bluuebunny/crossref_metadata_2025_split huggingface dataset:
2594 An Unusual Case of Small Bowel Intussusception
Authors: El Imad Talal , Gao Yinglin , Gumaste Vivek 
Published: October 2019

INTRODUCTION:
Intussusception is the telescoping of a part of the intestine into a more distal segment. The first case of intussusception was reported in 1674 by Barbette and detailed in 1789 by John Hunter. It is often classified by location into entero-enteric (65%), Ileocecal (19%), Colo-colic (9%) and finally duodeno-duodenal (<5%). It typically presents between the age of 6 and 36 months making adult presentation rare. We report a rare case of Duodeno-duodenaI intussusception secondary to tubular adenoma.

CASE DESCRIPTION/METHODS:
A 57 year old African American female with a history of rheumatoid arthritis and hysterectomy presents to the emergency room with complaints of epigastric pain for two days. The pain was intermittent, aggravated by food, and associated with nausea and two episodes of vomiting. She denies any other symptoms or similar episodes in the past. Last bowel movement was reported a day prior to presentation. Vital signs upon admission were within normal limits. On physical examination abdomen was soft, non distended with epigastric tenderness. Blood work on admission was unremarkable except for White blood cell count of 11.6 k/ul and Lactate level of 1.6 mmol/L. Computer Tomography (CT) scan of Abdomen showed telescoping of the apparent 2nd and 3rd portions of the duodenum compatible with intussusception (Figure 1). Patient underwent upper endoscopy with biopsies that showed a 3 cm duodenal polypoid lesion with pathology revealing tubular adenoma (Figures 2 and 3). Patient's symptoms resolved 2 day after presentation with supportive care only. Patient underwent endoscopic submucosal dissection of the lesion.

DISCUSSION:
Adult small bowel intussusception is a very rare entity that accounts for 5% of all cases of intussusception and 1%-5% of intestinal obstructions. The diagnosis can be challenging as symptoms are nonspecific and includes abdominal pain, nausea and vomiting. CT scan was found to be the preferred imaging study with specificity of 100% and sensitivity of up to 87% in adults. It often shows a “target sign” on the sagittal view or a sausage-shaped mass on axial and coronal views. It is always associated with a lead point such as a lipoma, hamartomatous polyps. The etiology in our case was a tubular adenoma which makes it more intriguing. Although duodenal intussusception is rare, recognition is critical for institution of appropriate therapy and prevention of complications. It should be considered in the differential diagnosis of any abdominal pain with signs of bowel obstruction.
2604 Celiac Disease: No Longer a Diagnosis of Exclusivity
Authors: Kim Brian , Chaput Kimberly J. , Wey Bryan , Tayel Hussam 
Published: October 2019

INTRODUCTION:
Celiac disease (CD) is a chronic autoimmune enteropathy that occurs in genetically susceptible individuals when exposed to gluten proteins. In the past, CD was thought to be exclusive to Caucasians of European descent. With the advent of serological screening tests, CD has become increasingly recognized in other ethnic populations around the world.

CASE DESCRIPTION/METHODS:
A 56-year-old female of Indian descent was evaluated for chronic epigastric abdominal pain. The pain did not radiate and worsened with certain movements and spicy foods. She also reported an occasional acidic taste suggestive of reflux. Medical history included arthritis, hyperlipidemia, and a cholecystectomy. A colonoscopy performed two years ago was unremarkable. She underwent an EGD which demonstrated a normal esophagus, mild antral gastritis, and flattening of duodenal villi. Biopsies were obtained and an anti-tissue transglutaminase (anti-tTG) IgA level was ordered for suspicion of CD. Histology of the duodenal mucosa revealed moderate villous atrophy and increased intraepithelial lymphocytes. Anti-tTG IgA levels were elevated at 39 U/mL (normal 0–3 U/mL). H. pylori testing was negative. CD was diagnosed based on the histological findings and positive serology. The patient was instructed to begin a gluten-free diet (GFD) and referred to a medical nutritionist for further assistance. After starting a GFD, she reported significant symptomatic improvement.

