bluuebunny/crossref_metadata_2025_split huggingface dataset:
1944 BRTO for Treatment of Persistent Gastric Variceal Bleed in a Patient With HCC
Authors: Villavicencio Jaimy , Guerrero Daniela , Elkhattib Ismail 
Published: October 2019

INTRODUCTION:
Gastric varices are often associated with formation of spontaneous left-sided porto-systemic shunts, which arise to relieve portal hypertension or bypass obstruction. Gastro-renal shunts are the most common (80%), followed by gastro-caval shunts. Balloon Retrograde Transvenous Obliteration remains one of the primary measures to prevent re-bleeding from gastric varices. This procedure consists of inserting a balloon into the outflow vein of a shunt, allowing injection of a sclerosant for occlusion. It has the advantage of not diverting blood to bypass the liver, but it can worsen portal pressure and increase risk for ascites or esophageal variceal bleeding.

CASE DESCRIPTION/METHODS:
67-year-old male with past medical history of untreated Hepatitis C was admitted after syncope. He also had nausea, lightheadedness and hematemesis. In the ED, his blood pressure was stable with an Hb of 9.5 mg/dL. Ceftriaxone, an octreotide drip and PPI were promptly started. 3 units of blood were transfused. Urgent endoscopy did not reveal esophageal varices, but profuse active bleeding in the fundus was seen. Attempts to control the hemorrhage were ineffective due to lack of visibility. CT scan of the abdomen showed a cirrhotic liver with a 6 cm mass in the right lobe and a large gastric varix with a gastrorenal shunt. Importantly, there was no evidence of portal or splenic vein thrombosis. Left-sided TIPS was tried, but attempts to pass from left portal vein to left hepatic vein were futile due to challenging anatomy. After multiple transfusions the patient eventually underwent successful BRTO. He had no further bleeding and was ultimately diagnosed with HCC.

DISCUSSION:
BRTO is indicated primarily for prevention of recurrent gastric variceal bleeding. It is useful in patients with elevated MELD score, right-sided heart failure or hepatic encephalopathy, who are at high risk for TIPS. Patients with gastric variceal bleeding and concomitant HCC usually have more advanced cirrhosis and lower possibility of HCC treatment. This is due to bleeding-related hepatic decompensation and overall poorer liver functional reserve. Although BRTO has its disadvantages, its ability to divert blood flow towards the liver is thought to possibly preserve hepatic function. This might make patients with HCC and gastric varices good candidates for BRTO, allowing better possibility for treatment and increased survival. Further long-term studies are needed to evaluate prognosis and complications of BRTO in these patients.
1951 Not All Diverticular Bleeds Are Colonic: A Rare Case of Zenker's Diverticulum Bleeding and Endoscopic Treatment
Authors: Henry George , Allawy Allawy , Matherly Scott , Vachhani Ravi 
Published: October 2019

INTRODUCTION:
Zenker's diverticulum (ZD) is a retropharyngeal pouch formed with herniation through Killian’s triangle. The diverticulum is thought to be developed through traction & pulsion but precise mechanism is unknown. Prevalence estimated to be 0.01–0.11%; ZD is predominantly in adults age >60. ZD is associated with dysphagia, halitosis, regurgitation & cough. But very rarely associated with bleeding - only 7 cases reported in the literature. Aspirin irritation is theorized as the etiology, as all reported cases involved aspirin or other anti-platelet medication.

CASE DESCRIPTION/METHODS:
A 73 year-old male with history of obesity, GERD, former smoker, & coronary artery disease presented with hematemesis & hemoptysis. 1 week prior to onset of bleeding, he was hospitalized for STEMI requiring intubation which was traumatic with minor bleeding, & he underwent drug eluting stent placement to the left anterior descending artery. He was discharged home on aspirin & clopidogrel. Patient had awakened due to the sensation of liquid pooling in the back of his throat; he cleared this with a cough & noted the liquid to be gross blood. He then had ongoing small volume hemoptysis & hematemesis. He denied dysphagia, NSAID usage & breakthrough reflux symptoms on daily PPI. On exam, tachycardic to 120s, otherwise vitals normal; diaphoretic & pale but otherwise benign exam. Patient’s hemoglobin had decreased from 13.3 g/dL at discharge to 8.7 g/dL in the ER; also notable for blood urea nitrogen of 45 mg/dL. ENT evaluated initially due to complaint of hemoptysis & recent traumatic intubation. Laryngoscopy revealed blood pooling at the esophageal inlet; this could be cleared voluntarily by patient, but it immediately reaccumulated. Otherwise the oropharyngeal exam was normal. EGD was subsequently performed & this revealed large ZD which was filled with fresh blood. This area was lavaged & small ulcer seen at base; multiple clips were placed with successful hemostasis. Further exam of esophagus, stomach & proximal duodenum revealed no additional source. Patient’s bleeding stopped & tolerated resumption of aspirin & clopidogrel without further incident.

