and fluid support as needed. Surgical intervention or antibiotic therapy may be needed in certain cases of emphysematous gastritis5. In our patient, we suspect her development of gastric emphysema was due to her intractable nausea and vomiting. As in the majority of cases, her symptoms improved with conservative treatment and follow-up radiological imaging revealed resolution of her findings.
2703 Gastric Metastasis From a Primary Ovarian Cancer
Authors: Nathani Komal G. , Zamir Asif 
Published: October 2019

INTRODUCTION:
Metastasis to stomach is very rare in general and often related to a breast or a lung primary. Ovarian cancer metastasizing to the stomach is extremely rare. We are reporting a very unusual case of a lady who had gastric metastasis from the primary ovarian cancer more than 3 years after the initial diagnosis. Serosal tumors are more likely to metastasize in comparison to the mucinous type.

CASE DESCRIPTION/METHODS:
A 49 year old Hispanic lady who had originally presented 3.5 years prior to her recent admission with abdominal pain and bloating. Work-up confirmed bilateral ovarian masses. Staging was negative for liver, lung and brain involvement. She had surgery. The pathology confirmed papillary serous adenocarcinoma with appendiceal and omental involvement. Estrogen and progesterone receptors were positive. She was considered to have Stage III-C disease, and started with chemotherapy. Unfortunately, within a few months, she came in with shortness of breath with imaging showing bilateral pleural effusions. She had thoracentesis which confirmed metastasis from her primary ovarian cancer. Her staging status was changed to IV. She was started on palliative chemotherapy. She would respond partially at first, but then she did show progression of the cancer. She then presented to the hospital recently with GI bleeding, anemia, sepsis, acute renal failure, leukocytosis and respiratory compromise. An upper endoscopy showed a large cratered malignant appearing ulcer in the body of the stomach. Biopsies confirmed adenocarcinoma from the ovarian source. Based on her advanced disease, and multi-system organ failure, the family decided on hospice care.

DISCUSSION:
Ovarian cancer metastasizing to the stomach is exceedingly rare. The symptoms are usually vague as the involvement is often serosal or sub-mucosal from local infiltration from the peritoneal carcinomatosis. However, hematogenous spread can occur as well. Presentation is often late, months to years after the initial diagnosis of the cancer. EGD should be considered in ovarian cancer patients presenting with upper GI symptoms. EUS/FNA biopsy may help in the diagnosis of the submucosal lesions. Prognosis is usually poor with average life expectancy after the diagnosis of gastric metastasis being 15 months.
2709 Metastatic Gastric Cancer to the Colon: A Rare Entity
Authors: Then Eric O. , Deda Xheni , Ofosu Andrew , Gayam Vijay , Liao Guanghong , Gaduputi Vinaya 
Published: October 2019

INTRODUCTION:
Gastric cancer is one of the most common and deadly cancers worldwide, especially amongst older males. Current data suggests gastric cancer is the fifth most common neoplasm and the third most deadly cancer, with an estimated 783,000 deaths in 2018. Here we report a deadly case gastric cancer with colonic metastasis.

CASE DESCRIPTION/METHODS:
Patient is a 66 year old male with a medical history of hypertension and gastric cancer (status post partial gastrectomy) who presented to the emergency department complaining of progressive lower abdominal pain for the past 2 months. Notable laboratory workup included a hemoglobin of 10.1 gm/dL. Notable imaging included a computed tomography scan of the abdomen showing a mid transverse colon apple core mass measuring 30 mm × 44 mm resulting in proximal colonic obstruction. Given the size of the mass a joint endeavor between the gastroenterology service and surgery service was pursued in the operating room. A colonoscopy was initially done and showed a stenotic segment in the transverse colon with friable edematous mucosa. A stent deployment was attempted, but was unsuccessful due luminal compression by the tumor. Subsequently the surgical team performed an en bloc resection of the mass. The resected specimen was sent for biopsy and returned showing metastatic adenocarcinoma consistent with gastric origin. This diagnosis was supported by cell positivity to CK7 and negativity to CK20 and CDX2. Given his poor prognosis and complicated hospital course, the patient and his family decided to withdraw invasive care and opted for transfer to a hospice facility for end of life care.

