bluuebunny/crossref_metadata_2025_split huggingface dataset:
1879 Gastric Xanthoma: A Rare Endoscopic Finding
Authors: Harne Prateek S. , Mukherjee Samiran , Sharma Anuj , Manocha Divey 
Published: October 2019

INTRODUCTION:
Xanthoma is defined as a localized lipid deposit within organs that may manifest as papules, plaques or nodules, most commonly in the skin. The extra-cutaneous manifestation is rare and sparsely reported. Gastrointestinal tract xanthomas are rare benign lesions which have been reported in the esophagus, stomach, and duodenum, with the stomach being the most common site in the upper GI tract with a reported incidence between 0.2-0.8% 1,2. Commonly characterized by yellowish-white plaque in the antrum or the pylorus of the stomach, histologically reveals foamy macrophages in the lamina propria3.

CASE DESCRIPTION/METHODS:
We present a case of a 63-year-old female with past medical history most significant for ESRD on hemodialysis, CVA with right-sided residual paralysis, atrial fibrillation on warfarin who was brought in after being found in a comatose state, soaked in her own blood due to a hemodynamically significant painless GI bleed with H/H drop to 3.0/15.0 which required ICU admission. After stabilization, the patient underwent upper GI endoscopy, push enteroscopy and colonoscopy which revealed a non-bleeding gastric ulcer, non-bleeding internal and external hemorrhoids, non-bleeding angioectasias in the duodenum and a 10mm raised mucosal nodule in the gastric antrum which was biopsied which revealed dense infiltrate of foamy macrophages with positive with CD 163 immunostain that expanded the lamina propria consistent with a xanthoma. Additionally, random stomach biopsy revealed chronic gastritis with intestinal metaplasia.

DISCUSSION:
This case allows us to understand the similarity in the appearance of gastric xanthomas and malignancy like signet cell carcinoma as well as study its reported association with dyslipidemias, gastric dysplasias and carcinogenesis, chronic and atrophic gastritis as well as gastritis caused by Helicobacter pylori making it imperative to confirm by histopathology and maintain a close follow up for monitoring its behavior.
1889 Endoscopic Closure of Gastrocolic Fistula Using Hemostatic Clips: A Novel Approach
Authors: Akhavan Shahrzad Anita , Oak Rachana , Sinha Neera , Chum Christopher , Trillo John 
Published: October 2019

INTRODUCTION:
Traditionally, surgery is the mainstay of treatment for gastrointestinal fistulas; more recently, however, therapeutic endoscopic stent placement is being explored for high-risk patients. Successful endoscopic closure of these fistulas using hemostatic clips offers the possibility of an alternative, viable approach for patients who are nonsurgical candidates and may benefit from noninvasive endoscopic interventions.

CASE DESCRIPTION/METHODS:
An 82-year-old male with history of peptic ulcer disease, alcohol abuse, and Billroth II gastrojejunostomy >20 years ago was admitted due to bloody diarrhea. Physical examination was unremarkable except for melena. Laboratory testing revealed a hemoglobin level of 4.6g/dL. After resuscitation, upper endoscopy was performed and the patient was found to have a mucosal perforation at the anastomotic site with an adjacent clean-based ulcer (A, B) without active bleeding. The mucosal defect was closed using four hemostatic clips (C). Abdominal CT scan later confirmed a gastrocolic fistula successfully closed with clip placement (D). The patient’s symptoms resolved; his remaining hospital course was uncomplicated.

DISCUSSION:
Intervention during endoscopy precluded the need for surgical intervention in an elderly patient who would otherwise have been a poor surgical candidate. To the best of our knowledge, this is the first use of hemostatic clip placement for closure of a gastrocolic fistula.
1905 Appendiceal Neuroendocrine Tumor in an Inverted Appendix Discovered on Screening Colonoscopy
Authors: Abdallah Abdallah , Karim Ahmed , Alnakshabendi Imad , Alnazkhabendi Ibrahim 
Published: October 2019

INTRODUCTION:
Appendiceal carcinoid tumors are the most common appendix neoplasm. Most cases are diagnosed incidentally after an appendectomy. We present a rare case of neuroendocrine neoplasm from an inverted appendix manifesting as cecal polyp seen on a screening colonoscopy.

