bluuebunny/crossref_metadata_2025_split huggingface dataset:
1635 Adenomas Masquerading as Filiform Polyps
Authors: Voaklander Rebecca , Seibert Donald G. 
Published: October 2019

INTRODUCTION:
We present a case of adenomatous filiform-like polyps, raising concern for an unrecognized neoplastic potential in these polyps which typically are of an inflammatory origin.

CASE DESCRIPTION/METHODS:
A healthy 64-year-old man with a history of tubular adenomas presented for a routine surveillance colonoscopy. He reported feeling well and denied any recent illness including abdominal pain, diarrhea or blood in his stool. He did not have a history of inflammatory bowel disease, infectious colitis, tuberculosis or histiocytosis X. On colonoscopy, a cluster of worm-like mucosal projections was found in his distal transverse colon. The shape was typical of filiform polyps. Under white light and narrow band imaging (NBI), the pit and vascular pattern of each polyp and stalk had a stacked hoop appearance (as opposed to the typical radial array pattern characteristic of an adenoma). The surrounding mucosa appeared normal with a clear demarcation at the base of the stalk. These polyps were completely removed at the base by cold snare polypectomy, including a small margin of normal appearing mucosa. Histopathalogic examination of the resected specimens consisted of primarily adenomatous tissue with a few small fragments of normal mucosa. There were no inflammatory nor serrated polyp features. Three other typical diminutive tubular adenomas were resected elsewhere in the colon.

DISCUSSION:
Filiform polyps are described as non-neoplastic inflammatory polyps. This is a case of adenomatous filiform-like polyps in a healthy adult without risk factors for inflammatory polyps. They were found in a cluster, which is more typical of filiform polyps rather than adenomas. The polyps appeared to have a stalk but were found to be comprised entirely of adenomatous tissue, necessitating resection at the base rather than transection through the pseudostalk. This unusual finding raises concern that endoscopists should be more cautious of these polyps and complete in their resections as they may have previously unrecognized potential for malignant transformation. A thorough examination of the entire polyp (including the stalk/pseudostalk) for atypical pit and vascular patterns with white light and NBI may aid in differentiating between benign and premalignant growths.
1639 Chronic Diarrhea Due to Pancolitis Caused by Trichuris trichiura
Authors: Adiwinata Sheila , Adiwinata Randy , Uwan Willy brodus , Gunawan Budiman 
Published: October 2019

INTRODUCTION:
Indonesia as one of the largest tropical countries in the world, shared the particularly high burden cases of parasitic colitis especially due to worm infections; Therefore patient with chronic diarrhea in tropical country should be evaluated for parasitic infections such as Trichiasis.

CASE DESCRIPTION/METHODS:
22-year-old woman presented with prolonged diarrhea with mucus and no blood since one month ago. She had two to four times bowel movements once a day. She also complained for having recurrent diffuse periumbilical pain and nausea every day. She also reported for having weight loss of 3 kg. She had no remarkable past medical history. She admitted for having poor hygiene lifestyle and using non purified ground water as drinking water. She previously had visited nearest hospital for consultation, the blood test showed hemoglobin of 12.8 g/dl, white blood cell of 28,000/mL; stool analysis showed positive microscopic erythrocyte and leukocyte without worm eggs or other parasites. Other laboratory value was normal. She was admitted and treated with Levofloxacin, attaplugite, and probiotic. After five days of hospitalization, no improvement was seen, therefore she was referred to our hospital endoscopy unit for colonoscopy. Colonoscopy examination showed inflammation of the entire colon with erosion and ulceration, also multiple Trichuris trichiura were found. She was treated with mebendazole. She had clinical improvement and re-colonoscopy was done after two weeks. Re-colonoscopy examination showed no inflammation and no worms were found.

DISCUSSION:
Patients with Chronic diarrhea in tropical countries should always be evaluated for parasitic infections. Stool examination and colonoscopy may be helpful to establish the diagnosis. Trichuris trichiura infections may manifest as asymptomatic infection or chronic diarrhea or dysentery which may mimic inflammatory bowel disease.
1644 Isolated Metastatic Colorectal Cancer Involving the Kidney and Adrenal Gland: A Rare Occurrence
Authors: Saha Aditi , Saha Biplab , Mabourakh Davita , Laharwal Mehak , Bajaj Nikki , Sapru Sunil 
Published: October 2019

INTRODUCTION:
Distant metastases in colorectal cancer (CRC) commonly involve liver, lung, brain and bone. Adrenal gland involvement is not uncommon on autopsy in the setting of diffuse metastatic disease. In most reported cases, it is seen as metachronous disease and is diagnosed during extensive work up or on follow up. Isolated synchronous disease involving the kidney and adrenal gland is extremely rare. We present a case where the diagnosis was established intraoperatively during a laparotomy performed for suspected primary adrenocortical malignancy.

