bluuebunny/crossref_metadata_2025_split huggingface dataset:
3193 The First Case of Hepatocellular Carcinoma in Male Patient Arising From Resolved Hepatitis B After Seroconversion Without Liver Cirrhosis in Indonesia
Authors: Bestari Muhammad Begawan , Palungkun Ivonne Golda , Abdurachman Siti Aminah 
Published: October 2019

INTRODUCTION:
Approximately 18 million people chronically infected with Hepatitis B Virus (HBV) in Indonesia. HBV is a major contributor for the development of hepatocellular carcinoma (HCC). The therapy endpoint for chronic HBV is HBsAg seroclearance or seroconversion. However, in small percentage, HCC can still develop even after seroconversion. This is the first case of such occurrence reported in Indonesia.

CASE DESCRIPTION/METHODS:
A 57-years old male with abdominal pain on right upper quadrant was diagnosed with chronic HBV infection 9 years ago by serologic marker HBsAg 3688 IU/mL, HBeAg (+), anti HBeAg (−), HBV DNA 2.57 × 107 IU/mL, AST 560 IU/L, ALT 440 IU/L, and fasting glucose level 92 mg/dL. After entecavir therapy for 6 years HBV DNA clearance and HBeAg seroconversion were achieved, however HBsAg persisted at 19.66 IU/mL. The treatment then switched to PegIFN α-2a 180 mg for 1 year. The patient reached HBsAg seroclearance at the end of treatment with normal abdominal ultrasound (US) and hepatic elastography of 5.6 kPa. Three months later he developed anti HBsAg 14 mIU/mL. The patient was loss to follow up for 2 years, until current symptoms appeared with serologic markers HBsAg (−), anti HBsAg 121.5 mIU/mL, HBeAg (−), anti HBeAg (+), anti HBcAg (+), HBV DNA (−), anti HCV (−) and AFP 1.93 IU/mL. US suggestive HCC in right lobe and CT scan suggestive of HCC with multiple nodules on both lobes, minimal ascites and portal vein thrombus. Liver biopsy revealed columnar cells arranged in irregular tubular pattern, with nuclear polymorphism, coarse chromatin and presence of mitotic activity. Stroma consisted of fibrous collagen bands, with infiltration of inflammatory cells. No family history of HCC nor habitual alcohol intake identified.

DISCUSSION:
This patient with Hepatitis B has achieved HBsAg seroclearance and seroconversion without cirrhosis. Unfortunately, covalently closes circular DNA (cccDNA) was not identified because the examination was not commercially available, thus it may still persist intrahepatically and may further develop to HCC. Study done by Kuang et al. in 2016 identified the risk factor for developing HCC after HBsAg seroclearance were cirrhosis, male, age >50, and possibly family history of HCC. We suggest Asian descent is more susceptible to develop HCC even after seroconversion, since the incidence is higher in Asian race. Further demographic study is required to confirm this statement to narrow down the surveillance criteria.
3204 Abdominal Pain From the Sahara: An Atypical Source for a Common Complaint
Authors: Narasimha Shruthi , Robinson Katherine 
Published: October 2019

INTRODUCTION:
Chest and abdominal pain are staple symptoms that plague the emergency room and the differential that it poses is vast and can sometimes be misleading. The more common cardiac and gastrointestinal causes are well known and can easily be discerned but every once in a while, an unlikely source emerges and urges clinicians to think outside the box.

CASE DESCRIPTION/METHODS:
This case looks at the story of a 61-year-old recently immigrated Ethiopian male with a history of diabetes mellitus and hypertension who presented with a twenty one day history of intermittent chest and abdominal pain. His initial troponins were negative and his electrocardiography showed no ischemia. Due to his historical risk factors, he was admitted and an echocardiogram and stress test were done but no ischemic changes were noted. Although troponins and images were negative, labs showed eosinophilia and due to recent travel to Ethiopia, additional stool workup was initiated after he started to complain with concurrent symptoms of nausea. Gastroenterology weighed in by performing an endoscopy that showed mild erosive gastropathy but benign biopsies. Lab results came back positive for the strongyloides antibody and the ova and parasite culture showed some strongyloides larvae. Infectious disease advised two doses of ivermectin and patient reported improvement through his hospital course and was eventually discharged.