DISCUSSION:
Few population studies in the past have looked at the prevalence of CD in non-Caucasian ethnic groups where the disease may have been underdiagnosed. Several recent studies suggest that gluten intolerance is more common than previously estimated in certain populations. Cataldo et al reported that 26–49% of Indian children presenting to tertiary care hospitals with chronic diarrhea had been diagnosed with CD.1 And a review by Yachha et al of an earlier study from the UK found 20 of 106 CD patients to be of South Asian origin.2 This case highlights the changing global paradigm of CD prevalence and provides valuable insight for clinicians in Western countries serving diverse immigrant populations. In conclusion, we recommend that physicians assess for CD without racial bias if clinical suspicion warrants an evaluation.
2605 Distal Intestinal Obstruction Syndrome Resulting in Gastric Perforation in a Patient With Cystic Fibrosis
Authors: Li Muyi , Syed Bakhtiar , O'Brien Corey 
Published: October 2019

INTRODUCTION:
Distal Intestinal Obstruction Syndrome (DIOS) is a unique entity that occurs in patients with cystic fibrosis. DIOS results from the accumulation of mucous and undigested food contents in the small intestine due to decreased luminal water secretion which ultimately leads a proximal obstruction that can cause perforation, shock, and death if not treated. DIOS has an incidence rate of 35 in 1000 adults with cystic fibrosis. Here, we present a unique of DIOS which resulted in gastric perforation.

CASE DESCRIPTION/METHODS:
A 43-year-old male with cystic fibrosis and double lung transplant was admitted with cramping abdominal pain and decreased oral intake. On admission, he was noted to have abnormal liver function tests with total bilirubin of 9.6 and alkaline phosphatase of 888. A CT scan showed dilation of his common bile duct to 1 cm with ultrasound demonstrating distal common bile duct stones. He underwent endoscopic retrograde cholangiopancreatography with stone extraction and improvement in abdominal symptoms. He received significant narcotics for pain, and his hospital course was then complicated by constipation, worsening abdominal pain, and emesis. Gastroenterology was consulted and recommended a nasogastric tube (NG) and hyperosmolar enema to treat DIOS. An NG tube was unable to be passed and the patient’s abdominal pain suddenly worsened. An upright x-ray was obtained and demonstrated lucency over the right crus with non-contrast CT confirming pneumoperitoneum suggestive of a small bowel perforation. He was emergently taken to the operating room where he was found to have a 2 cm gastric perforation. A gastric wedge resection and omental patch was performed. The patient’s post-operative course involved total parenteral nutrition, scheduled enemas, and strict NPO status. An upper GI series showed no extravasation of contrast. The patient was extubated, started on oral intake, and eventually discharged on an aggressive bowel regimen.

DISCUSSION:
This case highlights a rare complication of DIOS. Typically, patient with DIOS are at risk for intestinal perforation; however, this patient developed a gastric perforation possibly from prior area of structural weakness. This case also highlights the importance of an aggressive bowel regimen in patients with cystic fibrosis to prevent DIOS. Once DIOS is identified, hyperosmolar enemas such as hypaque enemas and oral laxatives containing polyethylene glycol should be used for aggressive treatment to stymie such complications.
2608 Teduglutide Therapy for a Patient With Chronic Intestinal Failure Following Multi-Visceral Transplantation
Authors: Kaur Randeep , Muszkat Yakir , Nagai Shunji , Jafri Syed-Mohammed 
Published: October 2019

INTRODUCTION:
The use of glucagon-like peptide-2 (GLP-2) agonists, such as Teduglutide, and recombinant human growth hormones (HGH), remain important for making advances in Short Bowel Syndrome and intestinal failure to reduce parenteral nutrition requirements. The efficacy of these agents have yet to be studied in the intestinal transplant population who experience decreased absorption with no evidence of acute rejection. We present a case of Teduglutide therapy for chronic intestinal failure following a multi-visceral transplant including stomach, pancreas and small bowel.

CASE DESCRIPTION/METHODS:
A 47-year-old Caucasian female presented with a history of corrected, congenital duodenal atresia, complicated by recurrent obstructions, requiring a Whipple procedure with bowel to bowel bypass and anastomosis. She developed short bowel syndrome and began to lose weight. She was placed on long-term total parenteral nutrition (TPN), with consequent hospital admissions for fungemia. She underwent a multi-visceral transplant including stomach, pancreas, and small intestine and placed on immunosuppressive therapy. Years later, she developed ongoing, severe watery diarrhea with recurrent need for TPN. She was placed on Pancrelipase and lipids, without any improvement. Intestinal biopsies repeatedly showed no signs of acute rejection or cytomegalovirus (CMV). Loperamide and Diphenoxylate were also trialed. Given a lack of progress, she was placed on Teduglutide. The patient experienced significant symptomatic improvement after 10 days of therapy. She was able to decrease her intravenous fluids (IVF) needs by 50%. After one month she again experienced worsening symptoms. She was placed on Linaclotide in addition to Teduglutide with the need to maximize TPN requirements. Repeat intestinal biopsies did not show evidence of infection or acute rejection. Teduglutide was discontinued after 10 months as it did not improve symptoms.

