bluuebunny/crossref_metadata_2025_split huggingface dataset:
1659 Double Scope Colorectal ESD Using a Gel-Based TAMIS Access Platform
Authors: Samarasena Jason , Hashimoto Rintaro , El Hage Chehade Nabil , Sowa Piotr , Lee David , Leevan Elyse 
Published: October 2019

INTRODUCTION:
Endoscopic submucosal dissection (ESD) is a promising endoscopic procedure that is increasingly being used for endoscopic resection of large colorectal lesions that may be difficult to remove en-bloc by snare polypectomy. The greatest challenge for ESD remains technical difficulty in achieving optimal traction. In the following report, we discuss the use of Gel-based Transanal Access Platform, typically used for Transanal Minimally Invasive Surgery (TAMIS), being used to facilitate ESD of colorectal lesions by facilitating use of two separate endoscopes simultaneously.

CASE DESCRIPTION/METHODS:
The procedure was first performed on a patient presenting for resection of a 3 cm × 3 cm rectal lesion. Endoscopic ultrasound was performed and the lesion was classified as T1. A decision was made to perform ESD. A 4 × 4 cm Gel based-TAMIS access device was inserted into the anal canal prior to the start of the procedure. Two access holes were made in the gel cover 2 cm apart with the pre-supplied trocars to allow for the passage of a 1T therapeutic gastroscope and an ultraslim gastroscope. After submucosal injection and circumferential incision, the pediatric forceps were passed through the working channel of the ultraslim scope, and the edge of the lesion was grasped and then manipulated to allow for traction of the lesion. ESD was done using a needle type ESD-knife and resection en-bloc was achieved. There were no complications from the procedure and the patient has no anal pain. Histologic examination demonstrated R0 resection Two additional procedures were carried out on two patients with rectal lesions >2 cm and en-bloc resection was achieved in both cases. Histologic examination in each showed tubulovillous adenoma with high grade dysplasia with clear margins.

DISCUSSION:
By using a commercially available Transanal Access Platform for the first time in an endoscopic procedure, the endoscopist noted more ease performing ESD. This device allowed the insertion of an additional scope which provided more traction and assisted in resecting each lesion without any reported friction between the two scopes. The set-up of this device is simple and this device appears suitable not only for laparoscopic surgical procedures but also for endoscopic interventions. Further studies are underway to determine the technical success, easy of use, and safety of this dual scope with TAMIS platform technique for colorectal ESD.
1662 Colonic Obstruction Leading to a Diagnosis of Polyarteritis Nodosa
Authors: Larson Brian , Shiralkar Malan , Flynn Ann 
Published: October 2019

INTRODUCTION:
Polyarteritis Nodosa (PAN) is a rare systemic necrotizing vasculitis that preferentially affects medium-sized arteries. Patients may present with systemic symptoms or with isolated organ involvement. PAN may involve the gastrointestinal (GI), renal, cardiac, musculoskeletal, skin and central nervous systems. When the GI tract is involved, abdominal pain is the most common presentation, thought secondary to transmural necrotizing inflammation of the mesenteric vessels leading to bowel ischemia. The small bowel is the most common site of involvement. Ischemic mucosal ulceration, bowel infarction and perforation can result. Case reports in the pediatric literature and a retrospective case series have described PAN causing severe GI strictures leading to intestinal obstruction. We report a rare case of PAN leading to a colonic obstruction.

CASE DESCRIPTION/METHODS:
A 36-year-old-male was admitted to the hospital with nausea, vomiting, abdominal pain and reduction in the passage of stool and gas for the previous 5 months. Computerized topography of the abdomen and pelvis demonstrated colonic dilatation and obstruction at the level of the sigmoid colon. A flexible sigmoidoscopy was performed and identified severe stenosis at the recto-sigmoid junction, 25 cm from the anal verge. This area could not be traversed with an upper endoscope or an ultrathin endoscope. Given the near complete obstruction of the sigmoid colon, exploratory laparotomy was performed, which revealed a sigmoid stricture with densely adherent loops of small bowel. Sigmoidectomy with en bloc small bowel resection was performed. Pathology demonstrated mucosal ulceration with transmural inflammation and injury of the medium-sized vessels. Some of the medium-sized vessels in the mesentery had evidence of acute injury, while others appeared to be in the healing state with obliteration and recanalization of the lumen. This admixture of early and late lesions was felt consistent with PAN. The patient was discharged with GI, surgery and rheumatology follow up.

