bluuebunny/crossref_metadata_2025_split huggingface dataset:
1556 IBD Mimicker: Vascular Ehlers-Danlos Presenting as Spontaneous Bowel Perforation
Authors: Hanada Yuri , Kane Sunanda 
Published: October 2019

INTRODUCTION:
Many diseases can mimic the clinical presentation of inflammatory bowel disease (IBD). Careful history to establish an event timeline that includes symptom onset and evolution, physical exam, imaging, pathology, and endoscopy can help narrow the differential. Here, we present a case of spontaneous colonic perforation due to vascular Ehlers Danlos Syndrome (vEDS) that was initially treated as IBD.

CASE DESCRIPTION/METHODS:
A 35 year old male with past medical history of childhood retinoblastoma s/p resection and chronic constipation (unremarkable colonoscopy 3 years prior) presented to clinic for a second opinion on a recent diagnosis of IBD. He had been in his usual state of health until 6 months prior to consultation, when he developed abdominal distension, followed by diffuse abdominal pain and vomiting. CT identified a bowel transition point in the mid-abdomen with pneumoperitoneum, prompting emergent exploratory laparotomy, during which sigmoid colon perforation was identified. Notably, no diverticular disease was present near the perforation site and the operative report commented on significant friability and tearing of the mesentery and small bowel. He ultimately underwent sigmoidectomy, ileocecetomy, and colonic mucous fistula creation. A commercially available IBD panel test returned positive and the patient was treated as presumptive Crohn Disease with infliximab, as well as frequent prednisone tapers. Upon referral to our center, the surgical pathology was reviewed and acute findings consistent with perforation were noted; no chronic inflammatory changes were found on either colonic or small bowel samples. CT enterography was unremarkable with respect to the bowel; however, the study incidentally identified dissection of the right common iliac down to the proximal superficial femoral artery. The patient was referred to Clinical Genetics, with subsequent testing revealing a COL3A1 mutation, diagnostic for vEDS.

DISCUSSION:
A broad differential beyond IBD should be maintained in cases of spontaneous bowel perforation. Unexpected tissue fragility should raise the possibility of a connective tissue disorder, and genetic testing is indicated if the perforation originates from the sigmoid in particular, as this is one of the major vEDS diagnostic criteria. In gastroenterology practice, unnecessary endoscopic procedures should be avoided whenever possible, and in cases where surgery is required, experienced colorectal surgeons should be consulted.
1561 Appendiceal Colic Intussusception Due to Mucocele of Appendix: Is Appendectomy Alone Sufficient?
Authors: Patel Saumil , Ghosh Sudeshna , Jiyani Rucha , Aswani Yashant 
Published: October 2019

INTRODUCTION:
Mucocele of appendix is a rare clinical entity (0.2-0.3% of appendectomy specimens) with obstruction to drainage of mucus from the appendicular lumen. Rarely, does it manifest as bowel obstruction owing to intussusception of mucocele of appendix (0.01%). Diagnosis of mucocele or its intussusception is radiological, can't differentiate if the cause of obstruction is a benign or a malignant process.

CASE DESCRIPTION/METHODS:
A 40 year female presented with complaints of right lower quadrant pain since a few days, was dull, aching, intermittent, associated with nausea without any obvious aggravating or relieving factors and history of trauma to the abdomen or previous surgery. Abdominal examination revealed tenderness in right lower quadrant without any guarding or rigidity and lump could be felt in the same quadrant. On auscultation sluggish bowel movement. An abdominal CT: intussusception of mucocele of appendix of 4.5 × 3.1 × 2.5 cm. Open appendectomy was planned to avoid accidental spillage of contents and resected margins and regional nodes were negative for malignancy as per histopathology. The postoperative period was uneventful.

