bluuebunny/crossref_metadata_2025_split huggingface dataset:
3129 Management of a Massive Peptic Ulcer Bleed With Over-the-Scope Clip
Authors: Namn Yunseok , D'Souza Lionel , Guillaume Alexandra 
Published: October 2019

INTRODUCTION:
Actively bleeding ulcers located in the posterior duodenal bulb are often difficult to manage with conventional endoscopic treatment. We present a case of a successful use of over-the-scope-clip (OTSC) of a spurting artery after failing multiple standard endoscopic therapies.

CASE DESCRIPTION/METHODS:
A 60 year-old man with a history of myocardial infarction in 2014 on aspirin and plavix presented with pre-syncopal symptoms and five episodes of melena that started one day prior to admission. The patient denied prior use of anticoagulants and history of gastrointestinal bleeding. Upon presentation, his vitals were stable and initial lab values were as follows: hemoglobin 9.8 g/dL (baseline 15 g/dL), platelet count 342 K/uL, INR 1.2, and BUN 29 mg/dL. He was started on an intravenous proton pump inhibitor. An esophagogastroduodenoscopy showed multiple large cratered ulcers measuring 1-2.5 cm involving most of the duodenal bulb. There was evidence of active bleedingfrom a spurting pulsatile vessel along the posteroinferior wall at the apex of the duodenal bulbnear the sweep (Figure 1). Initial attemptsat hemostasis wereunsuccessful despite injection of 1:10,000 solution of epinephrine andthe use of thehemostatic spray. The use of a coagulation forceps was unsuccessful as well. Given the location of the vessel and mucosal friability, the lesion was not amenable to through the scope clipping. Hemostasis was finally achieved after successful placement of a 12 mm OTSC (Figure 2). In addition, the area was retreated with the remainder of the hemostatic spray (Figure 3). The patient was transferred to the medical intensive care unit where overnight, the hemoglobin decreased from 8.2 g/dL to 7.2 g/dL without overt evidence of bleeding. The patient underwent angiography which did not reveal any active extravasation and empiric coil embolization of the gastroduodenal artery was performed.

DISCUSSION:
We present a case of a massive peptic ulcer bleed that was difficult to manage with standard treatment based on the large size and posterior bulb location. OTSC is commonly used for severe recurrent bleeding but its role during the index endoscopy is still unclear. OTSC should be considered as a potential first line therapy in bleeding lesions at high risk of standard endoscopic treatment failure.
3132 Duodenal Spindle Cell Lipoma as a Rare Cause of Upper GI Bleeding
Authors: Hafiz Nazar , Pandit Sudha , Rashid Shazia , Maruvada Smita , Alexander Jonathan , Jordan Paul , Manas Kenneth J. , Morris James D. 
Published: October 2019

INTRODUCTION:
Spindle cell lipomas are benign tumors commonly seen arising from subcutaneous tissue. Incidence of duodenal lipoma as a cause of GI bleed is very rare, however spindle cell variant of duodenal lipoma has never been reported per our review. To our knowledge this is the first case of duodenal spindle cell lipoma in an atypical location presenting as upper GI bleed.

CASE DESCRIPTION/METHODS:
A 68 year old lady with medical history significant for coronary artery disease with stents and GERD came in with complaints of shortness of breath. She also complained of melena and weight loss without any hematemesis or abdominal pain. Vitals were stable. Labs remarkable for Hb 9.9, iron panel suggestive of significant iron deficiency with serum iron of 16, ferritin 17. Endoscopy showed a 5 cm non bleeding submucosal lesion with ulceration which was concerning for GIST and a possible source of chronic bleeding. Mass was not biopsied, however patient later underwent duodenal bulb lesion resection with end to end gastroduodenostomy. Pathology of intestinal resection showed duodenal mucosa with an associated spindle cell lipoma. Immunohistochemical stain of duodenal lesion was positive for S100 and CD34, and immuno-negative for remaining stains (CD117, beta-catenin, and EMA), thus consistent with spindle cell lipoma. On follow up, Hb increased and pt reported clinical improvement.