DISCUSSION:
ZD bleeding is an extremely rare event, so treatment modalities may not be readily familiar to most medical staff. We report the third case of ZD bleeding treated with endoscopic hemostasis; all cases have been successful & well tolerated. Traditionally, ZD bleeding has been treated surgically, but this may not be an option in certain populations or situations.
1961 Everolimus-Associated Gastric Antral Vascular Ectasia in a Patient With Advanced Breast Carcinoma
Authors: Richardson Elizabeth B. , Chen Vida , Kaufman Adam B. 
Published: October 2019

INTRODUCTION:
Targeted cancer therapies have led to improvement in survival time and quality of life for patients with various cancer types, including advanced breast cancer. Everolimus is a mammalian target of rapamycin (mTOR) inhibitor approved for use in combination with exemestane for advanced hormone-receptor positive, HER2-negative breast cancer in post-menopausal women. While typically well-tolerated, a few cases of upper gastrointestinal bleeding from gastric antral vascular ectasia (GAVE) associated with everolimus have been described, primarily in oncology literature. In our patient, we present a case of gastrointestinal bleeding due to GAVE during treatment with everolimus. Given the clinical consequences of this adverse effect, gastroenterologists must maintain awareness of the associated risk of gastrointestinal hemorrhage and approach to treatment in patients treated with this agent.

CASE DESCRIPTION/METHODS:
Our patient is a 64-year-old female with stage III left breast invasive ductal carcinoma (HER2-negative, estrogen receptor positive, progesterone receptor positive). She underwent left lumpectomy, adjuvant doxorubicin and cyclophosphamide, paclitaxel, and radiation. Follow-up revealed bony metastases and right upper lobe pulmonary metastatic disease. She was initiated on exemestane and everolimus. Three weeks later, she presented with severe weakness and dyspnea. Rectal examination with dark hemoccult positive stools. Laboratory findings revealed Hgb of 6.0 g/dL. An upper endoscopy showed no source of bleeding. The patient responded to blood transfusions and Hgb stabilized. One month later, the patient represented with symptomatic anemia. A repeat upper endoscopy revealed blood with diffuse gastric antral oozing consistent with GAVE. She was treated with argon plasma coagulation (APC), and everolimus was discontinued. The patient stabilized after endoscopic therapy and was discharged after recovery.

DISCUSSION:
Gastrointestinal bleeding due to GAVE while undergoing treatment with everolimus is an uncommon event with an unknown mechanism. Review of current literature shows that few similar cases have been previously reported. Our patient responded well to therapy with APC. However, progression to life-threatening bleeding with poor response to endoscopic therapy has been described. As use of everolimus increases, we are more likely to encounter gastrointestinal bleeding due to GAVE. Clinicians should remain alert to the risk of severe bleeding and the utility of APC in these patients.
1966 Jejunal Submucosal Hemangioma as a Cause of Massive Gastrointestinal Bleeding: A Case Report
Authors: Numan Laith , Elkafrawy Ahmed A. , Tomaw Andrew , Campbell Donald R. 
Published: October 2019

INTRODUCTION:
Small intestinal hemangiomas are uncommon tumors that usually present with gastrointestinal bleeding (GIB). Hemangiomas account for only 0.05% of all intestinal tumors. The most common location in the small intestine is the mid-jejunum. Diagnosis, detection, and treatment can be challenging and may require surgery.