DISCUSSION:
A Mucocele of appendix (MOA) is an abnormal accumulation of mucus in appendix. A cystadenoma, mucosal hyperplasia, retention cyst or mucinous cystadenocarcinoma may be the cause of this obstruction. Multi-detector CT is imaging of choice, classic appearance of a well circumscribed, fluid-filled, distended appendix. Presence of mural calcification differentiate from appendicular abscess. Further, an intussusception of MOA has been likened to a cup & ball pattern. However, features like enhancing mural nodules within the mucocele/size >2 cm point towards a malignant cause. Definitive management is surgery, a mucocele with compromised base, >2 cm require a primary typhlectomy, otherwise a primary appendectomy suffices. Hence, open surgery is preferred over laparoscopic to prevent spillage. Positive margins and/or lymph node involvement translates into right hemicolectomy. A cystadenoma is followed up like an adenomatous polyp while follow up similar to colonic carcinoma is employed in cases of cystadenocarcinoma of appendix.
1568 Don't Skip the Retroflexion: A Case of Disseminated Anorectal Mucosal Melanoma
Authors: Chittajallu Vibhu , Simons-Linares Roberto , Oshilaja Olaronke , Chahal Prabhleen 
Published: October 2019

INTRODUCTION:
Less than 4% of melanomas are of mucosal origin with primary anorectal mucosal melanomas comprising a small subset. Mucosal melanomas are often diagnosed late due to delay in patient presentation and obscured tumor origins noting a more aggressive behavior and less favorable prognosis when compared to cutaneous melanomas. We present a case of metastatic anorectal mucosal melanoma with a negative colonoscopy 1-year prior.

CASE DESCRIPTION/METHODS:
A 68 year-old female presented to the hospital with a history of several months of intermittent fecal impaction complicated by sporadic outlet type rectal bleeding and a negative colonoscopy 1-year prior. She endorsed progressive anorexia and a 20 lb. weight loss over the last few months. She was hemodynamically stable with normal hemoglobin level. CT imaging depicted multiple lesions in the liver and lungs concerning for metastatic disease. A colonoscopy was repeated and revealed a rigid mass on rectal exam and granular nodularity with ulceration in the rectum at the dentate line on retroflexion (Figure 1). Excisional biopsy confirmed mucosal melanoma. Same session endoscopic ultrasound showed several lesions in the left lobe of the liver with FNA demonstrating malignant melanoma (Figures 2 and 3). MRI revealed primary tumor involvement of the anal canal and rectum in addition to metastases to the liver, lungs, and lymph nodes. The patient was diagnosed with T4N1M1, stage IV anorectal mucosal melanoma (BRAF/C-KIT negative) and was recommended to undergo ipilimumab and nivolumab (I3/N1) immunotherapy with palliative radiation.

DISCUSSION:
Anorectal mucosal melanomas occur infrequently, but at the time of diagnosis, are more likely to be metastatic with poor prognoses. Rectal bleeding is the most common symptom, and diagnosis is often seen in fifth to seventh decade of life. This case is a prime example of not only the aggressive nature of anorectal mucosal melanoma presenting with disseminated disease despite normal colonoscopy 1-year prior but also of the significance of the rectal exam and retroflexion maneuver during colonoscopy.
1569 Duodenocolic Fistula Presenting as Feculent Emesis: An Unfortunate Case of Aggressive Colon Adenocarcinoma in a Young Patient
Authors: Makar Ranjit , Maklad Muthena , Aziz Hamza , Lankarani Daisy S. , Saud Bipin , Jayaraj Mahendran , Wahid Shahid , Ohning Gordon 
Published: October 2019

INTRODUCTION:
Duodenocolic fistula is am extremely rare complication of colon adenocarcinoma. Patient typically present with nausea, vomiting and abdominal pain. Rarely patients can present with feculent emesis in which case diagnosis can be confirmed with imaging and endoscopic evaluation. We present an unfortunate case of duodenocolic fistula in a young patient.

CASE DESCRIPTION/METHODS:
34 yo Hispanic male presented to the Emergency room with complains of weight loss, early satiety and vomiting of brownish fluid for the past 3 days. Patient has a previous history of Cecal adenocarcinoma diagnosed at age 32 and underwent right hemicolectomy. Patient was lost to follow up and failed to follow up with oncology. Lately patient had been experiencing early satiety and family members had been complaining of halitosis. He later developed nausea and vomiting of brown color fluid concerning for fecal matter. He denied any abdominal pain and continued to have regular bowel movements. Clinical exam was significant for extreme halitosis although no signs of bowel obstruction. Initial workup was positive for microcytic anemia. CT abdomen revealed 5.1 × 4.8 cm thick walled circumscribed fluid collection contiguous with the descending portion of the duodenum communicating with the adjacent colon near the hepatic flexure (Figure 1). Upper Endoscopic examination revealed a large ulcerated fistulous connection between the duodenal bulb and the colon along with large amount of fecal matter pouring into the stomach through the fistulous connection (Figures 2 and 3). Ulcer edge biopsy confirmed recurrence of colon adenocarcinoma. Patient subsequently underwent whipple's procedure with resection of the previous ileocolic anastomosis and creation of a new ileocolic anastomosis. Testing for DNA mismatch repair gene by immunohistochemistry revealed loss of MSH2 & MSH6 suggestive of microsatellite instability consistent with Lynch Syndrome. Patient and family were subsequently referred for genetic counselling.