DISCUSSION:
PAN is a rare systemic vasculitis that can present with a wide range of symptoms including abdominal pain, nausea, vomiting, GI bleeding, diarrhea and weight loss. Intestinal stricture due to bowel ischemia can occur with resultant obstruction. The small intestine is the most common site of ischemia in the GI tract. As such the differential diagnosis of intestinal strictures should include chronic ischemia from systemic vasculitis.
1666 A Rare Case of Colonic Malakoplakia in an Immunocompetent Man With Prior Chronic Hepatitis C Virus Infection
Authors: Palmer Quinton D. , Broadfoot Brannon , Perisetti Abhilash , Johnson Kemmian D. , Garcia-Saenz-de-Sicilia Mauricio 
Published: October 2019

INTRODUCTION:
Malakoplakia is a rare chronic granulomatous condition related to a defect in macrophage phagolysosomal response in which engulfed bacteria are not destroyed. The urinary bladder is the most common site for malakoplakia to present and the gastrointestinal tract is a distant secondly reported site. Malakoplakia is often associated with conditions that cause immunodeficiency. We report a rare case of colonic malakoplakia (CM) in an asymptomatic, immunocompetent man with history of successfully treated hepatitis C virus (HCV) infection.

CASE DESCRIPTION/METHODS:
A 70-year-old African American man with a past medical history of treated HCV due to prior intravenous drug use, was referred by his primary care provider for screening colonoscopy. He was asymptomatic and clinical history was negative for inflammatory or other infectious diseases. He denied use of immunosuppressant medications. HCV RNA was undetectable. HIV serology was negative. No remarkable findings on physical examination. During colonoscopy, a single 5 mm sessile polyp was noted in the transverse colon and was removed (Figure 1). Histopathological analysis of polyp identified targetoid calcospherites on Von Kossa calcium stain consistent with Michaels-Gutman bodies, diagnostic of malakoplakia (Figures 2 and 3). On repeat colonoscopy four months later, a single 14 mm sessile polyp was found in the proximal descending colon with histopathology consistent with tubular adenoma. No findings suggestive of malakoplakia was noted, however, exam may have been limited due to poor bowel prep.

DISCUSSION:
In summary, malakoplakia has been reported to involve the urinary tract in approximately 75% of cases while the gastrointestinal tract is involved less than 10% of reported cases. CM is often associated with neoplasms such as adenocarcinoma, adenoma, and lymphoma and other non-neoplastic conditions such as infections, sarcoidosis, diabetes mellitus, alcoholic liver disease, immunosuppressive therapy, or other conditions of immunodeficiency. Though not previously reported, HCV could have played a role in development of CM. HCV as been reported to be associated with the development of cutaneous malakoplakia; therefore, we cannot exclude association of other extrahepatic manifestations. In conclusion, CM is a rare chronic granulomatous condition that can be incidentally found in immunocompetent individuals, more studies warranted to evaluate any association with HCV.
1670 Simultaneous Diagnosis of Colorectal Adenocarcinoma and Non-Hodgkin Lymphoma
Authors: Ginsberg Terrie , Powell Leonard , Shienbaum Alan , Truscello David , Shah Maulik 
Published: October 2019

INTRODUCTION:
This is a case of an 84-year-old female who presented to the hospital complaining of constipation secondary to a new rectosigmoid mass. Histopathologic examination revealed an invasive adenocarcinoma of the colon along with a previously undiagnosed small lymphocytic lymphoma (SLL) in the regional lymph nodes. It is highly unusual to make a simultaneous new diagnosis of two separate malignancies found from the same specimen. We aim here to enlighten readers to the likelihood of finding this presentation in affected patients.

