bluuebunny/crossref_metadata_2025_split huggingface dataset:
3033 Acute Pancreatitis Complicated by Pancreatic Pseudocyst and Splenic Hematoma, Management Considerations
Authors: Zarrin Arash , Choksi Vivek , Sorathia Sufian , Kasmin Franklin , Priyadarshni Shivani 
Published: October 2019

INTRODUCTION:
Pancreatic duct disruption is a known complication of pancreatitis which leads to the formation of pancreatic pseudocysts, pancreatic ascites, and high amylase pleural effusions. Pancreatic pseudocysts migrate along with the pancreatic tissue and rupture either into surrounding organs or into the free peritoneal cavity. Splenic complications of pancreatitis are rare and include splenic vein thrombosis, splenic artery rupture, splenic rupture or infarction, and splenic hematoma.

CASE DESCRIPTION/METHODS:
39 y/o alcoholic male admitted for acute pancreatitis. Imaging revealed pseudocysts and ascites. Initially, he improved with supportive care but abdominal pain recurred owing to splenic rupture with resultant splenic hematoma. Splenic artery coiling was employed to stop bleeding. He returned for recurrent abdominal pain and new chest pain with interval increase in size of pseudocyst and interval development of pleural effusion. EUS revealed a multiloculated pancreatic pseudocyst, as well as pancreatic duct disruption. Transgastric drainage of the pseudocyst was performed with an Axios stent. Repeat endoscopy at interval showed complete resolution of the cyst.

DISCUSSION:
Studies estimate the incidence of pancreatic pseudocyst rupture into the spleen at a rate of up to 1.1% of patients with acute pancreatitis. Another study of patients with chronic pancreatitis reports splenic pseudocyst as the most common lesion, followed by splenic rupture and hematoma. A more recent study of 500 men with chronic alcoholic pancreatitis found that only 2.2% develop splenic complications with intrasplenic pseudocyst being the most common lesion, followed by splenic rupture and subcapsular hematoma. Findings associated with the highest risk of developing splenic complications included pancreatic tail necrosis, distal pseudocyst, or splenic vein occlusion. Previously, the mainstay of treatment for splenic hematoma was splenectomy with distal pancreatectomy. However, with the advent of advanced endoscopic procedures, patients are safely managed with splenic artery embolizationand EUS guided pancreaticogastrostomy or percutaneous drainage. Endoscopic drainage and percutaneous drainage of symptomatic pseudocysts are preferred to surgical management. Furthermore, recent reviews show that endoscopic drainage is superior to percutaneous drainage with lower rates of reintervention, shorter hospital stays, and need for less follow-up imaging.
3034 Acute Pancreatitis in a Patient With a Choledochal Cyst
Authors: Yang Grace H. , Apfel Tehilla , Shulik Oleg 
Published: October 2019

INTRODUCTION:
Biliary cysts, also called choledochal cysts, are cystic dilatations that may occur singly or in multiples throughout the biliary tree. Cysts may be congenital or acquired and have been associated with a variety of anatomic abnormalities. The incidence of biliary cysts in Western populations has been estimated to be 1:100,000 to 1:150,000. Biliary cysts are associated with an increased risk of cholangiocarcinoma, pancreatic cancer, and gallbladder cancer. Malignancy is more common in patients who are older and in those with Type I and II cysts. As such, surgical resection is necessary. Due to stasis of bile flow in the cyst, other well-known complications include choledocholithiasis and pancreatitis.

CASE DESCRIPTION/METHODS:
A 35-year old woman presented to the ED with epigastric pain and lipase elevation to 700. She reported a history of a congenital hepatic cyst and previous history of cholecystectomy as a child. Over the last 2 years, she had been admitted to other hospitals for similar complaints. Initial ultrasound of the abdomen revealed common bile duct (CBD) dilatation to 2.3 cm with a filling defect of 1.5 cm. MRCP showed intra- and extra-hepatic dilatation and confirmed evidence of a filling defect in the CBD concerning for multiple intraductal and intracystic stones. The patient was conservatively managed while in the hospital and was discharged with close outpatient follow up. The following week, she underwent a Roux-en-Y hepaticojejunostomy. She was found to have a Type 1c choledochal cyst and an abnormal pancreaticobiliary junction.