DISCUSSION:
Primary GI lymphoma is common in stomach. Small intestine and colonic lymphoma account for 9% and 1% respectively. There have been multiple reports published citing association of lymphoma in IBD patients treated with immunomodulators. Our patient had two stomas (ileostomy and colostomy). Both peristomal biopsies were positive for B cell lymphoma. Peristomal lymphoma has been rarely reported. Parnesh et al. (Case 1) reported a similar case of stomal lymphoma in a patient with history of Ulcerative Colitis. Levecq et al. (Case 2) reported a stromal lymphoma in a patient with transfusion related AIDS who underwent total colectomy and ileostomy for indeterminate colitis. The lymphoma was diagnosed at 20 years (case 1) and 2 years (Case 2) post-stoma formation. Lymphoma should be in the differential of stoma being complicated by peristomal tissue proliferation, fistula and infection.
3134 Rare Complication of Delayed Bleeding After Polypectomy
Authors: Truscello David , Torres Justin , Shah Maulik , Weston Joshua , Blair Brian 
Published: October 2019

INTRODUCTION:
Colonoscopic polypectomies have been the mainstay in polyp removal since the 1970s and are associated with a much better morbidity and mortality than surgery. However, clinically evident bleeding can occur in 0.2-1.0% of cases. Herein lies a case report of postpolypectomy bleeding following a routine esophagogastroduodenoscopy and colonoscopy. We also discuss the risk factors and management of these patients.

CASE DESCRIPTION/METHODS:
Patient is a 77 year old male who present to the Emergency Department from home after an elective EGD and colonoscopy earlier that day. The patient was found to have a deep antral polyp and required cautery. A sigmoid polyp was also found, and was removed. After the elective procedure earlier in the day, the patient denied any signs overt bleeding. However, upon returning home he felt very weak. The patient had a bloody bowel movement at home and became pale and diaphoretic. Patient was taken to Emergency Department and found to be hypotensive at 60/40 mmHg and had a witnessed episode of hematemesis. Hemoglobin on admission was 8.0 g/dL. Protonix drip was started yet despite a 1L bolus of saline and 2 units of RBCs in ED, patient remained unstable. His AIMS65 score was 3 which was indicative of a 10.3% mortality. Patient was on coumadin for afib but it was held 5 days prior to procedures. Overnight patient had a 3 more bloody bowel movements and 5 more units of RBCs given, however he remained hypotensie and required ICU monitoring and norepinephrine. Emergent EGD revealed no active bleeding but a large 2 cm clean based ulcer where antral polypectomy occurred earlier. No intervention was done due to lack of active bleeding and size of ulcer. By day 9 patient had hemodynamically stabilized and biopsy from initial endoscopy resulted as hyperplastic histology concerning for mild dysplasia.

DISCUSSION:
Bleeding can occur immediately following a polypectomy or can be delayed from hours to weeks. Delayed PPB can occur due to sloughing of eschar or scab that covered a blood vessel, or an increasing zone of necrosis induced by the thermal energy used to resect the polyp and cauterize the site. Rates of delayed PPB range from 0.02-2.0% with a variety of risk factors. The larger the polyp, the higher the risk of PPB with some reports indicating an increase incidence of 9-13% for every 1 mm in polyp diameter. Patients should have any antiplatelet therapy held, with the exclusion of aspirin, prior to these procedures. NSAIDs should be avoided up to two weeks after polypectomies.
3142 Atypical Presentation of an Upper Gastrointestinal (GI) Bleed Manifesting as Extranodal Involvement of Diffuse Large B-Cell Lymphoma (DLBCL) Diagnosed in a Community Setting
Authors: Giang Jimmy , Ruzkowski Charles , Woslegel Colin E. 
Published: October 2019

INTRODUCTION:
Diffuse large B-cell lymphoma (DLBCL) is the most common type of Non-Hodgkin's Lymphoma (NHL), with 5.4 new cases diagnosed per 100,000 persons as of 2016. There is a male predominance, with an average age of 64.2. One extranodal site involves the GI tract, predominantly the stomach. Commonly seen are mucosa associated lymphoid tissue lymphomas and DLBCL. The majority of cases present at stage III/IV, with 40% presenting as local involvement. Here we present an unusual case of extranodal DLBCL in a patient presenting with dysphagia and an upper GI bleed.