CASE DESCRIPTION/METHODS:
A 66-year-old man presented with sudden worsening lower abdominal pain for 6 hours. The pain had started 4 weeks ago and was persistent, non-radiating. He reported a 50 pounds weight loss over the last 3 months. Physical exam was significant for tenderness over the right lower quadrant. Laboratory data showed anemia with hemoglobin of 8.3 g/dl. CT of abdomen and pelvis revealed a mass that was possibly originating from the right adrenal gland. MRI revealed a large heterogeneous, multilobulated, adrenal mass measuring 10 × 7.4 × 13.2 cm. A primary adrenocortical malignancy was suspected. Endocrine and metastatic work up was negative and a laparotomy was planned for adrenalectomy and possible nephrectomy. Intraoperatively, he was found to have an ulcerative tumor involving the terminal ileum and appendix penetrating through the serosa. Right hemicolectomy and nephrectomy with adrenalectomy were performed. Histopathology was consistent with poorly differentiated adenocarcinoma of colon with metastasis to right adrenal gland and kidney.

DISCUSSION:
Common primary tumors that metastasize to the adrenal gland include breast, lung and kidney. In most cases of CRC, adrenal or kidney metastases usually indicate distant hematogenous spread and are associated with poor prognosis. The mean survival is 7 to 8 months. However, CRC with isolated metastasis to adrenal gland and kidney is extremely rare. Retrospectively, an interesting feature in this case was the presumption of the metastatic lesion as the primary tumor as there was no radiologic abnormality involving the gastrointestinal tract. Surgical resection followed by chemotherapy has been shown to promote long term survival in several studies, but there is no prospective data due to the rarity of this condition. In patients with incidental finding of an isolated adrenal/renal mass, an evaluation for occult GI malignancy should be considered.
1645 A Case of Proctocolitis Secondary to the Use of Coffee Enema
Authors: Lee Anna , Kabashneh Sohaip , Rahim Usman , Khan Mir , Anees Mohammad , Levine Diane 
Published: October 2019

INTRODUCTION:
Proponents of coffee enemas advocate for its role in cancer treatment, where it is believed to detoxify via vasodilation and toxin excretion. However, there is no science-based evidence to verify these claims, and its use is associated with harmful effects, including electrolyte imbalances and death. We present a case of coffee-enema induced proctocolitis (PC).

CASE DESCRIPTION/METHODS:
A 40-year-old woman presented with acute abdominal pain, bloody diarrhea, and tenesmus. She denied recent travel or sick contacts. She had mixed-type IBS, but denied ever experiencing symptoms this severe. Her brother had ulcerative colitis (UC) and aunts had Crohn’s Disease. CT showed severe PC from rectum to descending colon. WBC 21.8, CRP 23, FLA was positive; however, C. Diff, shiga toxin, stool culture, lipase, LFTs were unremarkable. On day 2, she admitted to using 500mL of room temperature coffee enema to treat gallstones, hours prior to symptom onset, which “never came back out.” Flexible sigmoidoscopy displayed severe rectal inflammation, extending to 60cm depth. She was empirically started on Solu-Medrol. Biopsy revealed necrotic mucosa and purulent exudate, suggesting ischemic colitis (IC), but no crypt abscesses. Repeat sigmoidoscopy on day 10 showed improvement of damage, extending to 30cm depth. Clinical improvement was slow, and she was finally discharged on day 13.

DISCUSSION:
A few South Korean reports of coffee enema induced PC exist in literature. Our patient presented similarly to those cases, suggesting a consistent process through which it achieves its damage. PC occurs in UC, but our patient’s biopsy was more suggestive of IC. IC usually spares rectum due to rich blood supply; our patient’s rectum was not spared. Caffeine may decrease blood flow through a variety of mechanisms (e.g., blocking cGMP formation) and could lead to ischemia. Additionally, it blocks adenosine A2 receptors (AA2Rs). In animal models, AA2R activation attenuates intestinal inflammation, so inhibition may lead to inflammation. Our patient’s PC was likely due to direct contact injury, as well as damage from activation of inflammation and blood flow alteration. Our patient planned to follow up with her naturopathic doctor who recommended the enema. She blamed herself for using too much coffee and could not be persuaded that coffee enemas pose more risk than benefit. It is imperative we educate on risks of “natural” remedies and work to develop trusting relationships with patients so they accept evidence-based practice.
1647 To Flex or Not to Flex? A Case of Immune Checkpoint Inhibitor-Induced Colitis
Authors: Cerne Carlie , Ordway Sarah , Bhushan Anita 
Published: October 2019