DISCUSSION:
The approach to management of patients with biliary cysts depends on the cyst type. Patients with Type I, II, or IV cysts usually undergo surgical resection of the cysts due to the significant risk of malignancy, provided they are good surgical candidates. Type I and IV cysts should be completely resected with creation of a Roux-en-Y hepaticojejunostomy. The presence of an abnormal pancreaticobiliary junction (APBJ) increases the risk of malignancy, especially gallbladder cancer. Our patient had already had a cholecystectomy as a child. Patient continued to do well post-operatively without recurrence of her symptoms.
3039 Esophageal Ulcers: A Presenting Symptom of Acute HIV Infection
Authors: George Rollin , Ketwaroo Gyanprakash Avinash , Verstovsek Gordana 
Published: October 2019

INTRODUCTION:
Dysphagia and odynophagia are commonly encountered in patients who are immunocompromised from chronic Human Immunodeficiency Virus (HIV) infection. Acute HIV infection can also cause odynophagia due to abrupt onset of oropharyngeal mucosal disease. We describe the eventual diagnosis of acute HIV infection in a patient presenting with dysphagia and odynophagia following endoscopic finding of esophageal ulceration.

CASE DESCRIPTION/METHODS:
A 43-year-old man presented with one week of epigastric pain, dysphagia, and odynophagia in the setting of recent fever (TMax 102.8F) and chills. He had intermittently taken a PPI following an emergency room visit the previous week. Oropharyngeal exam was negative for ulcers or thrush and abdominal exam was benign. Initial labs were normal aside from mild leukopenia (WBC 3,100/uL) with a low absolute neutrophil count. He underwent EGD showing several deep distal esophageal ulcers. Pathology showed acute esophagitis with mild to severe neutrophilic infiltrate and neutrophilic microabscesses. Staining of the ulcer biopsy specimens was negative for cytomegalovirus (CMV), herpes simplex virus (HSV) and fungal elements. The unknown etiology of his esophageal ulcers prompted testing for HIV. HIV immunoassay was positive however antibody differentiation was indeterminate. A subsequent HIV viral load was positive indicating acute HIV-1 infection. He was placed on anti-retroviral therapy soon after. A repeat EGD was performed three months later, demonstrating complete resolution of the previously seen ulcers.

DISCUSSION:
Presenting signs and symptoms of acute symptomatic HIV infection are nonspecific and the diagnosis is often missed or delayed. Esophageal ulceration may be underrecognized as an acute manifestation of illness. In one study of 16 men presenting with odynophagia who were eventually found to have acute HIV infection (HIV serology negative at presentation), all 16 were found to have esophageal ulceration during index endoscopy. Identification of viral particles resembling HIV-1 within ulcer biopsies with electron microscopy and isolation of HIV-1 from an ulcer biopsy specimen raise the possibility of direct viral infection of esophageal cells. With this in mind, endoscopists and gastroenterology providers should have a high index of suspicion for acute HIV infection in patients with odynophagia secondary to esophageal ulcer of unknown etiology.
3042 It's Appendagitis, Not Appendicitis!
Authors: Khan Zarak H. , Korpole Pranay R. , Jarodiya Vijay , Singh Tejveer , Wolok Ryan 
Published: October 2019

INTRODUCTION:
Epiploic appendages are small peritoneal fat pouches located around the colon. There are no specific etiologic factors leading to EA. Because this disorder involves the sigmoid colon, descending colon, and cecum, symptoms often imitate diverticulitis and appendicitis. Although they are found spread all over the serosal surface of the colon, they are much more abundant and larger on the sigmoid and transverse colon walls. Two retrospective studies reported that men (70%) were affected more than women with an age range of 26 to 75 years.

CASE DESCRIPTION/METHODS:
66-year-old gentleman with past medical history of hypertension, type 2 diabetes mellitus and hyperlipidemia presented to the outpatient clinic with 1 day history of right lower quadrant pain. Pain was gradual in onset, 6/10 in intensity, throbbing in quality, non-radiating and associated with some nausea and four episodes of non-bloody vomiting. He denied fever, chills, back pain, bloating, hematochezia, constipation, diarrhea or heartburn. Lab work that was done was complete blood count, comprehensive metabolic panel, lipase, and urinalysis which showed a white blood cell count of 11,100 with 9,210 neutrophils but was otherwise unremarkable. CT scan of the abdomen and pelvis demonstrated epiploic appendagitis involving the sigmoid colon. Patient was advised to continue diet and over-the-counter painkillers as analgesia. Patient's symptoms resolved in the next 2 days and he was back to baseline.