DISCUSSION:
Strongyloides is a helminthic parasite that is usually shed in human feces and the larvae in the stool find their way through the skin of another host and eventually deposit themselves in the small bowel until they are ready to shed their new larvae into the feces; thereby restarting the cycle. Though the disease may be more common in third world areas, it only affects a fraction of patients in the United States. Per the Center for Disease Control, small studies showed that it affected 0 to 6.1% of people tested in the United States. Most patients present with cutaneous, gastrointestinal, or pulmonary findings but cardiac complaints are rare. His eosinophilia helped prompt further investigation and eventually brought forth a formal diagnosis. However common or mundane a symptom may be, every clinical picture is unique and should be evaluated thoroughly with a wide differential. Had his disease been misdiagnosed, it could have lead to a hyperinfection syndrome and may have caused sepsis and even death. Thus, whether a patient is in suburbia or the Sahara, it is vital to keep a broad differential.
3207 An Unusual Metastatic Location of Colorectal Cancer
Authors: Rojas Patricia Guzman , Gonzaga Ernesto Robalino , Oharriz Juan 
Published: October 2019

INTRODUCTION:
Malignant neoplasms of the small bowel are rare, and mostly found as metastatic lesions from other neoplasms like lung cancer, renal cell carcinoma, breast cancer and melanomas. CRC is the 3rd cause of death associated to malignancies, and mostly metastasizes to liver, lung, and peritoneum. Duodenum as site of metastasis is rarely reported, reason why there is no specific prevalence of this entity and by 2017, there were less than cases reported in the literature.

CASE DESCRIPTION/METHODS:
We present a 52 yo man with a PMH of stage IIIB colon cancer s/p right hemicolectomy and chemotherapy, currently on remission. He had a recent normal colonoscopy 6 months prior this admission. The patient is admitted to the hospital complaining of abdominal discomfort, nausea, non-bloody vomiting, weight loss and melena for the past 2 weeks. His vital signs were stable. Laboratory results showed a hemoglobin of 6.6 g/dL and for this reason one pack of red blood cells was transfused. An EGD showed an ulcerated lesion on the duodenum (Figure 1). Biopsies were taken and these showed invasive, moderately differentiated adenocarcinoma. PET scan was done showing extensive metastatic liver and duodenal disease (Figure 2). The patient was referred to oncology for initiation of treatment with chemo and radiotherapy.

DISCUSSION:
Malignant tumors of the small intestine are very rare and involve only 1-2% of all gastrointestinal neoplasms. Metastasis from CRC has an unclear mechanism but is thought to be secondary to lymphatic spread or direct contact. Given its slow growth rate, duodenal tumors usually remain asymptomatic at onset. However, later in the course of the disease, the reported manifestations are melena, abdominal pain, and small bowel obstruction symptoms. Diagnosis is made through EGD and radiological studies. There is no stablished treatment, but surgery has been reported to be curative in some cases. Adjuvant chemotherapy can be used as a palliative option and survival rates have been reported to be 23% in 5 years. We report this case due to its rarity, since CRC tumors hardly metastasize to the duodenum. Furthermore, we would like to encourage expanding the research about treatment modalities, in order to improve prognosis in this entity.
3210 Aortoenteric Fistula—Rare, Deadly and Obscure
Authors: Harris Adam , Vemulapalli Roopa , Harris Samar , Greenan Garrett , Philip Justin 
Published: October 2019

INTRODUCTION:
Small-bowel bleeding comprises a majority of obscure gastrointestinal bleeding, and is caused by various diseases. For its diagnosis, history-taking, physical examination, diagnostic testing such as cross-sectional imaging, followed by videocapsule endoscopy and deep enteroscopy are all used according to the severity of hemorrhage and patient condition.

CASE DESCRIPTION/METHODS:
A 74 year old male with an open AAA repair, CKD stage 3, diverticulosis, and ongoing overt obscure GI bleeding × 1.5 years s/p segmental small bowel resection was admitted for an episode of rectal bleeding with hemodynamic instability. He had innumerable upper endoscopies, colonoscopies, video capsule endoscopies and intraop enteroscopy with no clear etiology and had gotten over 70 units of packed RBCs. Records revealed He underwent repeat endoscopy and colonoscopy, but a video capsule endoscopy showed active bleeding in the sigmoid likely from diverticulosis and venous ectasias seen on CTA. He underwent sigmoid resection but bleeding recurred. He then underwent a provoked angiography which was normal. He continued to have bleeding episodes which was characterized by large volume hematochezia and hemodynamic instability. After extensive discussion he underwent a loop ileostomy to determine exact source of his bleeding (small bowel versus colon). Unfortunately 24 hours after surgery, he became unresponsive and developed large volume hematemesis which led to his demise. An autopsy was performed and showed a secondary aortoenteric fistula. This is perhaps one of the only are reported cases of AEF presenting as an obscure GI bleed.