DISCUSSION:
Risk factors associated with the development of gastric cancer include obesity, gastroesophageal reflux disease, helicobacter pylori infection, and low socioeconomic status. Diagnosis of gastric cancer can be accomplished by endoscopy, which allows the clinician to obtain a biopsy specimen. Endoscopic ultrasound is also an important modality that is helpful in assessing tumor invasion. The most common sites of metastatic gastric cancer in descending order are the liver, peritoneum, lung and bone. Rarely will gastric cancer metastasize to the colon. When suspected prompt evaluation with colonoscopy should occur for possible intervention and subsequent diagnosis of metastasis via biopsy. Surgery is the treatment of choice in gastric cancer limited to the stomach. In metastatic disease however, treatment with chemotherapy and targeted radiotherapy should be pursued.
2717 Gastric Mucormycosis and Pneumatosis in a Patient With APECED
Authors: Platt Jesse M. , Chu Jacqueline N. , Yarze Joseph C. 
Published: October 2019

INTRODUCTION:
To describe a case of progressive, fatal gastric mucormycosis.

CASE DESCRIPTION/METHODS:
A 33 yo female with a history of APECED (autoimmune polyendocrinopathy, candidiasis, ectodermal dystrophy) and autoimmune hepatitis was admitted to the hospital with epigastric pain, nausea and vomiting. Medications prior to admission included levothyroxine and azathioprine. An initial CT scan of the abdomen revealed only subtle nonspecific “stranding” around the pancreas. Blood cultures were positive for E coli. Initially, the source of septicemia was unclear and the patient was treated with IV vancomycin and meropenum. A repeat CT scan 10 days later revealed gastric pneumatosis (Figure 1). EGD revealed a 3 cm ulcer in the gastric cardia (Figure 2). Biopsies of the ulcer revealed inflamed gastric mucosa with broad, sparsely-septated 10 to 20- µmfungal hyphae (with 90 degree branching) invading the mucosa, most consistent with mucormycosis. PCR of gastric biopsies were consistent with Rhizopus oryzae (a fungus in the family of Mucoraceae). A multidisciplinary decision was made to treat the patient nonoperatively with IV liposomal amphotericin, micafungin and nasojejunal feeding. She initially made slow, steady recovery but later had decompensation which led to the diagnosis of a gastro-pleural fistula. Extensive surgical debridement with resection of grossly abnormal stomach, spleen, diaphragm spleen and distal pancreas was performed. Pathology revealed extensive angioinvasive mucormycosis. She was then treated with a prolonged course of antifungals and antimicrobials (liposomal amphotericin B, posaconazole, terbinafine, meropenem, daptomycin). After a prolonged hospitalization, the patient gradually deteriorated and ultimately chose comfort measures and succumbed.

DISCUSSION:
Despite aggressive management with multidisciplinary expertise, widespread angioinvasive mucormycosis can be associated with a fatal outcome. Although there is no known association, the spector is raised as to whether the patient's underlying APECED was in some manner a predisposing or exacerbating factor in this patient's illness.
2721 Back Pain Can Be Hard to Digest
Authors: Mendelson Avery , Iskenderian Ziyad 
Published: October 2019

INTRODUCTION:
With over 1,000,000 new cases of gastric cancer in 2018, and 783,000 estimated deaths, gastric cancer remains an important cancer worldwide.1 Gastric malignancy will commonly present in patients with weight loss and persistent abdominal pain. Patients can also present with findings of metastatic disease. This clinical vignette is an example of a rare metastatic location of gastric cancer.