CASE DESCRIPTION/METHODS:
Patient is a 58-year-old female with no significant past medical history or family history of colon cancer who presented for colorectal cancer screening. She denied any fevers, night sweats, flushing, palpitations, weight loss, abdominal pain, or changes in bowel habits. She denied any prior abdominal surgeries. Patient underwent colonoscopy which revealed internal hemorrhoid, two polypoid lesions in the cecal area measuring 8 mm, and 1.3 cm. A total of 6 mL of normal saline was injected underneath to lift them up and snaring polypectomy technique applied. Endo Clip was applied at the base of the large polyp and the specimen was retrieved and sent to the pathology. Pathology revealed well-differentiated neuroendocrine tumor, grade 1, 0.4 cm, involving submucosa and muscularis propria of probable inverted appendix/appendiceal stump. IHC stains for CDX 2, Pankeratin, Chromogranin, and Synaptophysin were positive. Stains for CK7/CK 20/PAX 8/Vimentin were negative. Patient returned for a follow-up office visit and was doing well after the procedure. She was later referred for a CT abdomen pelvis with contrast which failed to show an appendix, any cecal masses, or other acute intra-abdominal pathologies. Patient was then referred to a general surgeon for further evaluation who recommended a one-year surveillance colonoscopy.

DISCUSSION:
Neuroendocrine tumors are the most common tumor of the appendix. They are typically discovered incidentally from an appendectomy but rarely manifest in an inverted appendix. Additionally, they are usually located in the distal 1/3 of the appendix and for that reason most patients do not present with obstructive symptoms. Management of tumor depends on the size of the tumor. If the carcinoid is < 2 cm, appendectomy is generally sufficient. In this case the tumor was only 0.4 cm and was completely excised endoscopically in the inverted appendix.
1916 Gastrointestinal Stromal Tumor: Cause of Massive Lower Gastrointestinal Bleed in Young Patient
Authors: Rashid Mamoon Ur , Khan Muzammil Muhammad , Ullah Waqas , Zafar Hammad , Hussain Ishtiaq , Hasan Badar , Ur Rehman FNU Asad , Hurairah Abu 
Published: October 2019

INTRODUCTION:
Gastrointestinal stromal tumor (GIST) is one of the rare causes of gastrointestinal malignancies. GIST most commonly occurs in stomach. It arises from one of the specialized cells of GI tract, called as Interstitial Cells of Cajal (ICC) and mutations in one of the KIT gene or PDGFRA are responsible for the development of this tumor. We are here presenting a case of massive GI bleed in a very young patient from GIST tumor in small intestine.

CASE DESCRIPTION/METHODS:
26-year-old male presented to ED complaining of having 3–4 bloody bowel movements in the last 2 days. He stated having soft stool mixed with a large amount of bright red blood. Patient denied abdominal pain, nausea, vomiting, recent travel, sick contacts or weight loss. Patient had low systolic blood pressure in the range of 70–80 on admission. Blood pressure was stabilized with IV fluids. Patient dropped hemoglobin during hospitalization to 5.8 and was transfused 7 PRBC’s. CT abdomen w/contrast revealed a circumferential, lobulated proximal ileal small bowel mass measuring 2.3 × 2.2 × 2.9 cm. EGD and Colonoscopy were done initially which showed extensive amount of blood and clots throughout the colon with very limited views of underlying mucosa but terminal ileum was normal in appearance. No active bleeding was noted. General surgery was consulted and resection of the tumor, that appeared to be the source of the bleeding, was performed in the mid ileum. A 5 cm resection of segment of small bowel was done. Pathology report showed GIST tumor. Patient bleeding stopped subsequently after surgery.

DISCUSSION:
GIST most commonly arises in fifth and sixth decades of life. It may be familial or sporadic. Mutations of KIT (80 %) and PDGFRA (10 %) are associated with both familial and sporadic causes. GIST tumors majority of the time are incidental findings but when symptomatic presenting complaints may include abdominal pain and swelling, nausea, vomiting, loss of appetite, or weight loss. Patient may also present with bowel perforation, acute abdomen and peritonitis. Rarely, they present with GI blood loss resulting in symptomatic anemia and hemodynamic instability. Almost 30% of the GIST tumors are malignant with the histological findings including highly cellular spindle cells or epitheloid mesenchymal tumors. The diagnosis is confirmed by immunohistochemical techniques and expression of tyrosine kinase receptor. Treatment for resectable tumors is surgery while those of non-resectable tumors is Imatinib a tyrosine kinase inhibitor.
1919 Hemobilia Due to Cystic Artery Pseudoaneurysm: A Rare Cause of Hematemesis in a Pediatric Patient With Obstructive Jaundice
Authors: Patel Nishaben , Minkoff Nathan , Bahia Gracielle 
Published: October 2019