DISCUSSION:
Epiploic appendagitis has been reported in 2-7% of patients with a presumed clinical diagnosis of acute diverticulitis and 0.3-1% of those suspected of having acute appendicitis. Owing to the nonspecific nature of presenting symptoms, physical signs, and laboratory findings, it is extremely difficult to make the correct diagnosis before radiological investigations. Therefore the vast majority of cases are detected incidentally on CT scans while ruling out other intra-abdominal pathologies. CT scan is the gold standard of diagnosis. Our case report is meant to shed light on the diagnosis and management of the condition. It requires only conservative management. Therefore physicians should keep in mind to avoid unnecessary hospitalizations, antibiotic use and surgical interventions. Nevertheless, more common and serious pathological conditions that necessitate urgent surgical or medical interventions should always be ruled out.
3044 Malignant Non-Hodgkin Lymphoma Presenting Only in the Sigmoid Colon as Suspicious Mass
Authors: Pacha Faris , Skrove Jamie L. , Mohan Karthik 
Published: October 2019

INTRODUCTION:
Non-Hodgkin Lymphoma (NHL) is defined as a myriad of malignant neoplasms derived from B, T, Mature B, Mature T, and NK cells. The clinical presentation of NHL varies depending of the type and the areas of involvement. Most typical can be classified into aggressive and indolent. Aggressive present acutely with a rapidly growing mass and systemic B symptoms. These include diffuse large B cell lymphoma, Burkitt lymphoma, precursor B and T lymphoblastic leukemia,/lymphoma, and Adult T cell leukemia-lymphoma. Indolent lymphomas are more insidious in nature and are slower in growth. They demonstrate slow growing hepatomegaly, splenomegaly, or cytopenias. Examples of lymphomas that typically have indolent presentations include follicular lymphoma, chronic lymphocytic leukemia/small lymphocytic lymphoma, and splenic marginal zone lymphoma. Gastrointestinal Lymphoma presents with anorexia, weight loss, nausea and vomiting. Some patients can present with GI hemorrhage and early satiety along with the mentioned symptoms listed above.

CASE DESCRIPTION/METHODS:
Patient is a 52 year old Hispanic woman presented outpatient for several days of diarrhea and bright red blood in the bowl. Outpatient imaging with contrast showed a soft tissue density in the left lower quadrant demonstrating inflammatory changes. Patient had no family history of CRC, other CA's or hereditary disorders. Labs demonstrated microcytic anemia and Hgb of nine. The patient received a flexible sigmoidoscopy and “25 cm from the anal verge demonstrated a large abscess appearing mass in the sigmoid colon attributable to diverticulitis.” Antibiotics were administered followed by a colonoscopy in three months. Colonoscopy demonstrated “Abscess formation 25 cm from anal verge larger than previously noted on flexible sigmoidoscopy and multiple biopsies taken and sent to pathology.” Pathology revealed “monotonous atypical infiltrate with ulceration and necrosis highly suspicious for a malignant non-Hodkin Lymphoma.” The patient was then referred to oncology and oncological surgery.

DISCUSSION:
This case was chosen because cases in NHL are majority male (5 to1), found on the right side of the colon (70-75% in the cecum vs 1.2-5% in the Sigmoid colon), and have B-symptoms. In our patient she had no B-symptoms and the primary presentation was in the sigmoid colon. Also, the NHL to be intramural accounts for less than 4% of all extranodal NHL. Primary site for NHL in the colon accounts for less than 1% of all acute NHL.
3049 Mantle Cell Lymphoma in Routine Screening Colonoscopy
Authors: Vuong Stephanie , Sotiriadis John 
Published: October 2019

INTRODUCTION:
The incidence of colorectal cancer has been on the rise in young and middle aged adults in the United States. While adenocarcinoma remains the most common type of colorectal cancer, lymphoma, particularly mantle cell lymphoma (MCL) is a rare type of lymphoma that can occur in those between the ages of 35-85. We present a case of MCL seen during routine colonoscopy.