CASE DESCRIPTION/METHODS:
55-year-old Middle Eastern male presents with intractable low back pain. An MRI of the thoracic and lumbar spine revealed multiple osseous lesions of the thoracic vertebral bodies and fractures of the L2 and L3 vertebral bodies, concerning for metastasis (Figure 1). A CT of the chest, abdomen and pelvis revealed enlarged mediastinal and hilar lymph nodes. Enlarged lymph nodes at the gastrohepatic interval and celiac level measuring up to 2 cm were noted, and multiple enlarged mesenteric and retroperitoneal lymph nodes. The patient underwent bone biopsy during kyphoplasty of the L2 and L3 vertebrae, which revealed metastatic carcinoma. Serum markers of malignancy were unrevealing, a CA19-9 of 15, CEA of 7.1, and PSA of 0.74. Urology was consulted and cystoscopy performed. No mass or filling defect was noted, and urine cytology returned negative for malignant cells. Gastroenterology was consulted and upon further history, the patient did acknowledge a history of H. Pylori, in 2016, with eradication confirmed by a negative stool antigen test. Gastroenterology recommended EGD and colonoscopy, but patient was unable to tolerate the bowel prep. The patient underwent an EGD, which revealed a 3.0 × 3.5 cm, cratered gastric ulcer without stigmata of bleeding at the incisura (Figure 2). Biopsy of this ulcer was positive for adenocarcinoma.

DISCUSSION:
This case demonstrates a presentation of bony metastasis of gastric cancer. This metastatic location is rare and unusual. It highlights the importance of maintaining high clinical suspicion in patients with metastatic disease. Additionally, it reinforces the relevance of a multidisciplinary approach when evaluating malignancy.
2733 Gastroduodenal Intussusception: An Interesting Presentation of a Gastrointestinal Stromal Tumor in a Bahamian Male
Authors: Deleveaux Spencer , Rolle Gemma 
Published: October 2019

INTRODUCTION:
Gastrointestinal stromal tumors (GISTs) are a mesenchymal neoplasm considered to be the most common nonepithelial neoplasm of the gastrointestinal tract. GISTs occur with a frequency of about 0.68 per 100,000 in the United States, but the incidence of GIST in the Bahamas is unknown. These tumors arise from the interstitial cells of Cajal, which assist in motility via the myenteric plexus. Mutation to the c-kit oncogene is highly implicated in this process. Symptomatic GISTs are primarily a disease of the middle aged and elderly and have been found to be more frequent in males and minorities, especially in the black population. This case serves to highlight a presentation of GIST that is uncommon in current literature.

CASE DESCRIPTION/METHODS:
A 59 year old male with history of alcohol abuse and no known chronic liver disease presented with history of four episodes of coffee-ground vomitus and two episodes of melena stools over a one day period. The patient presented with an Hb of 8.2 mg/dl and at the time of endoscopy it had fallen further to 6.6 mg/dl. On endoscopy, it was noted that a portion of the mid stomach telescoped through the pyloric channel into the duodenum, causing obstruction the gastric outlet. On reduction of this intussusception, a mass with a central ulcer with stigmata of recent hemorrhage was observed at the greater curvature. Due to the nature of the significant, symptomatic bleeding that preceded presentation the decision was made not to use endoscopic ultrasound with fine needle aspiration, but rather proceed to surgical resection. A wide local excision was later performed with the lesion measuring 4.1 × 3.7 × 3.2 cm. Pathology confirmed suspicion of GIST, with chemical markers positive for CD117 and negative for S-100 and CD34, while the mitotic count was low (<5.5 mm2).

DISCUSSION:
This case report describes an interesting case of a GIST. Although GISTs most commonly present as gastrointestinal bleeding, the unexpected finding of an intussuseption is a rare finding of a relatively uncommon lesion. A 2018 literature review found that there were 28 reports of intussusception secondary to GIST, with only 18 having immunohistochemical confirmation of the tumor. The diagnosis of GIST should be entertained in adults who give history of melena with additional gastrointestinal symptoms. As diagnostic methods improve, further study of GISTs in the Bahamian population may be warranted to ascertain the incidence of the tumor compared to the current data of other populations.
2735 Phlegmonous Gastritis
Authors: Gonzalez Lisandro , DeCino Andrea , Patel Harsh D. , Wright Randy P. , Parker Allan L. 
Published: October 2019

INTRODUCTION:
Phlegmonous gastritis (PG) is a rare cause of abdominal infection with a mortality rate up to 42%. PG presents a diagnostic and therapeutic challenge given the low incidence and non-standardized treatment options. We present a case of PG successfully treated with early antibiotic therapy.