INTRODUCTION:
Hemobilia is a rare cause of upper gastrointestinal (GI) bleeding, especially within the pediatric population. Here we present a case of hematemesis initially presumed to be secondary to a Mallory-Weiss tear in the setting of choledocholithiasis and later found to have hemobilia due to cystic artery pseudoaneurysm. The triad of right upper quadrant abdominal pain, obstructive jaundice and upper gastrointestinal bleed should prompt consideration of hemobilia.

CASE DESCRIPTION/METHODS:
A 16 year old male with history of obesity and gastroesophageal reflux disease presented to the emergency department with severe epigastric pain and hematemesis. Labs were notable for elevated transaminases [AST 347 (U/L), ALT 422 (U/L)] and conjugated hyperbilirubinemia [direct bilirubin 2.6 (mg/dL), indirect bilirubin 0.3 (mg/dL)]. Abdominal ultrasound showed a large gallstone with a dilated common bile duct (CBD) dilation (1.1 cm). MRCP was negative for filling defects, but showed mild central intrahepatic and extrahepatic ductal dilation with a large gallstone and debris filling the gallbladder lumen. An EGD was performed and a superficial ulcer was seen in the duodenal bulb and presumed to be the source of bleeding. Due to persistence of hematemesis, transaminitis, and up trending GGT 585 (U/L) and direct bilirubin 3.7 (mg/dL), there was question of a distal CBD obstruction. An ERCP was performed, and fresh blood clots were coming from the ampulla. A cholangiogram showed multiple filling defects in the common bile duct from blood clots. Sphincterotomy and CBD stent placement were then performed. Abdominal CT angiography showed a focal arterial density collection along the posteromedial gallbladder mucosal surface, consistent with a pseudoaneurysm vs vascular malformation. A visceral angiogram demonstrated a pseudoaneurysm arising from the posteromedial wall of the cystic artery with successful cystic artery coil embolization. A laparoscopic cholecystectomy was attempted, but was converted to an open surgery, which removed the gallbladder and a large gallstone. He had an unremarkable recovery.

DISCUSSION:
Hemobilia is an uncommon cause of upper GI bleeding within the pediatric population. Most commonly hemobilia is the result of trauma or iatrogenic from hepatobiliary procedures. Angioembolization is often indicated and followed immediately with surgery. In summary, the triad of right upper quadrant abdominal pain, biliary obstruction and upper gastrointestinal bleed should prompt consideration of hemobilia.
1924 Bleeding Beyond the Line: Anorectal Melanoma as a Cause of Lower Gastrointestinal Bleeding
Authors: Phan Huy , Tabibian James H. , Tan Hongying 
Published: October 2019

INTRODUCTION:
Anorectal melanoma is a rare malignancy that can present as hematochezia similar to other gastrointestinal bleeding sources. The diagnosis of anorectal melanoma may be challenging given its rarity, nonspecific presentation, and need for histopathology, but accurate and timely diagnosis is essential given that associated bleeding may not respond to conventional treatments.

CASE DESCRIPTION/METHODS:
An 88-year-old male was admitted for septic shock after being found lethargic at his nursing facility. He was started on intravenous antibiotics and vasopressors and intubated for airway protection. Though slowly improving overall, on hospital day 6, he had 4 episodes of large red clots per rectum. Rectal examination showed bright red blood and a rubbery mass palpable on the posterior rectal wall without visible hemorrhoids. Due to the acute drop in hemoglobin to 6.3 g/dL, the patient was transfused 2 units of packed red blood cells, empirically started on intravenous pantoprazole, and administered parenteral Vitamin K and a dose of desmopressin. Over the next two days, the patient continued to have multiple bowel movements with blood clots requiring additional blood transfusions. Given these findings, the patient underwent flexible sigmoidoscopy.