DISCUSSION:
Development of an aortoenteric fistula (AEF) is a devastating and life-threatening condition, which is as difficult to diagnose as it is to treat. Fortunately, it is rare, most commonly seen as a delayed complication of aortic reconstruction. Two types are recognized: primary and secondary. Primary fistulas occur de novo between the aorta and bowel, most commonly duodenum. Secondary fistulas occur between an aortic graft and segment of bowel. Diagnosis of AEF requires a high index of suspicion in patients who present with either signs of infection or gastrointestinal hemorrhage.
3212 Weight Loss Due to Chronic Mesenteric Ischemia
Authors: Ullah Waqas , Mehmood Asif , Rashid Mamoon Ur , Zafar Yousaf , Shafiq Muhammad , Hurarirah Abu 
Published: October 2019

INTRODUCTION:
Chronic Mesenteric Ischemia, also known as abdominal angina, is an uncommon condition defined by a state of attenuated blood circulation in the mesenteric vasculature affecting one or more abdominal viscera, and is more common in the female and elderly populations.

CASE DESCRIPTION/METHODS:
An 81-year-old woman presented with low blood pressure, she had a six month history of alternating constipation and diarrhea and lost 40 pounds. She appeared cachectic and abdominal examination revealed a bruit on auscultation, positive bowel sounds. Her blood work was unremarkable. Computed Tomography Angiography (CTA) of abdomen/pelvis showed chronic occlusion of the proximal celiac axis and proximal superior mesenteric artery. The distal portions of the vessels were reconstituted through large inferior mesenteric artery collaterals. CTA also revealed chronic occlusion of the proximal celiac axis and proximal superior mesenteric artery with reconstitution of the distal portions of the vessels via large inferior mesenteric artery collaterals. Patient was provided gentle hydration with intravenous fluids, and symptomatically treated with ondansetron and proton pump inhibitor. After the confirmation of diagnosis of mesenteric ischemia by CTA, cardiology was taken on board and patient underwent successful mesenteric artery bypass surgery.

DISCUSSION:
Chronic Mesenteric ischemia is a rare condition but can lead to considerable malnutrition and weight loss, and have fatal consequences such as bowel infarction, necrosis, perforation, sepsis and death. Timely diagnosis is associated with a better prognosis, which can be done with imaging or invasive angiography (gold standard).
3213 Giant Gastric Heterotopia (GH) in the Duodenal Bulb (DB): A Possible Cause of Gastric Outlet Obstruction (GOO)
Authors: Gil Arcelia Guerson , Singh Vikram , Timsar Ali Kazerouni , Brandt Lawrence 
Published: October 2019

INTRODUCTION:
The presence of gastric mucosa within the DB usually is an incidental finding during endoscopy and is seen in up to 8.9% of cases. While GH usually produces no symptoms, our patient presented with symptoms of GOO, which we attributed to the large size of the GH lesion, occupying >50% of the DB. This case of DH merits attention due to its uncommon appearance and presentation.

CASE DESCRIPTION/METHODS:
A 47-year-old woman with a history of insulin-dependent diabetes mellitus presented with abdominal pain, nausea, and post-prandial emesis for 1 year. Physical exam was normal, without a sucussion splash or post-prandial abdominal distention. Hematologic testing showed a Hb 9.8 mg/Dl. Other labs, including basic metabolic panel and liver biochemical tests, were normal. Abdominal CT without IV contrast was non-diagnostic. EGD identified a single polyp in the DB measuring 1.5 cm × 2 cm (Figure 1). Additionally, there was a more distal, irregular, cratered mass in the duodenum that was surrounded by a “carpet” of mucosal nodularity consistent with the appearance of Brunner's gland hyperplasia (BGH) (Figure 2). Both areas were biopsied. The pathology of the polyp showed gastric heterotopia (Figure 3) and the cratered mass showed peptic duodenitis.