CASE DESCRIPTION/METHODS:
An 84-year-old female was admitted for a 12-day hospital stay following a 2 week history of constipation. She was found to have a new rectosigmoid mass. Abdominal CT revealed new stranding of the perirectal fat with thickening of the adjacent segment of the rectosigmoid colon. Also seen was a small tissue lesion in the adjacent fat abutting the serosal surface of the rectosigmoid colon. Colonoscopy showed a near-obstructing mass lesion located within the rectosigmoid region at approximately 18 cm from the anal verge. The obstructing lesion was encompassing approximately 90% of the colonic lumen. She underwent exploratory laparotomy with lower anterior resection with end colostomy and appendectomy. Histopathologic examination demonstrated an invasive adenocarcinoma of the rectosigmoid measuring 6.5 cm in greatest dimension. The surrounding regional lymph nodes identified in the specimen were involved by a mature B-cell lymphoma most consistent with small lymphocytic lymphoma (SLL).

DISCUSSION:
Detailed histopathologic examination was undertaken to establish the diagnosis, prognosis, and treatment modalities. Dual diagnoses occur uncommonly and warrant a further and more detailed investigation. Histopathologic evaluation of the regional lymph nodes within the rectosigmoid resection utilizing immunohistochemical staining, showed that the lymphocytes of the lymph nodes stained positively with CD20, CD79a, CD5 (DIM), CD23, and BCL-2. This staining pattern supports the diagnosis of a mature B-cell lymphoma most consistent with small lymphocytic lymphoma. Simultaneous diagnosis of SLL and colorectal adenocarcinoma is largely coincidental. This simultaneous development may be the result of long-term immunosuppresion secondary to the previously undiagnosed small lymphocytic lymphoma (SLL). Such a finding warrants further investigation of potential mechanisms which may lead to the development of these two separate malignancies presenting simultaneously.
1677 Few Bumps in the Road Led to Surgical Prophylaxis: Cowden’s Syndrome
Authors: Fernandez Wilfor Diaz , Buse Paul E. 
Published: October 2019

INTRODUCTION:
PTEN syndrome is caused by a germline mutation in phosphatase and tensin homolog (PTEN) gene. As a syndrome, it has different clinical manifestations, Cowden syndrome being one of them. We present the case of a 41-year-old female found to have multiple polyps throughout the large and small bowel. Biopsy showed hamartomous type polyps and ganglioneuromas. Genetic testing revealed de novo PTEN mutation.

CASE DESCRIPTION/METHODS:
41-year-old female presented with acute diarrhea to the emergency department. Medical history was relevant for hypothyroidism secondary to thyroidectomy for goiter and multiple skin tags. Colonoscopy showed the small and large bowel carpeted with polyps and biopsies were taken. Pathology showed hamartomatous-type polyps and ganglioneuromas. Genetic testing was positive for PTEN de novo mutation. A multidisciplinary team was involved in the case for cancer surveillance. Estrogen/progesterone receptor positive and HER2-negative invasive lobular carcinoma was found after bilateral prophylactic mastectomy. Follow up endoscopy showed small esophageal nodules and multiple gastroduodenal polyps found to be hyperplastic on pathology. Hysterectomy is planned with subsequent Arimidex as adjuvant therapy.

DISCUSSION:
First reported in 1963, Cowden syndrome has a prevalence of 1 in 200,000–250,000 with 20–34% of individuals having germline PTEN mutation. PTEN acts as a tumor suppressor. A mutation of this gene leads to an increased prevelance of a variety of malignancies (colorectal, breast, thyroid, renal, endometrial skin, and brain) and non-neoplastic growths (trichilemmoma, papules, acral keratosis). The purpose of bringing attention to this very rare polyposis syndrome is increase awareness about the multidisciplinary approach needed for cancer surveillance. Annual physical exam should be performed starting at age 18; baseline screening colonoscopy at age 35 with follow up screening earlier than 5 years. Annual urinalysis and cytology to screen for renal cancer is recommended to start at age 35. Surveillance for thyroid cancer includes baseline thyroid ultrasound starting at age 18, and then annual thyroid exams thereafter. Women with PTEN mutations should have annual breast cancer screening starting at age 25. Our patient was advised to undergo appropriate cancer surveillance according to the National Cancer Center Network guidelines.
1678 When Crime Does Pay: How a Stolen Colon Went Viral and Raised Global Screening Awareness
Authors: Peterson Erin , DeBord Sarah 
Published: October 2019