DISCUSSION:
Flexible sigmoidoscopy revealed a 3 cm ulcerated mass in the distal rectum which involved the dentate line. Endoscopic hemostasis was not feasible, but a biopsy was obtained which showed malignant melanoma invading the lamina propria and muscularis with associated ulceration. Considering the patient's age, clinical status, and advanced dementia, the medical team and unrepresented patient committee agreed that it was ethically appropriate to not pursue further work-up or treatment of the patient's melanoma. Following medical stabilization, the patient was transitioned to home comfort care. This case illustrates a rare etiology of bright red blood per rectum and the importance of additional investigation in the setting of clinically significant anemia and/or inadequate response to conservative measures. Anorectal melanoma, similar to other rare disorders which can mimic internal hemorrhoidal bleeding, frequently requires endoscopic techniques for diagnosis and management. Despite this patient's clinical course and the generally poor prognosis of anorectal melanoma, early diagnosis can allow for surgical excision and/or adjuvant therapies that may provide a potentially curative outcome or delay disease progression and mitigate bleeding complications.
1930 Ventriculoperitoneal Shunt Migration Into the Stomach: Case Report and Review of Literature
Authors: Reddy Yala K. , Lingala Shilpa , Ahmed Nazneen 
Published: October 2019

INTRODUCTION:
Complications of ventriculoperitoneal (VP) shunting includes shunt migration, meningitis, peritonitis and peritoneal pseudocyst. Bowel perforation following VP shunt placement is rare, occurring in about 0.01 to 0.03% with the colon being the most common site. We report a case of migration of a VP shunt catheter into the stomach, in a patient who presented with iron deficiency anemia.

CASE DESCRIPTION/METHODS:
A 65-year-old African-American woman was referred to gastroenterology clinic for iron deficiency anemia. She had no gastrointestinal symptoms and fecal immunochemical test was negative. Colonoscopy was unremarkable. EGD showed no evidence of peptic ulcer disease or any arteriovenous malformation up until the fourth part of duodenum. A foreign body protruding into the gastric fundus [Figure 1] was noted. On review of her PMH, she had a VP shunt procedure in 1995 after clipping of an intracranial aneurysm. CT of abdomen confirmed the presence of the VP shunt in the stomach [Figure 2]. The patient was referred to General Surgery for laparoscopy. During surgery, approximately five-six cm of the distal tip of the VP shunt was intragastric, forming a fistula between the stomach and the abdominal wall. The fistula was sealed, and the shunt was repositioned intraperitoneally. The patient was stable after the surgery.

DISCUSSION:
From a review of the literature, our patient’s presentation with iron deficiency anemia and no gastrointestinal symptoms was unusual. Only 16 cases of intragastric migration of a peritoneal catheter have been previously described. Most patients complained of abdominal discomfort prior to the intragastric perforation. This complication predominantly affects children . The mean interval between the last shunt procedure and perforation was approximately 48.3 months (1 day to 23 yrs) and is unpredictable. The possible mechanisms of bowel perforation includes catheter adherence causing a local inflammation resulting in fibrosis or the continuous pressure from the catheter tip leading to erosion of the bowel and delayed perforation. Our patient could also have had chronic gastric bleeding which may have contributed to her iron deficiency anemia. Treatment approaches include injection of fibrin glue to close the perforated stomach wall, and direct suture of the stomach wall by laparotomy. In our patient, the latter approach was taken. To our knowledge, this is the only reported case of a patient with intragastric migration of a VP shunt presenting with iron deficiency anemia.
1934 Atrioesophegeal Fistula, a Rare but Devastating Cause of Upper Gastrointentinal Bleeding
Authors: Ball Timothy , Kaila Vishal , Franklin Jay , Assar Manish , Frost Beth , Barnard Jeffrey , Jain Rajeev 
Published: October 2019

INTRODUCTION:
Atrial fibrillation is the most common cardiac arrhythmia globally, with an estimated prevalence of 33.5 million persons. Over the past 20 years, catheter ablation for atrial fibrillation has grown in acceptance and is now a first-line treatment option for patients with symptomatic paroxysmal atrial fibrillation. Atrioesophegeal fistula (AEF) is a rare but often fatal complication associated with atrial fibrillation ablation.