DISCUSSION:
GH is seen throughout the adult GI tract but most commonly in the duodenum, with an incidence of 0.5% to 8.9%.
1
In most cases, GH causes no symptoms and is undiagnosed. When symptomatic, GH may cause abdominal pain from mucosal irritation secondary to the release of hydrochloric acid from parietal cells. Rarely, as in our patient, obstructive symptoms may be present.
2
For symptomatic patients, proton pump inhibitors (PPIs) are the cornerstone of treatment as they help to decrease acid secretion and, therefore, mucosal irritation. After EGD, our patient was started on a PPI and rapidly had symptomatic improvement. We suspect that her abdominal pain resolved due to decreased acidity within the DB, and that obstructive symptoms improved secondary to decreased inflammation within the DB. We present this case as a rare example of GOO caused by GH.
3228 The Tale of Two Tumors: Mixed Neuroendocrine-Non-Neuroendocrine Neoplasm Masquerading as Gastric Outlet Obstruction
Authors: Zafar Yousaf , Albawaliz Anas , Elkafrawy Ahmed A. , Mahmoudi Tahar 
Published: October 2019

INTRODUCTION:
Mixed neuroendocrine-non-neuroendocrine neoplasms (MiNEN) are tumors with two distinct neuroendocrine and non-neuroendocrine cell origins with each component comprising at least 30% of the entire neoplasm. These are rare tumors that have been reported in different parts of the digestive tract. We report the case of MiNEN identified in the duodenum of a patient who presented with gastric outlet obstruction.

CASE DESCRIPTION/METHODS:
A 61-year-old African American male with past medical history significant for stage 2 prostate adenocarcinoma (in remission) and alcohol induced cirrhosis who presented with abdominal pain, intractable nausea and vomiting for one week and concomitant weight loss over the past few months. He was tachycardic and normotensive on presentation. Physical examination was remarkable for gastric splash without notable abdominal distention. A Computed Tomography of the abdomen showed focal thickening in the duodenum near the ampulla. An esophagogastroduodenoscopy was remarkable for a periampullary, protruding and fungating mass in the second part of the duodenum that was biopsied and confirmed to be adenocarcinoma. The endoscope could not traverse beyond the identified lesion. Patient underwent Whipple procedure and intra-operative biopsy revealed invasive well-differentiated intra-ampullary adenocarcinoma, arising in intraductal papillary mucinous neoplasm, in addition to a well-differentiated neuroendocrine tumor in the second part of the duodenum. Post-operative course was complicated by upper gastrointestinal bleeding from anastomotic site, hepatorenal syndrome, abdominal compartment syndrome and acute hypoxic respiratory failure. Due to poor prognosis and worsening condition family elected to pursue comfort care and the patient passed away.

DISCUSSION:
The occurrence of MiNEN is rare and to our knowledge this is the first case to present as gastric outlet obstruction. Biopsies are needed to confirm diagnosis and surgical intervention is mainstay for management.
3239 Gastric Outlet Obstruction in Setting of Acute Cholecystitis With Duodenal Lipoma
Authors: Dalal Kunal , Chaaya Adib 
Published: October 2019

INTRODUCTION:
Gastric outlet obstruction (GOO) overall incidence has declined after improved treatment of its benign etiologies. The only remote association between GOO and acute cholecystitis is through Bouveret syndrome, which is characterized by a gallstone ileus in setting of a bilioenteric fistula. Duodenal lipomas are very rare, and literature review reveals only 39 cases reported specifically in the second portion of the duodenum. This is the first reported case of GOO occurring in setting of severe acute cholecystitis and duodenal lipomas, with complete resolution after treatment of the acute cholecystitis.

CASE DESCRIPTION/METHODS:
A 71 year-old male presented for an unrestrained motor vehicle crash with multiple fractures including left femur fracture requiring surgical intervention. CT on admission showed mild gastric distention, 1.2 cm calcified cholelith. One week postoperatively, he complained of new onset right upper quadrant pain, with subsequent nausea and non bloody emesis. His physical exam was positive for Murphy's sign. His vitals showed tachycardia. His labwork revealed increasing leukocytosis from 13K to 43K with concerns for sepsis. Liver chemistries were WNL, except elevated alkaline phosphatase 171. Repeat imaging demonstrated new findings of acute cholecystitis, duodenal wall thickening, duodenal lipomas, and gastric distention with fluid suggesting gastric outlet obstruction, presumably secondary to the inflammatory process. The patient had nasogastric tube decompression with 2.6 liter output, followed by emergent percutaneous cholecystostomy tube. The patient gastrointestinal symptoms, gastric distention, and leukocytosis significantly improved. Then two days later, EGD was notable for LA Grade D esophagitis and two large duodenal lipomas the in second portion.