DISCUSSION:
Duodenocolic fistula is a rare presentation of colon cancer. There have been only a few case reports of colon cancer presenting as Duodenocolic fistula. Diagnosis requires a high degree of suspicion especially in patients presenting with feculent emesis, which can be confirmed with imaging and endoscopic evaluation. Successful surgical management with fistulectomy along with Whipple's procedure has shown good outcomes.
1571 A Case of CMV Colitis Seen in DRESS
Authors: Malik Anam , Vaze Reema , Buckshaw Ricky , Nellis Eric , Shah Hiral 
Published: October 2019

INTRODUCTION:
Cytomegalovirus (CMV) is a member of the family of herpes virus, which persists for life after a primary infection. It is known to cause colitis in both immunocompromised and immunocompetent hosts. This virus is prevalent in about 50%-80% of the general adult population. CMV enters a latency phase after initial infection. Reactivation can occur anywhere along the gastrointestinal tract. The colonic mucosa is the most common site of reactivation. Clinical, endoscopic, and histological appearance of CMV colitis can mimic inflammatory bowel disease. Given this circumstance is it important to avoid misdiagnosis and mismanagement of CMV colitis given high morbidity associated with it.

CASE DESCRIPTION/METHODS:
A 59-year-old female with rheumatoid arthritis on chronic steroids and recently prescribed leflunomide presented with a diffuse rash, stomatitis, eosinophilic dominant leukocytosis, and severe diarrhea. A skin biopsy confirmed the diagnosis of drug reaction with eosinophilia and systemic symptoms (DRESS). The patient's diarrhea worsened despite negative comprehensive stool panel, clostridium difficile toxin and stool ova/parasites. A CT abdomen revealed diffuse colitis, and as a result the patient underwent flexible sigmoidoscopy showing circumferential colitis with ulcerations (Figure 1). Biopsies taken from the distal colon confirmed Cytomegalovirus (CMV) by viral inclusion bodies seen on hematoxylin-eosin staining (Figure 2). The patient was initiated on IV ganciclovir, however expired after developing septic shock.

DISCUSSION:
Gastrointestinal (GI) disease caused by CMV is diagnosed on the presence of clinical symptoms, viral inclusion bodies on biopsy, and endoscopically visualized ulcers. The most common sites of CMV related GI involvement is the esophagus and colon. Biopsy with immunohistochemical testing using monoclonal antibodies against CMV is considered the gold standard (Figure 3). Owl's eye inclusion bodies on staining are highly specific for infection with CMV. The gastrointestinal tract is thought to contain latent CMV after a primary infection This case highlights the importance of recognizing the risks of long term medical treatment with immunomodulatory drugs such as leflunomide or corticosteroids, including local reactivation of a latent virus as in our patient.
1577 Right Side Ischemic Colitis or Colon Cancer: Case Reports
Authors: Bella Saif , Alom Md S. , Bank Leslie 
Published: October 2019

INTRODUCTION:
Ischemic colitis remains an enigmatic disease with a wide array of pathogenic mechanisms and variable outcome. Recent series indicate that right-sided ischemic colitis (RIC) may have a worse prognosis compared to left-sided colitis (LIC). We are presenting two interesting cases of RIC believed to be colon cancer.