CASE DESCRIPTION/METHODS:
An 81-year-old female presented to the emergency department with a one-week history of melena, associated with fatigue and palpitations. She denied hematemesis, hematochezia, NSAIDs use, or the use of anticoagulants or antiplatelet agents. Her vital signs were stable, and her physical examination was unremarkable except for lower limb edema. Hemoglobin was 4.7 g/dl, which was lower than her baseline of 8 g/dl. The patient was transfused to maintain her hemoglobin above 7 g/dl, and a proton pump inhibitor infusion was initiated. Esophagogastroduodenoscopy was performed, and benign-appearing and non-bleeding polyps were detected in the gastric fundus and body. Colonoscopy did not detect significant abnormalities other than moderate diverticulosis, internal hemorrhoids and old melenic liquid throughout the colon but no active bleeding. Due to continued blood transfusion requirements, a video capsule endoscopy was performed, and active bleeding was detected. Push enteroscopy was performed, and a polypoid nodule with central umbilication and red spot was detected in the proximal jejunum [Figure 1]. The lesion was biopsied, and post-biopsy bleeding developed. Hemostasis was achieved by injection of epinephrine (1:10000 concentration) and application of three hemoclips. Subsequently, the patient underwent a laparoscopic segmental jejunal resection. Histologic examination of the resected specimen demonstrated a jejunal submucosal hemangioma with surrounding hemorrhage, an organizing hematoma, and no evidence of dysplasia or malignancy.

DISCUSSION:
Submucosal hemangiomas are a rare cause of GIB. They can present with melena and severe anemia. As the most common site is mid-jejunum, it is difficult to detect submucosal hemangiomas. In this case, the lesion was detected by video capsule endoscopy and was reached by push enteroscopy. Surgery is usually required for a definitive diagnosis and definitive treatment.
1969 Splenic Artery Pseudoaneurysm Presenting as GI Bleed: A Diagnostic Conundrum
Authors: Zahir Fathima Z. , Mehta Amit , Wan David 
Published: October 2019

INTRODUCTION:
The splenic artery is a common site of visceral artery pseudoaneurysms following the aorta and iliac arteries. It is a rare complication of pancreatitis (52% of cases), abdominal trauma, post-op complications and peptic ulcer disease. This report discusses a patient with recurrent pancreatitis, admitted for upper GI bleed who was found to have a SAP.

CASE DESCRIPTION/METHODS:
A 25-year-old man with history of recurrent pancreatitis complicated by pseudocyst status post cyst-gastrostomy, presents with 1 week of fatigue, dyspnea and a sensation of “fluids sloshing around” in his abdomen. He noted dark black stools, and had an episode of hematemesis. There was no blood per rectum. Hemoglobin was 6.5 and he was poorly responsive to transfusions. A CTAP revealed a 10 × 4 × 7 mm pseudoaneurysm arising off the proximal splenic artery without active arterial bleed. He was thought to have a brisk upper GI bleed, right-sided colonic bleed or a fistula between the GI tract and splenic artery. An EGD was aborted as it revealed >500cc of blood in the gastric body, after which the patient underwent emergent IR coil embolization of the SAP via the femoral artery. The patient received a total of 6 units of pRBCs, 1 unit of FFP and platelets each during his hospital course. He remained hemodynamically stable off vasopressors, with repeat hemoglobin of 8.

DISCUSSION:
Recurrent pancreatitis causes enzymatic digestion of the splenic arterial wall, leading to elastic tissue fragmentation, resulting in SAP formation. It is also hypothesized that a long-standing pseudocyst (as in the case of our patient) can induce SAP due to vascular erosion from enzymes within the pseudocyst. While ∼2.5% of cases are found incidentally, most reported cases present with abdominal pain, GI bleed, hemosuccus pancreaticus and hematemesis. A patient with recurrent pancreatitis presenting with persistent anemia or GI bleed without obvious explanation should be managed with a high clinical index of suspicion for SAP. SAPs carry a 35% risk of rupture, and must be promptly managed due to mortality rates reaching 90% if left untreated. While it is challenging to diagnose SAP that presents as GI bleed, the patient’s history of recurrent pancreatitis increases the likelihood of SAP. Once the SAP is detected via imaging, the exact location, size and risk of rupture must be communicated to perform the correct form of treatment, with an aim to prevent life-threatening bleeds, and preferably preserve the spleen for its immunologic functions.
1975 Not Your Typical GI Bleeding: Gastrointestinal Involvement in Systemic Amyloidosis
Authors: Zhang Danmei , Buffie Charlie , Martin Tracey , Wan David 
Published: October 2019

INTRODUCTION:
Systemic amyloidosis is a rare disease that occurs preeminently in the elderly and can affect different kind of organ systems depending on the locality of amyloid build-up. Most typically fibril formation causes damage to the kidney and heart. Here, we report the case of a man with systemic amyloidosis and sudden onset of Hematochezia.