INTRODUCTION:
On the night of October 19, 2018, a shipping container containing a 10' × 12' inflatable colon was stolen out of the back of a truck in suburban Kansas City, MO. The night of the caper, the colon was loaded and prepared to attend a breast cancer awareness walk on Saturday morning, ready to educate the people in attendance about colorectal cancer and the importance of screening. What would unfold over the next 10 days can only be described as the most unintentional global colorectal cancer awareness campaign ever. The message of the importance of screening would reach more than the 100s of people in attendance at that one event, it would reach 100s of millions of people.

CASE DESCRIPTION/METHODS:
Using traditional, online, and social media tracking tools the staff at the Colon Cancer Coalition, the owners of this now famous colon, were able to track the number of stories and the number of people who were exposed to this important health message. Throughout the 10 days that this visual and attention-grabbing educational tool was missing and in the immediate aftermath of its recovery on October 29, online media stories featuring the “stolen colon” totaled 962, reaching a potential 955,302,697 people. The #stolencolon hashtag on social media was shared over 6,500 times, resulting in over 36,050,000 impressions.

DISCUSSION:
This type of coverage of this unexpected crime is unprecedented. The stolen colon caught the attention of People Magazine, Forbes, The New York Times, and more. The lifesaving messages of colorectal cancer prevention and the importance of screening were found on the “Late Show with Stephen Colbert” to the Kansas City Police Department's Twitter feed. Commentaries took a light-hearted view of the incident, with an underpinning of the serious message of screening. The goal of using an educational tool such as an inflatable colon is to educate the public about the colon and preventative cancer screening. The surprising benefit to this unsolved crime is the conversations and engagement across the globe. An additional benefit of this petty thievery is the money donated to purchase an additional two inflatable colons. One person's wrongdoing resulted in an unprecedented conversation about colorectal cancer and the importance of screening for this largely preventable cancer.
1679 Polyposis With a Mutation in the CHEK2 Tumor Suppressor Gene
Authors: Greenberg Ian , Khan Omar , DePersia Allison 
Published: October 2019

INTRODUCTION:
Fifteen to twenty percent of colorectal cancer (CRC) is familial and genetic alterations are commonly encountered. Genetic testing is recommended in patients with a personal history of young onset CRC, significant family history of CRC, or high polyp burden, defined as having greater than 10 adenomas. Mutations in CHEK2 are associated with a variety of cancers, including CRC. However there is limited literature describing CHEK2mutations and polyposis.

CASE DESCRIPTION/METHODS:
A 47-year-old male with a personal history of thyroid cancer was evaluated for a six-month history of diarrhea. Family history was notable for multiple relatives on both sides with thyroid, breast, pancreatic, or colon cancer. Given progressive symptoms and family history, he underwent colonoscopy revealing 15 polyps varying in size, diffusely spread throughout his colon. Pathology revealed three polyps were tubulovillous adenomas with high-grade dysplasia, one polyp revealed focal invasive adenocarcinoma, and the remaining eleven polyps were low-risk tubular adenomas. Given the patient’s age, polyp burden, and complex cancer history, there was high suspicion for a genetic etiology of his thyroid cancer, colon polyps and CRC. He was referred for a genetic evaluation. A multi-gene cancer panel identified a heterozygous mutation, c.1072C > T (p.Gln358*) in CHEK2.