DISCUSSION:
To our knowledge this is the first documented case of GOO associated with acute cholecystitis in the setting of duodenal lipoma. With our case we concluded the GOO pathophysiology was dependent on the degree of inflammation from cholecystitis causing worsening intraluminal narrowing in relation to the specific location of the lipoma. Given the entities have varying presentations, clinical suspicion should remain high, and diagnosis relies on successful imaging and endoscopic evaluation. Treatment of the underlying acute cholecystitis should be urgent with either percutaneous cholecystostomy tube or cholecystectomy, if feasible. The excision of the benign duodenal lipoma can be made on a case-by-case basis.
3246 Long-Term Survival in a Patient With Recurrent Gastric Cancer With Peritoneal Seeding Undergoing Chemotherapy and Mistletoe Extract Treatment
Authors: Oh Sung Jin , Suh Byoung Jo 
Published: October 2019

INTRODUCTION:
Recurrent gastric cancer with peritoneal seeding is associated with poor overall survival. Mistletoe extract has been widely used for complementary cancer therapy such as pancreatic cancer, ovarian cancer, and melanoma which support the quality of life and prolong overall survival. However, the effect of treatment for recurrent gastric cancer remains controversial.

CASE DESCRIPTION/METHODS:
A 71-year-old man with advanced gastric cancer underwent radical total gastrectomy (stage IIIb, T4b N1 M0). Abdominopelvic computed tomography performed 7 months after surgery revealed the increased ascites with an enhanced peritoneal thickening. He was diagnosed with peritoneal seeding and received 2nd line chemotherapy (Irinotecan). However, he was refused the chemotherapy due to side effects after 1 cycle. He starts receiving alternative therapy with Viscum album extract (mistletoe) instead of chemotherapy. Malignant ascites had decreased gradually after mistletoe extract therapy. So we start 3rd line chemotherapy (docetaxel) with mistletoe extract. The patient achieved good health with complete response postoperative 32 months after combination treatment. The patient has survived for 51 months after surgery without disease progression. We report a case of recurrent gastric cancer with peritoneal seeding that was successfully treated by docetaxel monotherapy with long-term mistletoe extract treatment.

DISCUSSION:
Mistletoe extract contributed to the reduction of malignant ascites and improved quality of life during chemotherapy. This case suggests that the synergistic effect of mistletoe extract treatment could be expected when used together with chemotherapy for recurrent gastric cancer.
3248 SIBO and Gastroparesis: Downstream Effects of Diabetes
Authors: Grosch Gretchen , Evans Neil , Jadav Puja 
Published: October 2019

INTRODUCTION:
Homeostasis of the GI mucosal environment depends on gut motility and normal gastric acid secretion. The autonomic nervous system plays an important role in these processes. Diabetes has been shown to injure the enteric nervous system, resulting in slowed motility. Gastroparesis and small intestinal bacterial overgrowth are two consequences of the enteric injury associated with diabetes.

CASE DESCRIPTION/METHODS:
A 23-year-old male with type 1 diabetes presented with 6 months of diffuse abdominal pain and diarrhea, which had recently worsened. He noted 4-6 loose bowel movements daily and vomiting after food. He had previously been seen by gastroenterology and had an unremarkable colonoscopy, EGD, and celiac testing. He had been trialed on rifaximin and neomycin, which improved his symptoms for a short period. He tried eluxadoline with little effect. On presentation, he was hemodynamically stable with labs significant only for mildly elevated AST (58 units/L). WBC, ESR, CRP, feces ova and parasites, and C. difficile Ag were all unremarkable. A gastric emptying study revealed moderate (24%) gastroparesis. A right upper quadrant ultrasound was unremarkable. Small intestinal bacterial overgrowth related to gastroparesis was suspected. A trial of rifaximin and metoclopramide improved his symptoms leading to empiric diagnosis of SIBO.

DISCUSSION:
Small intestinal bacterial overgrowth occurs when the normal homeostatic mechanisms that control bacterial populations are in some way disrupted. Frequently, this occurs with decreased gastric acid secretion or dysmotility of the small intestine. The most common symptoms of SIBO include bloating, abdominal discomfort and distention, chronic diarrhea, weight loss, and malabsorption. One proposed theory for SIBO in gastroparesis is the idea that phase 3 migratory motor complexes may be diminished in frequency or altogether absent. While the gold standard for diagnosis requires jejunal aspirate, lactulose and glucose breath testing have been used as indirect measures of SIBO. Multiple studies have been done to analyze the relationship between gastroparesis and SIBO with results showing up to 60-70% of study participants with gastroparesis test positive for SIBO via lactulose breath testing. Once the diagnosis of SIBO has been established, the goal of therapy is to correct the underlying cause, provide nutritional support, and treat overgrowth with a course of antibiotics.