CASE DESCRIPTION/METHODS:
An 85 year-old female presented for evaluation of dysphonia, ongoing for several months. The patient complained of bilateral submandibular adenopathy, dysphagia, trouble breathing, and a 15 pound weight loss over two weeks. Computed tomography of the neck revealed a nasopharyngeal mass in the left (L) nasopharynx extending into the nasal cavity, right (R) nasopharynx, and eroding into the skull. Additionally, bilateral necrotic cervical lymph nodes and L supraclavicular adenopathy were also seen. Histologic sample was consistent with DLBCL, non-germinal center type. Fluorescence in-situ hybridization was negative for MYC rearrangement, t(8:14), t(4:18), and Epstein Barr Virus, but indeterminate for BCL6 rearrangement. She was staged IIA and underwent radiation therapy without chemotherapy. During treatment, the patient was admitted for evaluation of an upper GI bleed associated with dysphagia, fatigue, and progressive weakness. She underwent an esophagogastroduodenoscopy with findings showing Los Angeles class A esophagitis, large, inflammatory nodular tissue within the lesser curvature of the stomach with associated linear ulcerations, multiple punctate ulcers throughout the gastric body and antrum, duodenitis, and a small, clean-based ulcer in the duodenal sweep. Histology of the gastric mass revealed an atypical clonal lymphoid infiltrate involving the gastric mucosa, suggestive of DLBCL, with clonal immunoglobulin heavy chain gene rearrangement.

DISCUSSION:
This case represents an atypical presentation of an upper GI bleed that is the result of extranodal involvement of DLBCL. An atypical presentation like this should have lymphoma in the differential for those with a history. Treatment is dependent upon the extent of disease, usually starting with the regimen of rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone therapy. If left untreated, this disease can progress rapidly and prove fatal.
3143 Gastric Volvulus: Coffee Ground Emesis and NGT Resistance in an Otherwise Asymptomatic Elderly Man
Authors: Chaudhury Samiran Roy , Oak Rachana , Akhavan Shahrzad Anita , Lapin Seth , Mun Michael 
Published: October 2019

INTRODUCTION:
Adult gastric volvulus is generally diagnosed by the symptoms of abdominal or chest pain. Acute presentation include symptoms of pain, vomiting, and failure of placement of naso-gastric tube (NGT) also known as Borchardt Triad. Severity of sequelae is dependent on significance of the rotation with rotations of >180° causing possibly outlet obstruction, strangulation, necrosis leading to perforation and severe sepsis leading to death.

CASE DESCRIPTION/METHODS:
A 92 year old gentleman is admitted for UTI related sepsis and started on antibiotics. On day 8 of his admission, patient complained of abdominal epigastric pain and had two episodes of dark red colored particulate emesis. Hemoglobin was stable and physical exam showed mild distention and slight tenderness on palpation but was otherwise nonsignificant. Multiple attempts at nasogastric tube placement were difficult due to resistance during insertion at below oro-pharyngeal levels. Abdominal CT scan (Figures 2 and 3) was completed showing left diaphragmatic hernia with herniation of the stomach with upside down stomach is noted with partial gastric outlet obstruction with the distended stomach, indicating organo-axial volvulus. This was not obviously noted in the admission chest X-ray (Figure 1). Given requirement for gastrostomy, patient was transferred to hospital of their choice where he subsequently received surgery and was discharged 4 months later.

DISCUSSION:
The diagnosis of gastric volvulus in this patient was not initially apparent as his abdominal pain complaints were very mild, his labs were normal and stable, and his initial admission was for sepsis. It was primarily the resistance in the placement of the NGT and the coffee-ground emesis that raised suspicion and prompted the CT imaging scan, which revealed the diagnosis. Therefore, it is important to have medical professionals remain cognizant of the possibility of the diagnosis of gastric volvulus, no matter how rare, in an elderly patient with resistance to NGT placement. And although the Borchardt triad is apparent in 75% of acute gastric volvulus cases, it is important to remember that up to 25% of patients do not present classically, and therefore gastric volvulus should not be excluded as a possible diagnosis.
3145 Dieulafoy's Lesion: An Underdiagnosed and Underrecognized Cause of Gastrointestinal Bleed
Authors: Riaz Sana , Kudaravalli Pujitha , Saleem Sheikh A. , Gupta Anand 
Published: October 2019

INTRODUCTION:
Acute gastrointestinal bleed accounts for nearly 50-150 cases per 100,000 each year. The etiology in the majority of cases is peptic ulcer disease (PUD). Dieulafoy's lesion is a rare (accounts for 1-2%), but potentially life-threatening cause of gastrointestinal (GI) bleed. We present a case of recurrent hemodynamically significant upper GI bleeding requiring multiple hospitalizations and endoscopies to identify a duodenal Dieulafoy's lesion as the primary source for bleed.