CASE DESCRIPTION/METHODS:
A 90 y/o male with a history of chronic heart failure due to amyloidosis of unknown origin, CAD, AFib, HTN, HLD, OSAS, peripheral vascular disease, CKD and diverticulosis presented to the ED with one episode of bright red blood per rectum and microcytic anemia. On arrival patient did not have any abdominal pain, nausea, vomiting, or diarrhea. He continued to have several bloody episodes. Rectal exam showed bright red blood with clot and hard brown Bristol 1 stool balls without blood. Initial work up including CBC, CMP, and coags was notable for Hb 9.7 g/dl, Plts 137 × 10(3)/uL, Troponin 0.19 ng/mL, PT 36.6s, and INR 2.8. The patient received IV fluids and 3 units of RBCs, blood thinners and anti-platelet medication were held, and patient was prepped for colonoscopy. Endoscopy showed diffuse, friable, patchy, hemorrhagic mucosa in the transverse colon, hepatic flexure, ascending colon, and cecum, consistent with amyloid. Diverticulosis was confirmed with no evidence of active bleeding. No endoscopic interventions were performed given minimal benefit and risk of high rebleeding.

DISCUSSION:
There are about 30 different types of amyloidosis with a varying spectrum of clinical presentation.[i] In a retrospective study 3% of patients with amyloidosis had biopsy proven involvement in the GI tract.[ii] Intestinal involvement usually presents clinically with either GI bleeding, malabsorption, protein-losing gastro-enteropathy, or chronic gastrointestinal dysmotility. Given his cardiac and abdominal history and presentation with lower GI bleeding differential diagnosis were initially drawn to diverticular bleeding versus ischemic colitis. In this case, the colonoscopy results and pre-condition of amyloidosis were attributed to be the cause of hematochezia. Biopsies were not collected given bleeding risk and low impact on further management.
1976 It's a Bloody Tumor: A Case of Rare Neuroendocrine Tumor Presenting as Rectal Bleeding
Authors: McDonald Emmanuel , Trejoss Marisol , Choi David , Frontela Odayls , Gonzalez Felix 
Published: October 2019

INTRODUCTION:
Gastroenteropancreatic Neuroendocrine tumors (GEP-NETs) refer to a group of heterogeneous neoplasms arising from neuroendocrine cells of the embryological gut. Rectal NETs are rare and often discovered during routine colonoscopy screening. They are often incidental findings since 50% of cases present as asymptomatic. When symptomatic with rectal bleeding, bowel habits changes, weight loss, and even pain, patients often are in an advanced stage of the disease. The advances in routine endoscopic screening processes have increased the incidence and prevalence of rectal NETs over the course of the years. Rectal NETs have varied developmental processes, clinical presentations, and due to the lack of epidemiological research, risk factors are not well known. While routine screening has allowed for earlier detection of colorectal NETs, histology-specific management has not yet been established and the role of surgery has been questioned.

CASE DESCRIPTION/METHODS:
We present a case of a 67 year old male with PMHx of HTN, CAD, DM, and treated prostate cancer who presents to the outpatient clinic with three months of bloody bowel movements. He reported never having blood in his stool previously, and having about two to three normal bowel movements daily. Abdominal CT scan revealed a 1.5 cm extramural mass extending into the rectal fossa. He underwent flex sigmoidoscopy that revealed a large flat ulcerated mass which pathology confirmed as a neuroendocrine neoplasm of the rectum. Patient was referred to oncology and surgery for transanal resection.

DISCUSSION:
The incidence of NETs of the rectum has increased about ten-fold over the past 30 years and represent 29% of all GEP-NETs. Despite the increase in incidental findings attributed widely to the higher endoscopy screening rates, rectal NETs continue to be rare worldwide. Studies suggest genetics may be one predisposing factor as it is more commonly found in African Americans, Hispanic, and Asian populations. Due to the rarity of rectal NETs, there is a dearth of knowledge to the risk factors for disease. While new screening guidelines have allowed for earlier incidental findings for colorectal pathologies, there is yet to be a modified screening protocol. Because rectal NET can be indolent and has potential metastasize, there is an emphasis on timing of detection. This case study highlights the potential need to further study, modify and incorporate known risk factors to improve diagnostics and screening for rectal cancer.
1997 Isolated Duodenal Melanoma: A Rare Cause of Gastrointestinal Bleed
Authors: Shafiq Muhammad , Ullah Waqas , Rashid Mamoon Ur , Zafar Yousaf , Mehmood Asif 
Published: October 2019

INTRODUCTION:
Melanomas are known to be the worst dermatologist nightmare, being notorious due its widespread metastasis and recurrence. They can present with any symptom based on the involvement of the organ but it is exceedingly rare for melanoma to present as an isolated duodenal mass in the absence of skin lesions.