DISCUSSION:
Intestinal absorption can remain an issue in short bowel syndrome until transplant can be achieved. It remains problematic when multi-visceral transplant is performed and patients continue to experience malabsorption. Unfortunately, although our patient had a good initial response, this response did not persist and therefore therapy was discontinued. Research is ongoing to discover pharmacologic treatment options that significantly decrease the necessity of TPN and IVF. HGH and GLP-2 agonists are options at this time, however remain in question if they are effective long term.
2620 Salmonella typhi Gastroenteritis as a Rare Cause of Small Bowel Obstruction
Authors: Sandhu Sunny , Alhankawi Dhuha , Prajapati Devang 
Published: October 2019

INTRODUCTION:
Salmonella gastroenteritis is a common foodborne illness that presents with diarrhea, nausea, vomiting, and abdominal cramps or constipation after 6 to 72-hour incubation period, and resolves in 4–10 days. Small bowel obstruction (SBO) as a result of acute bacterial infection however is extremely rare. Here we report a case of SBO caused by Salmonella typhimurium, a rare clinical manifestation of the infection that has not been reported. In this case, we discuss how successful diagnosis and subsequent antibiotic therapy led to resolution of the small bowel obstruction.

CASE DESCRIPTION/METHODS:
A 72-year-old male with a history of remote testicular cancer, recent lung cancer pending resection, presented to the emergency department (ED) with fatigue, abdominal distention, vomiting and non-bloody diarrhea for 1 week. He reported having a new jalapeno artichoke dip a few days prior. No recent travel or prior abdominal surgery. In ED, vitals: BP 81/52, HR 117, RR 32, T 98.6. Exam showed abdominal distention with lower quadrant and rebound tenderness. Labs showed WBC 4 × 109/L (43% bands), lactic acid 7.3 mmol/L, and negative C. difficile. CT Abdomen showed significant small bowel dilation with abnormal thickening noted in the distal ileum; consistent with small bowel obstruction. He was admitted to ICU for sepsis likely secondary to SBO. IV fluids led to hemodynamic improvement, and conservative treatment with nasogastric tube and bowel rest were initiated. Serial X-rays showed persistent dilated bowel loops. Stool cultures returned day 4 for S. typhimurium, and ciprofloxacin was started with clinical improvement in 2 days. By day 7, X-ray showed resolution of dilated small bowel. Patient was transitioned to an oral diet and discharged in stable condition by day 9.

DISCUSSION:
Progression to SBO from Salmonella as in our patient, to the best of our knowledge has never been reported. Salmonella as a causal agent for enteritis or other complications can be extremely difficult to diagnose if not suspected. Terminal ileitis on CT can lead to mimicking of other diseases such as Crohn’s, however an infectious etiology should remain on the differential, even in the setting of SBO. Although definitive diagnosis is based on culture, CT findings of circumferential and homogenous thickening of the terminal ileum in the appropriate clinical context can also help facilitate timely initiation of antibiotics and avoid possible aggressive interventions including surgery
2622 A Case of Metastatic Renal Cell Carcinoma to the Jejunum Presenting as Iron Deficiency Anemia
Authors: Roccato Mary Kathryn , Choi Alyssa , Duh Erica , Samarasena Jason , Parekh Nimisha K. 
Published: October 2019

INTRODUCTION:
Small bowel malignancies comprise only 0.35% of all malignancies and small bowel metastases only comprise 2% of malignancies, only 7.1% of which are from a primary renal cell carcinoma (RCC).This case demonstrates a rare metastatic RCC of the small bowel diagnosed through video capsule endoscopy (VCE) prompting an antegrade double-balloon enteroscopy (DBE).