CASE DESCRIPTION/METHODS:
A 51 year old male with recent diagnosis of MCL by oncology was referred to gastroenterology for a screening colonoscopy. During the procedure innumerable large polypoid lesions were visualized in the cecum and ascending colon with similar findings scattered throughout the colon. Biopsies taken from the ascending colon revealed dense atypical lymphoid proliferation with immunohistochemistry confirming MCL.

DISCUSSION:
MCL comprises about 7% of non-Hodgkin lymphomas. Extranodal manifestations of MCL occurs in 25% of those that are newly diagnosed, with GI involvement estimated to be 15-60%. At the time of diagnosis, most patients present in the advanced stages of MCL. It is associated with poor long term survival and high relapse rates. However, recent advances in potential new therapies for MCL have shown promise. Our case is unusual in that the typical signs of intestinal malaise (abdominal pain, diarrhea, anorexia, and hematochezia) and/or systemic B symptoms were not present. With remission rates being dismal, and treatment strategies based on patient fitness and symptoms, early detection is imperative. It is important to be cognizant to the complaints patients have as it may warrant earlier colonoscopy and therefore diagnosis of colorectal cancer.
3050 Case of Vanishing Colonic Mass
Authors: Davis Nathan , Goyal Abhinav , Govil Yogesh , Zavala Stacey 
Published: October 2019

INTRODUCTION:
We present a case of left sided colonic mass as a finding of colonic ischemia.

CASE DESCRIPTION/METHODS:
A 58 year old female with a past medical history of multiple sclerosis (MS) requiring tracheostomy and gastrostomy tube, non-verbal at baseline, seizure disorder, and constipation presented to the emergency room for one day of maroon stools as reported by her caretaker. On arrival, the patient was on hemodynamically stable. Physical examination revealed a slightly distended, but non-tender and non-tense abdomen with intact PEG tube site. Maroon stool was present on rectal exam. Her labs revealed a hemoglobin of 10.1 g/dL, platelets 301 × 103/mcL, BUN 14 mg/dL, Creatinine 0.3 mg/dL, and lactic acid 0.87 mmol/L. Computed tomography of the abdomen showed distal colonic distension up to 7.9 cm, a large stool burden resulting in fecal impaction throughout the distal colon and an area of focal narrowing in the sigmoid colon. The patient was admitted and given four liters of polyethylene glycol, one bottle of magnesium citrate solution, and tap water enema for bowel preparation. She continued to have maroon stools with a decrease in hemoglobin from 11.1 g/dL to 9.1 g/dL. A diagnostic colonoscopy was then performed which could only be completed to the hepatic flexure due to redundant colon. Upon withdrawal, a 6 cm partially obstructing mass was noted in descending colon which was biopsied the colon proximal and distal to it was tattooed with carbon black. Pathology showed acute inflammatory cellular debris, fibrin and blood. Given the inconclusive biopsies, a flexible sigmoidoscopy was done two days after the colonoscopy. The previously seen mass was not visualized. The site had an ulcerated lesion with granular, erythematous mucosa. Biopsies were obtained from edges as well as center of this lesion. Histology revealed ulcerated colonic mucosa, granulomatous tissue, fibrin and acute inflammatory cellular debris raising the possibility of ischemia. The patient remained stable without further bleeding and was safely discharged to her nursing facility.

DISCUSSION:
We believe the initial mass like lesion was rather a large clot which subsequently got sloughed off permitting visualization of underlying mucosa. This is a very rare finding. A few case reports and case series have described cases of colonic ischemia presenting as masses but mostly in the right colon. We present the first case of this finding in the left colon. This case provides an important differential diagnosis for colonic mass.
3052 Colonic Polyp Found on Capsule Endoscopy After a Normal Colonoscopy: A Case Report and Literature Review
Authors: Nagirimadugu Ankita , Herman Michael , Bsrat Makda , Weisberg Ilan 
Published: October 2019

INTRODUCTION:
Video capsule endoscopy (VCE) is a vital diagnostic tool in detecting occult gastrointestinal bleeding but has limited use in detecting colonic polyps due to low sensitivity and specificity. We present a case of a missed colonic polyp by colonoscopy that was detected with capsule endoscopy.