DISCUSSION:
Checkpoint kinase 2 (CHEK2) is a critical tumor suppressor gene that serves as an upstream regulator of p53. In response to DNA damage, CHEK2 prevents cell maturation and progression into mitosis. Malfunctioning leads to uncontrolled cell cycle progression without apoptosis. CHEK2 is a multi-organ cancer susceptibility gene linked to increased risk of breast, colon, thyroid and prostate cancer. In addition to a personal history of young onset colon cancer, the patient had a personal history of polyposis. This case report raises the question of whether CHEK2 is also a polyposis gene as this finding has important implications for carrier screening. Genetic evaluation for CHEK2, along with other CRC/polyposis genes, should be considered in young patients with a high-grade dysplastic adenoma, large polyp burden, or a significant personal or familial cancer history. Screening guidelines remain variable at this time and patients found to have a pathologic CHEK2mutation should receive a multidisciplinary approach for cancer screening. Further studies are needed to evaluate the association of polyposis and CHEK2 mutations.
1680 Endoscopic Cyanoacrylate Glue in an Actively Bleeding Gastric Tumor
Authors: Dike Uzoamaka K. , Mistry Tejal , Thosani Nirav 
Published: October 2019

INTRODUCTION:
1 to 5 percent of upper gastrointestinal bleeds are due to tumors and it is not atypical for re-bleeding to occur. Most patients who experience severe hemorrhaging esophageal and gastric tumors die within 12 months. Currently, there are no well-defined guidelines regarding the implementation of cyanoacrylate glue in bleeding gastrointestinal tumors. Our primary aim is to demonstrate a novel technique for achieving hemostasis in an actively bleeding tumor.

CASE DESCRIPTION/METHODS:
A 55-year-old female with no documented past medical history presented with hematemesis. The patient experienced an acute drop of hemoglobin from 10 g/dl to 8 g/dl. The patient reported moderate alcohol use and denied use of NSAIDS. EGD was first performed and revealed a pulsating extravasating tumor. This was followed by the use of EUS to identify the bleeding vessel. Under EUS-guidance, cyanoacrylate glue was then precisely injected to achieve hemostasis.

DISCUSSION:
EUS-guided cyanoacrylate glue injection is a cost-effective therapy that may successfully achieve hemostasis in active tumor bleeds. It can serve as a primary method for hemostasis or when re-bleeding occurs. However, its potential for reduced rates of re-bleeding warrants further investigation.
Watch the video: http://bit.ly/2YdnmbC.
1681 Achieving Hemostasis in a Gastric Tumor With Color Doppler-Endoscopic Ultrasound Guided Cyanoacrylate Glue
Authors: Dike Uzoamaka K. , Mistry Tejal , Thosani Nirav 
Published: October 2019

INTRODUCTION:
Up to 5 percent of upper gastrointestinal bleeds are due to tumors and re-bleeding is common. Most patients with severe hemorrhaging esophageal and gastric tumors have a poor prognosis, resulting in death within 1 year. Currently, there are no well-defined guidelines regarding the implementation of cyanoacrylate glue in bleeding gastrointestinal tumors. Our primary aim is to demonstrate a novel technique for achieving hemostasis in a tumor bleed.

CASE DESCRIPTION/METHODS:
A 63-year-old male with a past medical history of smoking, non-insulin dependent diabetes mellitus type 2, and hypertension presented with melena and early satiety. The patient denied the use of NSAIDS and alcohol. Evaluation by EGD demonstrated a gastric tumor with stigmata of recent hemorrhage in the form of a non-bleeding visible vessel. EUS was then used to locate this feeding vessel. Color doppler was then employed to confirm the target vessel and to subsequently guide the precise injection of cyanoacrylate glue into the vessel. The cessation of doppler flow after glue embolization confirmed hemostasis of the feeding blood vessel. During this procedure EUS-FNA was also utilized to extract a sample of tissue for diagnostic purposes with a 19-gauge needle.

DISCUSSION:
Color doppler-EUS guided cyanoacrylate glue injection is a cost-effective therapy that may successfully achieve hemostasis in tumor bleeds. It can be utilized to confirm hemostasis of the targeted vessel after embolization, during an endoscopic procedure. Endoscopic confirmation may reduce the likelihood of re-bleeding and additional procedures, thus, improving the quality of care.
Watch the video: http://bit.ly/2M5YAE1.