CASE DESCRIPTION/METHODS:
A 73-year-old woman who underwent radiofrequency ablation for atrial fibrillation 7 weeks prior to presentation to the hospital presented with right-hand weakness, numbness, and ataxia. Initial laboratory evaluation was remarkable for hemoglobin 9.2 g/dL(13.0–17.0 g/dL). Initially, a head computerized tomography (CT) was unremarkable but a subsequent magnetic resonance imaging study demonstrated a right cerebellar stroke. Tissue plasminogen was not prescribed. Transthoracic echocardiogram showed normal left ventricular systolic function, with dilated atria. Later on the day of admission, she developed hematemesis. On day 2 of her admission, she underwent esophagogastroduodenoscopy (EGD) and was found to have a large esophageal defect with thrombus and active bleeding (See Figures 1 and 2). Her clinical status declined quickly and she was taken emergently to the operating room. Unfortunately, despite maximal supportive care, she died prior to surgery. Autopsy revealed an atrioesophageal fistula involving the middle 1/3 of the esophagus and the posterior wall of the left atrium adjacent to the left pulmonary veins. The defects measured 1.5 × 1.0 cm on the esophageal portion and 1 cm × 1 cm on the atrial aspect (See Figure 3). The stomach contained 910 cc of both liquid and clotted blood.

DISCUSSION:
AEF typically occur 20 ± 12 days post-ablation, ranging from 2 to 60 days. AEF has been reported in surgical RFA, percutaneous RFA, and cryoballoon ablation for atrial fibrillation. CT of the chest with intravenous contrast can show pneumomediastinum, pericardial effusion, and communication between the atrium and esophagus. EGD and transesophageal echocardiogram are not recommended if AEF is suspected, as air insufflation during either procedure may lead to massive air embolization and worsening bleeding. Following the diagnosis of AEF, early surgical intervention is critical as the mortality rate without intervention is 100%. AEF is a rare but often fatal complication of catheter ablation for atrial fibrillation. Untreated, the mortality rate of AEF is 100%.
1939 A Malignant Case of Gastrointestinal Bleed
Authors: Asif Samia , Saeed Lyla 
Published: October 2019

INTRODUCTION:
Richter’s Syndrome (RS) is an infrequent complication of chronic lymphocytic leukemia (CLL) involving transformation of CLL into aggressive large-cell lymphoma. Gastrointestinal (GI) involvement with RS is rare, previously described in only 9 case reports in literature. Here we present a unique case of RS manifesting as GI bleed.

CASE DESCRIPTION/METHODS:
A 70-year old male presented with one day history of painless hematochezia. He was diagnosed with CLL four years prior and was currently in remission following chemotherapy. Vitals revealed a blood pressure of 88/35 mmHg and pulse rate of 114/minute. Abdominal exam was unremarkable. Rectal exam showed blood in the vault. Work-up showed a hemoglobin of 4.8 g/dl and white cell count of 5300/microliter. Coagulation profile was normal. After initial resuscitation, an esophagogastroduodenoscopy (EGD) was performed showing an excavated lesion with minimal oozing in second part of duodenum; biopsy was obtained and endoclip was applied. Colonoscopy showed blood in terminal ileum and throughout the colon. Capsule study revealed scattered erosions and ulcers with hemorrhage in the jejunum and active bleeding from the distal ileum. Urgent tagged red-cell scan was obtained followed by coil embolization of a focus of brisk active extravasation arising from a terminal ileal branch of ileocolic artery by Intervention Radiology (IR). Duodenal biopsy demonstrated lymphocytic infiltrate consistent with his history of CLL with a background of larger lymphocytes concerning for Richter’s transformation to diffuse large B-cell lymphoma (DLBCL). Computed Tomography (CT) abdomen/pelvis showed splenomegaly and diffuse abdominal and pelvic lymphadenopathy. Pathology report of an excisional biopsy of left axillary lymph node confirmed Richter’s transformation to DLBCL. Systemic chemotherapy and immunotherapy was initiated. GI bleed resolved few days into chemotherapy.

DISCUSSION:
Patients with prior history of hematological malignancies presenting with GI symptoms such as nausea/vomiting, intestinal obstruction, acute perforation or GI bleed should be evaluated for recurrence. In addition to imaging, a low threshold for invasive work-up such as EGD or colonoscopy with biopsy of any lesions seen may be necessary for timely initiation of therapy. This case demonstrates that evaluation for etiology in each case of GI bleed has to be individualized. Identifying the correct diagnosis is the key to successful patient treatment.