CASE DESCRIPTION/METHODS:
A 52-year-old male with a history of chronic alcohol use was admitted to the intensive care unit for the third time within a one-year duration for recurrent episodes of melena. During the first two episodes, upper GI endoscopy was positive for mild gastropathy, and a small 4-5 mm partially healed duodenal ulcer respectively. The exam was negative for any esophageal varices or other upper GI pathologies. The patient responded well both times to medical therapy and subsequently discharged home. In the third admission for similar presentation with melena and hemodynamically significant GI bleed, endoscopy was positive for an actively bleeding duodenal Dieulafoy's lesion. Bleeding was controlled with hemostatic clips and epinephrine injections. He was discharged home 48 hours after stabilization. Post-discharge, he was followed for a year, and he remained asymptomatic. It was therefore concluded that Dieulafoy's lesion was the likely cause of GI bleed that had evaded diagnosis during the first two endoscopies.

DISCUSSION:
Dieulafoy's lesion is a dilated submucosal vessel that erodes the epithelium and most commonly found in the stomach. Approximately one-third of the lesions are extragastric and located in the duodenum and colon. They are typically seen in men, around the fifth decade, in the presence of comorbidities such as hypertension, diabetes, chronic kidney disease, or alcohol abuse. Dieulafoy's lesions are under-diagnosed as they are silent until presentation. Approximately 33% of the lesions may require more than one EGD to identify the active source of bleeding, especially in the presence of other causes of GI bleed such as PUD. In our patient, the culprit for his recurrent GI bleeding was identified as Dieulafoy's lesion on the third endoscopy. We want to highlight the importance of the diagnosis and management of Dieulafoy's lesion as it can significantly decrease the mortality from 80% to 8.6%.
3149 Ulcerative Colitis in an Octogenarian: A Diagnostic and Therapeutic Challenge
Authors: Debnath Dipanjan , Singh Pratiksha , Shrimanker Isha , Goel Siddharth , Cheriyath Pramil 
Published: October 2019

INTRODUCTION:
Individuals aged >60 years contribute to 10%-15% of inflammatory bowel disease diagnoses with merely 10% of them being over 80 years of age. Older-onset ulcerative colitis (UC) is more common than Crohn's disease, with a male preponderance. Compared to younger patients, UC in the elderly manifests more as proctitis, has a subtler presentation with lesser bleeding, diarrhea, and abdominal pain, and a lower risk of relapse, but with increased severity. Till date, literature regarding UC in the octogenarian age group is limited to a handful of case reports.

CASE DESCRIPTION/METHODS:
An 81-year-old-male, non-smoker, with a history of coronary artery disease and family history significant for systemic lupus erythematosus, presented with moderate to severe, dull, periumbilical abdominal pain of one-month duration, associated with mucoid diarrhea, intermittent high-grade fever, anorexia, and unintentional weight loss. He denied any nausea, vomiting, blood in vomit or stools, icterus or pruritus. He did not report any history of high-risk behavior or recent travel. His examination was unremarkable except periumbilical and diffuse lower abdominal tenderness. Laboratory evaluation was notable for leucocytosis (13.5 K/ul), hyponatremia (128 mEq/L) and hypokalemia (3.1 mEq/L). U/S abdomen showed intestinal distension and a trial of opioid receptor agonists and probiotics was initiated for a probable diagnosis of irritable bowel syndrome, which failed to show clinical improvement. Treatment with broad-spectrum antibiotics, based on CT findings suggestive of colitis, led to partial symptomatic relief. Colonoscopy was performed following a recurrence of symptoms that revealed multiple areas of ulcerations and a biopsy confirmed the diagnosis of UC. The patient received guideline-directed medical therapy with 5-aminosalicylates and corticosteroids, which led to clinical improvement, and since then, the patient has been in remission.

DISCUSSION:
The unique pathophysiology, clinical manifestations and disease course of UC in the elderly add to its diagnostic challenge. Additionally, the scarcity of literature regarding treatment guidelines and lack of clarity of appropriate clinical endpoints (objective vs.symptom control) limits evidence-based decision in this population with a higher hospitalization and mortality rate. Consequently, a high degree of suspicion needs to be maintained in the aging population presenting with clinical features of colitis to ensure prompt treatment and limit complications.
3155 Macroscopic to Microscopic: A Case of Crohn's Disease Progressing to Collagenous Colitis
Authors: Dwivedi Sankalp , Balagoni Harika , Piper Marc , Piper Michael 
Published: October 2019

INTRODUCTION:
Microscopic colitis (MC), sub-typed into lymphocytic and collagenous colitis is characterized by normal endoscopic/macroscopic/radiologic colonic mucosa but abnormal histological findings and presents as chronic, non-bloody diarrhea mostly in elderly females. Association of MC with inflammatory bowel disorders (IBD), Crohn's or Ulcerative colitis is unclear and has been rarely reported. Herein, we present a patient with Crohn's disease with eventual progression to MC.