CASE DESCRIPTION/METHODS:
A 47-year-old man with uncontrolled type 2 diabetes mellitus presented with four days of subjective fevers, abdominal pain, and vomiting. The patient was tachycardic (122 beats/min) and had epigastric tenderness without guarding or rebound. Initial studies revealed leukocytosis (30,000/mm³) and Gram-positive bacteremia, later identified as ß-hemolytic group A Streptococcus. The stomach was diffusely thickened to 16 mm on contrast-enhanced computed abdominal tomography (Figure 1). Endoscopy revealed diffuse gastric thickening with erythema and a nonbleeding 6 mm ulcer on the lesser curvature of the gastric body. Deep biopsy of the ulcer by cold forceps produced a purulent drainage (Figure 2). Subsequent endoscopic ultrasonography (EUS) found a 12 mm thickened gastric wall involving the deep mucosa, thus further biopsy was obtained. The biopsies from both endoscopy and EUS showed acute neutrophilic inflammation with micro-abscesses; Helicobacter pylori was not identified. The patient received three days of piperacillin/tazobactam followed by seven days of ampicillin/sulbactam, with resolution of symptoms.

DISCUSSION:
PG is a rapidly progressive and frequently fatal bacterial infection of the gastric wall. The etiology of PG remains unclear, but can be caused by local or hematogenous spread of infection. Streptococcusspp. accounts for 70% of cases, and up to one-third of infections are polymicrobial. Risk factors include gastric mucosal injury, diabetes mellitus, and alcoholism. Diagnosis is commonly delayed as clinical manifestations are nonspecific. High clinical suspicion and early radiographic testing are important to identify gastric wall thickening, which is supportive of the diagnosis. PG primarily affects the gastric submucosa but may extend to deeper layers. Histopathology is of limited benefit, as standard forceps biopsy collects insufficient submucosal tissue. Optimal treatment is not known. When diagnosis is delayed, surgical intervention is often required. Medical therapy alone has been associated with increased mortality rates; however, in cases of early diagnosis and empiric antibiotic treatment, medical therapy alone may be sufficient.
2761 Adenocarcinoma Presented as Massive Gastric Distention
Authors: Zakaria Ali , Khan Faizan , Ahmed Shehbaz , Turk Issam , Levinson Jay 
Published: October 2019

INTRODUCTION:
Chronic gastric distention is a rare condition that can occur due to an underlying obstruction or dysmotility. Gastric outlet obstruction can be secondary to luminal, mural or extrinsic compression. Gastric adenocarcinoma can rarely manifest as massive gastric distention due to partially obstructing mass or peptic stricture. Herein we presented a case of chronic massive gastric distention due to pyloric adenocarcinoma.

CASE DESCRIPTION/METHODS:
A 60 y/o male patient with PMHx of hepatitis C, hypertension and polysubstance abuse, presented to the ER complaining of diffuse abdominal pain, intermittent nausea and vomiting, early satiety and 25lb weight loss over the last 8 months. He seeked medical attention due to worsening symptoms. He described normal bowel movements. He denied any fever, hematemesis, hematochezia, or melena. On exam: Pulse 84 bpm, temp 36.6 C°, BP 144/68 and RR 18 bpm. His BMI was 22. He was alert and oriented with mild distress due to abdominal pain. His abdomen was mildly distended with tympanic percussion and normal active bowel sounds. His lab results revealed WBC 4.7k/mcl, Hgb 12.9 mg/dl and normal basic metabolic panel. CT scan of the abdominal revealed markedly distended stomach with ingested debris extending to the pelvis with a mass effect on surrounding abdominal structures [Figure 1]. He was treated conservatively with NG tube placement and 3L of fluid removed. EGD revealed ulcerated partially obstructive pyloric malignant looking lesion with large amount of retained bezoar/food [Figure 2]. Histopathology confirmed the diagnosis of gastric adenocarcinoma with mucinous differentiation and signet ring cells. The patient underwent total gastrectomy with Roux-en-Y reconstruction with plan for outpatient follow up.