CASE DESCRIPTION/METHODS:
A 50-year-old man with an extensive cardiac history on systemic anticoagulation presented with symptomatic anemia, intermittent melena, and labs consistent with blood loss anemia. He underwent an endoscopy and colonoscopy in July 2018 and a push enteroscopy in February 2019 due to persistent symptoms, which were all normal and did not identify the etiology of obscure GI blood loss. Given the unresolved symptomatic anemia, the patient underwent VCE that did not identify any etiologies of small bowel bleeding, however, it did show a medium to large sized sessile polyp in the colon that not appreciated on colonoscopy eight months earlier.

DISCUSSION:
A head to head comparison of colonoscopy and VCE has shown that VCE's sensitivity and specificity for detecting adenomas 6 mm or larger are 64% and 84%, respectively. In fair or poorly prepped colons, VCE sensitivity and specificity for detecting adenomas 6 mm or larger dropped to 44% and 81%, making VCE an inferior choice for colon polyp detection. While colonoscopy remains the gold standard for colorectal cancer surveillance, the potential for missed polyps exists. In a recent tandem study with same-day consecutive colonoscopies, the adenoma miss rate was 24.1%. However, advanced adenomas and carcinoma miss rate was lower and significantly dropped to 1.2% and 0%, respectively. Right-sided, sessile, small adenomas were more likely to be missed than left-sided, pedunculated, large adenomas. Additionally, findings greater than two polyps were also associated with an increased missed rate. Current proposed methods for increasing adenoma detection rate include increased withdrawal time, multiple observers, and enhanced imaging modalities such as narrow band imaging. In this case, VCE identified a polyp not seen on colonoscopy from eight months prior. Although VCE currently does not meet the standards of a colorectal cancer screening, VCE's minimally invasive nature, lack of sedation and patient preference warrants continued work to define its role in the cancer-screening algorithm.
3057 Unusual Presentation of MRSA Colitis Complicated With Acute Appendicitis
Authors: Estifan Elias , Nanavati Sushant , Kumar Vinod , Komal Fnu , Vora Aarohi , Agnelli Michael 
Published: October 2019

INTRODUCTION:
Clostridium difficile colitis has been the most aware bacterial enterocolitis for years and other bacteria been relegated such as Staphylococcus colitis. Staphylococcus enterocolitis following antibiotics had been one of the most frequent complications in surgical patients in 1950s and 1960s and now reappear with more resistance such as Methicillin-Resistant Staphylococcus Aureus (MRSA) colitis which brings a new challenge.

CASE DESCRIPTION/METHODS:
A 32-year-old Hispanic female with a history of Type I Diabetes Mellitus presenting with altered sensorium and a 2-day history of watery, non-bloody diarrhea, intractable emesis and diffuse crampy abdominal pain. About a month before the presentation, the patient had a soft-tissue laceration on left foot requiring a 7-day course of Cephalexin and Clindamycin that healed appropriately. On physical exam, she was tachycardic with HR of 110 bpm and tachypneic with RR of 28, somnolent but arousable with GCS >12. The abdomen was soft, tender diffusely to palpation without rebound or guarding. On the biochemical analysis, her blood glucose was 968 mg/dL with anion-gap metabolic acidosis (AG 46). In the ICU, she initiated on IV fluids, insulin and IV antibiotics for suspicion of colitis. C. diff testing was negative, but stool cultures grew MRSA for which she was started on Vancomycin and TMP-SMX. Due to continued abdominal pain on antibiotics, CT-Abdomen with Contrast showed acute appendicitis with inflammatory debris and without perforation or abscess (Figure 1) requiring laparoscopic appendectomy.

DISCUSSION:
Although Staphylococcal species are known to cause of antibiotic-associated colitis, MRSA colitis cases are unique and can pose a challenge in treatment if not ruled out and managed. When patients present with watery diarrhea, it is common to order C. diff testing, and stool culture is delayed or performed in an inappropriate time manner resulting in inconclusive cultures. Our case presented with DKA, which complicates the etiology of abdominal pain on admission for the clinician masking MRSA colitis associated with a rare complication of appendicitis double challenge and difficult to diagnose as most DKA patients present with abdominal pain. Oral Vancomycin is the treatment of choice, but our patient required coverage with TMP-SMX that proves to be effective double coverage. There were no case reports previously presenting with DKA or complication of acute appendicitis, which provides a learning opportunity in varied presentations.