CASE DESCRIPTION/METHODS:
56-year-old female presented with 12-day non-bloody diarrhea with nocturnal symptoms, weight loss, and diffuse cramping abdominal pain. No fever, sick contacts, travel, food contamination, recent antibiotics or new medications. CT Abdomen/Pelvis was normal. Labs showed leukocytosis, elevated CRP and fecal-calprotectin. Colonoscopy showed inflammation characterized by congestion, granularity, cobblestoning of mucosa from the rectum to the transverse colon. The IC valve was stenotic and difficult to intubate. Biopsy showed mild-chronic active colitis without granulomas or dysplasia. CT Enterography showed narrowing of TI and two other small bowel segments. The patient was started on steroids for possible Crohn's disease and bridged to Adalimumab. Despite being compliant, the patient was re-admitted with 10-day non-bloody diarrhea after 2-3 months. Colonoscopy showed improved endoscopic inflammation but biopsies revealed collagenous microscopic colitis. Trials of budesonide, cholestyramine, bismuth and loperamide along with Adalimumab were unsuccessful. The patient was on SSRI, which was discontinued. The patient continued to be symptomatic. Repeat colonoscopy showed endoscopically benign mucosa and continued presence of collagenous colitis on biopsy. Given the refractoriness of the patient's symptoms, she was referred to IBD specialist at a tertiary center.

DISCUSSION:
Concomitant presence of MC with IBD or progression of one condition to other is rare and the pathogenesis is unclear. It is hypothesized that IBD and MC may share common pathophysiologic pathway, but there is no clear data. A study proposed increased Th1/Tc1, TNFα-producing cells, and a subset of Th2/Tc2 cells, to be involved in MC-to-IBD transformation. The clinical relevance of our case is to emphasize the consideration of MC in a patient with UC or CD, who develops chronic, non-bloody diarrhea. Mucosal biopsies should be obtained to rule out MC. Once confirmed, the management should be adjusted accordingly.
3156 A Case of Rapidly Progressing Ulcerative Colitis
Authors: Laharwal Mehak M. , Vikraman Praveen K. , Sapru Sunil , Ramasamy Dhanasekaran 
Published: October 2019

INTRODUCTION:
Ulcerative colitis is often characterized by a relapsing and remitting course. Acute flare ups may present as a serious illness. Most patients show a good response to intravenous corticosteroids which is the cornerstone of management of flare ups. However, a number of patients may develop a rapidly progressive illness and will need a colectomy. We present one such case where a colectomy was needed within four weeks of presentation.

CASE DESCRIPTION/METHODS:
Case report: A 30-year-old female presented to the emergency department for evaluation of high grade fever and abdominal pain associated with vomiting and foul-smelling, non-bloody, diarrhea 5-6 times a day. She had a history of developmental delay with refractory epilepsy but no previous reports of bowel symptoms. Abdominal X-ray showed small bowel obstruction. Further, a dilated colon with intramural edema was seen on CT scan along with an obstruction of distal small bowel. Stool was positive for leukocytes and calprotectin. CRP was elevated. Blood and stool cultures were negative. Three days later, she started having bloody diarrhea. Flexible sigmoidoscopy showed features of chronic severe colitis with ulceration. The tissue was negative for cytomegalovirus. She was diagnosed with inflammatory bowel disease after positive serology and treated with mesalamine and intravenous steroids followed by infliximab infusions with minimal improvement. She developed recurrent bowel obstructions and toxic megacolon for which she underwent a total colectomy with end ileostomy which was life saving for her.

DISCUSSION:
Acute severe colitis is a medical emergency and despite improvements in medical care, a substantial number of patients fail to achieve remission. Based on the criteria developed by Truelove and Witt, acute severe ulcerative colitis is characterized by the presence of more than 6 bloody stools per day along with any one of the following: tachycardia >90 bpm, fever >37.8 °C, Hb <10.5 gm/dL, and/or ESR >30 mm/h. Nearly 20% of patients end up needing a colectomy during first admission. Intravenous corticosteroids are the mainstay of initial therapy. Response to steroids should be assessed after 3 days. This is indicated by an improvement in symptoms as well as laboratory parameters like CRP, hemoglobin and serum albumin. Partial or non-responders should be considered for alternative therapies. Colectomy is regarded as a lifesaving procedure in those not responding to medical treatment and must be considered as the next therapeutic step.