CASE DESCRIPTION/METHODS:
A 79 years old white male, with history of coronary artery disease was admitted with exertional shortness of breath and atypical chest pain. His symptoms started over a course of few days and was associated generalised weakness and fatigue. He never had an upper gastrointestinal endoscopy done and colonoscopy two years was normal. His home medications included aspirin and beta blocker. On examination, he was tachycardia with a heart rate of 100 bpm and blood pressure was 90/60. He was afebrile but tachypneic with a respiratory rate of 22/min. Systemic examination was unremarkable except pallor and rapid thready pulse. The laboratory investigation showed a hemoglobin of 8 g/dL, MCV of 80, platelet count of 189,000/mL and white blood cell counts of 8,000/mL. Esophagogastric duodenoscopy (EGD) was performed on the second hospital day which revealed a duodenal nodule. Biopsy was obtained from the lesion, no signs of active bleeding was observed. The biopsy was positive for metastatic melanoma. Immunohistochemical stains on parts A and B revealed the tumor cells to be positive for S100 and SOX10, and negative for synaptophysin, panCK, c-kit, and Dog 1.(Figure 1) Patient’s whole body was scanned but it did not show any other melanoma lesion and there was no primary melanoma on the skin either. Helicobacter pylori stains, performed on the gastric and duodenal biopsies, were negative. He was managed conservatively with pantoprazole 40 mg and regular follow up as patient refused surgery.

DISCUSSION:
It is exceedingly rare to have isolated duodenal melanoma in the absence of skin lesions and physicians should keep a high index of suspicion for these rare cases. Local resection of the mucosal melanoma (including in stomach and small intestine), with negative margins, should be considered first line treatment in patients without distant metastasis while conservative management with surveillance in patients can be considered in selected cases.
2017 An Uncommon Etiology for Gastrointestinal Bleed in Elderly: Blue Rubber Bleb Nevus Syndrome
Authors: Chandra Chakinala Raja , Kumar Anila , Li Lanxin , Olivier Sarah , Tewari Virendra 
Published: October 2019

INTRODUCTION:
Blue rubber bleb nevus syndrome (BRBNS) is a rare congenital anomaly characterized by multiple venous malformations that can appear anywhere on the body, but most often involve the skin and gastrointestinal (GI) tract. GI bleeding usually presents in childhood or early adulthood as iron deficiency anemia. We report a case of BRBNS as a rare presentation of GI bleeding in an elderly patient with no prior history of cutaneous or GI tract involvement of the disease.

CASE DESCRIPTION/METHODS:
87-year-old man with a past medical history of hypertension, coronary artery disease and atrial fibrillation (on Xarelto) was transferred to our hospital for evaluation of melena. He presented to an outside institution initially with complaints of dizziness and black tarry stools for 5 days prior to admission. He was hypotensive, labs were significant for hemoglobin (Hgb) of 5.5 g/dL and a positive stool occult blood test. Anticoagulation was discontinued. He underwent esophagogastroduodenoscopy (EGD), which showed friable mucosa in the duodenal bulb but no active source of bleeding. He received 8 units of packed red blood cells (PRBC), but his Hgb only improved to 7 g/dL. A repeat EGD was also unrevealing. He then underwent a nuclear scan, which showed a focus of bleed in left hemi-abdomen, but it was unclear if it was from the small or large bowel. On presentation to our hospital, his Hgb was 6.6 g/dL and he continued to have melena, requiring multiple PRBC transfusions. Push endoscopy revealed diffuse discontinuous multiple vascular blebs of the mucosa in the mid jejunum (Figure 1a), one of which was found bleeding (Figure 1b). Successful hemostasis was achieved with cauterization of the bleeding bleb with argon plasma coagulation (APC) (Figure 1c,d) and a hemoclip placement 2 cm distal to the lesion. Post-procedure, his Hgb remained stable above 8 g/dL throughout the hospitalization.

DISCUSSION:
Although BRBNS lesions can occur anywhere from mouth to anus, the small bowel is the most common site of GI tract involvement. Its presentation can vary from iron deficiency anemia to massive hemorrhage, intestinal torsion, and rupture. Some patients require lifelong iron replacement and repeated blood transfusions. Push endoscopy is the most important diagnostic modality for GI lesions. Treatment depends on the severity of lesions and can range from supportive therapies such as iron supplementation and blood transfusion to more invasive therapies such as mucosal resection, APC, sclerotherapy or bowel resection.