CASE DESCRIPTION/METHODS:
A 53-year old male with hypertension, diabetes mellitus, and anemia presented with a rapidly worsening, necrotic right lower quadrant abdominal wall lesion. Dermatopathology from a wound edge biopsy demonstrated an ulcer with neutrophils and karyorrhectic debris, consistent with pyoderma gangrenosum (PG). He was found to have iron deficiency anemia (IDA) requiring multiple blood transfusions and iron infusions. Colonoscopy and esophagogastroduodenoscopy were unremarkable. VCE demonstrated markedly abnormal mucosa in the proximal jejunum, occupying at least 75% of the lumen with several satellite lesions. Antegrade DBE revealed a large ulcerated jejunal mass with leakage of serosanguinous fluid. Pathology showed poorly-differentiated carcinoma of unknown etiology. Pan-CT revealed a 5.6 × 5.4 cm solid mass in the right kidney with invasion of the right renal vein with thrombus extending into the inferior vena cava, liver masses, and pulmonary nodules consistent with metastatic renal cell carcinoma.

DISCUSSION:
This is a rare case of RCC metastatic to the small bowel. Only three other case studies report this in the literature. Approximately 25–30% of patients have metastatic disease at time of RCC diagnosis. The most common sites of metastasis for RCC include lymph nodes, lung, bone, liver and brain. Metastasis to the small bowel often originate from cancers of the breast, lung, esophagus, head and neck, and melanoma. While there have been case reports of jejunal metastases many years status-post nephrectomy, there have only been three reported cases of synchronous jejunal metastases from RCC. Metastatic RCC to the small bowel can present as gastrointestinal bleeding and intussusception. VCE and DBE were useful diagnostic tools in our particular case. CT or MR enterography may have also served as an appropriate diagnostic alternative, and in retrospect may have helped to make the diagnosis sooner. Overall, it is important to consider small bowel malignancy on the differential diagnosis in a patient who presents with IDA.
2624 A Classic Case of Peutz-Jeghers Syndrome Presenting as Recurrent Intussusception
Authors: Shenoy Vinayak , Park Connie , Nguyen Andrew , Okolo Patrick 
Published: October 2019

INTRODUCTION:
Peutz-Jeghers syndrome (PJS) is a rare autosomal dominant genetic disorder associated with mucocutaneous hyperpigmentation and hamartomatous gastrointestinal polyps. Here, we present a case of PJS presenting as abdominal pain due to recurrent intussusception in a patient without family history of gastrointestinal conditions.

CASE DESCRIPTION/METHODS:
A 28-year-old African American female with a remote history of intussusception and small bowel resection presented with 5 days of epigastric pain. An EGD and colonoscopy from years prior reportedly revealed multiple benign polyps. There was no family history of PJS, gastrointestinal, ovarian, or endometrial cancer. On exam, right lower abdomen was tender and oral mucosa revealed hyperpigmentation. Labs were notable for iron deficiency anemia with a hemoglobin of 8.3 g/dL. Abdominal CT revealed a left lower quadrant enteroenteric intussusception with a 2.3 cm small bowel tumor functioning as a lead point and a 3 cm cecal mass. Retrograde enteroscopy to evaluate the small bowel tumor revealed ileal nodules, no intraluminal cecal mass, and 2 ileal polyps that were resected. Pathology showed polypoid fragments of ileal mucosa with marked submucosal lymphoid aggregates. Upright abdominal Xray was obtained for worsening abdominal pain and peritoneal signs, which showed an air fluid level in the small bowel, concerning for obstruction. She underwent a diagnostic laparoscopy revealing a cecal mass and ileal intussusception. She had an ileocecectomy and small bowel resection with a large polypoid mass in the resected ileum. Histology of the cecal mass revealed a cystic nodule of benign small bowel mucosa and the ileal polypoid mass demonstrated a hamartomatous polyp with ectopic extension into the muscularis propria, suggestive of PJS. Subsequent STK11 gene analysis revealed an exonic deletion, confirming the diagnosis.

DISCUSSION:
Up to 69% of patients with PJS experience intussusception. The risk of intussusception reaches 50% by age 20 in these patients. Although the association of PJS with intussusception is well-known due to polyps functioning as lead points, PJS is rarely diagnosed on recurrence of intussusception. Endoscopic polyp removal is recommended in these patients to avoid complications of surgery but surgical resection remains the definitive treatment in most cases. Recurrent intussusception in adult patients is a finding that should elicit consideration of PJS in patients with a history of polyps and no significant family history.
2632 Balloon Dilation via Colonoscopy to Treat Small Bowel Obstruction as a Complication of Surgical Resection of Carcinoid Tumor
Authors: Patel Pratik , Phan Ethan , Jampala Nannaya , Mudireddy Prashant 
Published: October 2019

INTRODUCTION:
Metastatic neuroendocrine neoplasms (NENs) are prevalent at initial prognosis. Surgery with the aim to cure is the current recommended guideline. However, there is not data in supporting therapy for complications from surgery. We successfully treated anastomotic stricture using endoscopic dilation, a modality recommended for treating of Crohn’s Disease stricture.