CASE DESCRIPTION/METHODS:
1st case: An 82-year-old Caucasian female who has a pertinent medical history of hypertension, GERD, dyslipidemia, and gout. She presented with right lower quadrant abdominal pain. The pain was followed by a loose non-bloody bowel movement. Her symptoms were associated with tiredness, nausea, subjective fever, and chills. She had normal hemodynamics upon presentation. Her exam was benign except for RLQ fullness. Initial blood work was consistent Leukocytosis. CT scan of the abdomen and pelvis mass like thickening of the proximal right colon which was concerning for colonic neoplasm (Figure 1). CEA was within normal. Fecal calprotectin level was increased at 309. Stool studies were negative for enteric pathogens or C. difficile infection. Colonoscopy demonstrated an area of moderately congested and ulcerated mucosa in the ascending colon and cecum. These findings were suspicious for ischemic colitis. Biopsies confirmed ischemic colitis and ruled out dysplasia or malignancy. She was treated successfully with intravenous fluids, bowel rest regimen, and IV antibiotics. 2nd case: A 70-year-old male who underwent CABG for underlying CAD. Postoperatively, he complained of right lower quadrant abdominal pain. CT scan of the abdomen and pelvis showed Cecal mass concerning for colon cancer (Figure 2). Colonoscopy revealed findings consistent with ischemic colitis (Figure 3). Patient treated with IV fluid and Antibiotics. He did well. 8 months later, colonoscopy was repeated and showed complete resolution of his colitis.

DISCUSSION:
RIC differs from left-sided ischemic colitis. RIC diagnosis could be challenging. Most common reported presentations were weight loss, diarrhea, vomiting or ileus, and no rectal bleeding. We are presenting rare cases of RIC misdiagnosed initially as colon cancer.
1590 Another Case of Duloxetine-Induced Lymphocytic Colitis
Authors: Prato Marie D. , Daid Sarav , Toubia Nabil 
Published: October 2019

INTRODUCTION:
Microscopic colitis comprises two histologic subtypes; Collagenous colitis (more severe) and Lymphocytic colitis (LC). The pathogenesis is unclear but likely multifactorial with some associations to smoking and diseases with autoimmune background. Potential causative drugs have also been implicated with the most common being NSAIDS, PPI and Selective serotonin-reuptake inhibitors (SSRI). We are reporting a case of Duloxetine, a selective serotonin and norepinephrine-reuptake inhibitor (SNRI), causing LC.

CASE DESCRIPTION/METHODS:
A 49 yo F, caucasian with PMH of GERD and recent diagnosis of fibromyalgia was referred to gastroenterology clinic for diarrhea of unexplained origin for 1 month. Patient claimed diarrhea began 6 weeks after starting Duloxetine. She reported around 5 episodes of explosive watery, brown bowel movements daily with bloating. She also endorsed fatigue, dizziness and joint pains. She denied fevers, chills, blood in the stools, abdominal pain, nausea, vomiting. She denied any recent travel, new food trial, sick contact, new medications other than Duloxetine. She didn't use NSAIDs or PPI. Her other home medications were Levothyroxine and Lisinopril. Her symptoms of upper body pain, loss of energy and mood swing had improved considerably, and her rheumatologist doubled the dose of Duloxetine and the patient noted that the number of daily bowel movements increased. Physical exam showed hyperactive bowel sounds and colonoscopy revealed a completely normal colon. The pathology of the biopsy taken reported diffuse mixed colonic inflammation, marked intraepithelial lymphocytosis and focal acute cryptitis favoring lymphocytic colitis with no evidence of collagenous colitis. Infectious etiologies were ruled out. Decision was made to taper the Duloxetine, and patient was started on Loperamide. Upon follow-up visit two months later, pt reported complete resolution of the diarrhea, but recurrence of her fibromyalgia symptoms for which she was given cyclobenzaprine, which seemed to be have helped.

DISCUSSION:
Lymphocytic colitis is often insidious but sudden onset was reported in forty percent of patients. There were two other published case reports of duloxetine-associated LC, and just like this case, discontinuation of the medication resulted in prompt resolution of the diarrhea. Microscopic colitis has been associated with excessive fluid loss and malabsorption caused by the inflammation and can easily result in dehydration, dizziness and weight loss affecting quality of life.
1612 Olmesartan Enteropathy and Pancolitis
Authors: Tabbalat Aya , Curras-Martin Diana , Pittman Meredith E. , Maltz Charles 
Published: October 2019

INTRODUCTION:
Olmesartan enteropathy is a well-documented uncommon cause of diarrhea. However, olmesartan induced colitis is an under-recognized entity. We report a case of olmesartan enteropathy and colitis in a patient on olmesartan for hypertension for over a year who presented with chronic diarrhea.