DISCUSSION:
Gastric distention was initially described by Duplay in 1833. Benign underlying etiology account for vast majority of cases, with one study calculated up to 90% of cases were seen in the setting of peptic ulcer disease alone. Amongst the malignant causes, gastric adenocarcinoma is important to consider, despite its rarity in the western countries. Gastric adenocarcinoma often presents with nonspecific symptoms and diagnosed at an advanced incurable stage. Serious complications of massive gastric distention include dehydration, ischemia and perforation that might lead to sepsis, multi-organ failure and death. Treating physician should keep high index of suspicion with prompt decompression and surgical intervention to prevent these dreadful sequelae.
2772 Choleperitoneum Due to Gastric Perforation Masquerading as Acute Pancreatitis in a Roux-En-Y Gastric Bypass Patient
Authors: Dixit Priyadarshini , Ponna Pramod , Diaczok Benjamin 
Published: October 2019

INTRODUCTION:
Approximately 200,000 patient undergo weight loss surgery in the United States annually. Nearly half undergo Roux-en-Y gastric bypass (RYGB). After RYGB, bile acid may reflux into the gastric remnant resulting in inflammation and occasionally, perforation. The prevalence of this complication in RYGB is under 1%. We present a patient with RYGB who was initially diagnosed with pancreatitis. When the patient did not respond to treatment, reevaluation revealed gastric perforation resulting in choleperitoneum. Physicians should be aware of complications related to weight loss surgery.

CASE DESCRIPTION/METHODS:
A 68-year-old lady with RYGB, cholecystectomy, and osteoarthritis, recently treated with naproxen 500 mg BID, presented with sudden onset sharp, continuous, 8 / 10, epigastric pain radiating to the right upper quadrant. She had no alleviating or aggravating factor. She had no associated nausea, vomiting, sweats or chills. Vital signs were unremarkable. Her abdomen was not distended. BS present. She had no pain to percussion, but tender to palpation in the epigastric region. Initial labs demonstrated WBC 14,800/mm3, AST 12 U/L; ALT 21 U/L; amylase 1,761 U/L and lipase 926 U/L. CT demonstrated a small volume of ascites, but no fat stranding or inflammation of the pancreas. A clinical diagnosis of pancreatitis due to naproxen was made. Despite conservative treatment, the patient deteriorated. Her abdomen became distended. Repeat CT demonstrated a large volume of ascites. Analysis of ascitic fluid revealed RBC 2/mm3; WBC 4/mm3; albumin 1.1 gm/dL with SAAG 0.9 gm/dL; and total bilirubin 7.5mg/dL. Choleperitonitis was diagnosed. Emergent laparotomy revealed a gastric perforation of the remnant stomach which was surgically repaired.

DISCUSSION:
Choleperitoneum is defined as the presence of bile in the peritoneum. An ascitic fluid bilirubin concentration greater than 6 mg/dL with an ascitic fluid/serum bilirubin ratio greater than 1.0 is diagnostic. Etiologies include liver laceration, gall bladder rupture, or bile duct leak. Amylase and lipase may be elevated. The clues suggesting an alternative diagnosis to pancreatitis was the sudden onset of pain (consistent with rupture of viscus) and normal appearing pancreas on CT despite elevations of amylase and lipase and a small collection of ascites. Physicians should keep in mind the prevalence and complications of weight loss surgery when evaluating abdominal pain.