CASE DESCRIPTION/METHODS:
69-year-old female with a history of HTN, hypothyroidism and metastatic Small Bowel Carcinoid Tumor s/p small bowel resection complicated by post-op ileus and now high grade small bowel obstruction (SBO). Initially diagnosed with carcinoid with imaging showing 2.2 × 1.4 cm nodularity in small bowel and mesenteric nodal involvement with elevated chromogranin and 5-HIAA. PET scan showed ileocolic mesenteric adenopathy with no hypermetabolic activity noted. Pathology from small bowel resection revealed high grade carcinoid tumor, for which octreotide therapy was initiated. Patient later developed a high grade SBO at the anastomotic site. She underwent colonoscopy and anastomotic stricture with severe stenosis of 3 mm was noted 10 cm from the ileocecal valve. A Visiglide wire was successfully passed through the stricture under fluoroscopic guidance. She was then serially dilated to 12 mm using a pyloric balloon dilator. Improvement in luminal narrowing was noted after dilation. Output from nasogastric tube began to decrease and her abdominal pain slowly improved. A few days later she began moving her bowels and nasogastric tube was removed. She was advanced from liquid to soft diet and was discharged in stable condition.

DISCUSSION:
Metastatic intestinal and pancreatic NENs represent 40–50% at initial diagnosis. Besides systemic therapies, current consensus guideline for metastatic NENs recommends for surgical resection with locoregional or ablative therapies. One complication of surgical resection is the development of anastomotic strictures. Strictures in the small bowel are commonly seen in Crohn's Disease. Literature has shown great success with endoscopic balloon dilation for the management of Crohn’s associated strictures. However, small bowel strictures as a complication of surgical resection of carcinoid tumors is not well documented. Our case illustrates how using an endoscopic technique known to manage Crohn’s complications can be novel to cases with similar pathophysiology but different etiology.
2640 Intractable Celiac Disease in IgA Deficiency
Authors: Gonzalez Lisandro , Lewis Megan , Kataria Archish , Gondin Lyan , Parker Allan L. 
Published: October 2019

INTRODUCTION:
Celiac disease is an immune-mediated disorder triggered by a reaction to gluten with elevated levels of IgA antibodies. Symptoms typically resolve with a gluten free diet. However, refractory cases have been reported despite dietary adherence. Our discussion involves an elderly woman with severe, refractory celiac disease with concomitant IgA deficiency.

CASE DESCRIPTION/METHODS:
An 80-year-old woman presented our clinic with exacerbation of chronic, non-bloody diarrhea. She has a history of celiac disease diagnosed 20 years ago after an episode of acute pancreatitis. She also has IgA deficiency and her total IgA level remains low at 37, despite infusions 3 times per week. She is strictly adherent to a gluten free diet, but continues to have multiple episodes of diarrhea and has lost over 100 pounds since her diagnosis. Patient had bidirectional endoscopy notable for antral gastropathy as well as fissures and flattening of the duodenal mucosa. Biopsies were consistent with celiac sprue. Capsule endoscopy showed diffuse flattening of the small bowel villi with erythema and cracked, scalloped mucosa as well as multiple, small, aphthous ulcers throughout the bowel (Figures 1, 2, and 3). Patient has had an extensive workup, but everything else have been unrevealing. Steroids have been initiated as a last-ditch effort, but she continues to have “more bad days than good days” despite being on a high dose prednisone.

DISCUSSION:
The diagnosis and treatment of celiac disease can be complicated by coexisting immunodeficiencies. Usually, titers of tissue transglutaminase IgA will be elevated and are involved in the immune reaction that causes damage to the lining of the small bowel with characteristic flattening of the villi as well as chronic diarrhea and malabsorption. A connection between IgA deficiency and celiac disease has been well established and likely contributes to the refractory nature of our patient’s disease. In patients with IgA deficiency it is important to utilize other forms of serologic testing, typically with IgG tissue transglutaminase, in addition to duodenal biopsies. Symptoms typically resolve with a gluten free diet. However, refractory cases have been reported with persistent diarrhea and villous atrophy for over 1–2 years. Symptom management can be difficult for these patients and may require the use of steroids as the last resource.