CASE DESCRIPTION/METHODS:
A 69-year-old man, with history of hypertension, on olmesartan for 1.5 years presented with 5 weeks of 4-5 daily episodes of watery, non-bloody diarrhea associated with nocturnal fecal incontinence, nausea, and vomiting. He had no abdominal pain, melena, weight loss, NSAIDs use, or recent travel. Patient had had multiple admissions for dehydration, and suspected infectious etiology for which he was given empirical antibiotics without clinical improvement. On exam he was afebrile, hemodynamically stable, with unremarkable physical exam. Laboratory testing revealed WBC of 10.8 × 103/ul, hemoglobin of 14.5 g/dL, creatinine of 1.53 mg/dL, and potassium of 2.8 mEq/L. Inflammatory markers and liver function test were not elevated. Stool PCR and C. Difficiletoxin were negative, as was anti-TTG with normal IgA levels. A CT abdomen and pelvis was unrevealing. EGD revealed blunted duodenal mucosa with biopsy showing chronic enteritis with villous shortening, crypt hyperplasia, and increased intraepithelial lymphocytes (Figure 1). Colonoscopy demonstrated multiple scattered non-bleeding aphthous ulcers in the entire colon (Figure 2). Colonic pathology showed focally active colitis and intraepithelial lymphocytes without granulomas (Figure 3). Olmesartan enteropathy was suspected and the medication was discontinued. The patient’s diarrhea resolved two weeks after olmesartan was discontinued.

DISCUSSION:
Olmesartan enteropathy can manifest with diarrhea, weight loss, iron deficiency anemia, dehydration, hypokalemia, and renal insufficiency. It mimics celiac disease clinically and microscopically, with the presence of villous atrophy in the small intestine biopsy. A negative celiac disease serology helps to distinguish between these two entities. In addition, drug-induced colitis has also been reported in patients on olmesartan. The presence of lymphocytic infiltrate, preserved architecture, and absence of granuloma on colon biopsy helps differentiate this entity from IBD or infectious colitis. Symptoms of olmesartan enteropathy may develop months or years after the initiation of therapy. However, mucosal changes in small and large intestine will resolve after discontinuation of olmesartan.
1620 Pneumatosis Intestinalis Associated With Clostridium difficile Colitis in Crohn’s Disease
Authors: Abraham Ann A. 
Published: October 2019

INTRODUCTION:
Pneumatosis intestinalis (PI) or pneumatosis cystoides intestinalis is defined as the presence of extraluminal bowel gas that is confined within the bowel wall. Characterized by intramural gas in the gastrointestinal tract, PI represents an alarming radiographic sign rather than a specific diagnosis. PI is associated with a wide spectrum of underlying pathological processes such as bowel ischemia, mechanical trauma, inflammatory/autoimmune bowel disease, intestinal neoplasms, bacterial infections like C. Diff, drug-induced including immunosuppression therapy. Differentiating these causes is critical in directing an appropriate care plan and specific treatment is best directed at the underlying disease process. Described here is a case of pneumatosis intestinalis associated with Clostridium Difficile infection in the setting of Inflammatory Bowel Disease (IBD).

CASE DESCRIPTION/METHODS:
11-year-old white male with Crohn's Disease on remission on Remicade and Methotrexate, presented with severe periumbilical pain radiating to right lower quadrant associated with fever, multiple episodes of loose stools and vomiting. Denied recent travel, sick contacts or recent exposure to antibiotics. On exam he had significant right lower quadrant abdominal tenderness with no guarding or rebound. Lab data only revealed mild elevation of CRP. US abdomen showed poorly visualized appendix. Subsequent CT abdomen revealed pneumatosis of ascending colon without wall thickening. Following, he was admitted and considering his stable clinical conditions and lab assays, he was treated conservatively with IV antibiotics and bowel rest. A day later, stool studies returned positive for C. Diff toxins. He was started on oral Vancomycin. Serial abdominal X-rays revealed disappearance of PI. Patient began to show clinical improvement, tolerating feeding advances gradually over the next four days.

DISCUSSION:
IBD is a rare cause of PI. Concurrently, patients with IBD are at increased risk of developing C. Difficile infection. C. Diff infections have a different and often more severe clinical course in patients with IBD. PI patients should be carefully evaluated for possible surgery due to the risk of severe complications. However, management decisions should be made on combined clinical, lab findings and underlying etiology. As in the above case, supportive care and appropriate antibacterial agents sufficed to alleviate symptoms and resolve the pneumatosis.