INTRODUCTION:
Diarrhea is a frequent and well-recognized adverse effect of checkpoint inhibitor therapy, occurring in up to 30% of patients. Management depends on the severity of the symptoms and endoscopic investigation should not delay treatment. We report a case of a patient with metastatic melanoma who developed severe checkpoint inhibitor-induced colitis responsive to one dose of infliximab, and did not require flexible sigmoidoscopy.

CASE DESCRIPTION/METHODS:
A 46-year-old male with metastatic melanoma on Ipilumumab and Pembrolizumab developed diarrhea after his third infusion. He presented to the emergency room with two weeks of 6-7 watery bowel movements daily, nocturnal stools, cramping abdominal pain and nausea. He denied melena, hematochezia or tenesmus. He denied other medical conditions, recent travel, frequent NSAID or recent antibiotic use. His vital signs were normal; physical exam was notable for generalized abdominal tenderness without peritoneal signs. Labs were notable for WBC 9.4 × 109/L, hemoglobin 13.8 g/dL, CRP 1.39 mg/L, and negative HIV-1/2 Ag/Ab screen, C. difficile PCR, stool culture, ova and parasites, Entamoeba histolytica Ag, CMV IgM, and Quantiferon Gold. CT of the abdomen and pelvis with IV contrast showed increased attenuation of the colonic mucosa from the transverse colon to the rectum, compatible with colitis. He received IV methylprednisolone and maximum dose loperamide with no improvement after 3 days. He was diagnosed with presumed checkpoint inhibitor-induced grade 3 toxicity colitis for which he received one dose of infliximab IV 5mg/kg. His symptoms rapidly improved within 24 hours and he was discharged on a steroid taper. Due to his rapid improvement, a previously planned flexible sigmoidoscopy was not performed.

DISCUSSION:
Gastroenterologists are becoming increasingly familiar with colitis as an adverse effect of checkpoint inhibitors. About 1% of patients with severe disease require treatment with immunosuppressive medications such as infliximab. Endoscopic evaluation is recommended for severe or persistent disease to confirm the diagnosis. Our patient suffered from severe colitis which resolved with one dose of infliximab and steroid taper. We propose that when clinical presentation is consistent with severe checkpoint inhibitor-induced colitis and thorough infectious work up is negative, flexible sigmoidoscopy should not delay treatment and may not be necessary prior to treatment with infliximab.
1649 Bone Metastasis in Appendicular Skeleton: Rare Occurrence in Colorectal Cancer
Authors: Vekaria Pratikkumar , Raiyani Chandrika , Patel Ravish , Vaishnani Devin , Raiyani Tejas 
Published: October 2019

INTRODUCTION:
Colorectal cancer (CRC) is considered as preventable cancer if diagnosed in the early stage. It is also second leading cause of death from cancer in US. Bone metastases (BM) is uncommon presentation with CRC and if it occurs, it involves axial skeletal more than extremities. Many case studies also reports that survival after BM is considerably poor than without BM. Cancer type and genetic mutations also play an important role in such metastasis.

CASE DESCRIPTION/METHODS:
62-year-old female with pertinent Past Medical History of adenocarcinoma of colon with 5.4 cm Cecal lesion s/p right hemicolectomy with 0/14 positive lymph nodes. She received Capecitabine post-operatively. Approximately one and a half year later, patient developed progressive left knee pain. MRI knee showed left medial femoral condyle mass with associated soft tissue and bone scan showed increased uptake in the same area. She ultimately underwent biopsy which revealed adenocarcinoma consistent with colon primary. Subsequent PET CT showed parotid gland nodule and lung nodule. There was also a central mesentery node and a soft tissue density in T9-T10 anterior vertebrae. She was referred for palliative Radiation and chemotherapy- FOLFOX-Bevacizumab and bisphosphonate. Relevant labs: Adenocarcinoma type CRC - positive for CK-20 and CDX-2. K-RUS mutation in codon 12 and 13 No NRAS, BRAF V600E or V600K mutation CEA- Within Normal Limit.

DISCUSSION:
CRC is considered as a curable cancer if diagnosed in the early stage, but it can be deadly if it gets metastasize to other organ system. Some studies show that prognosis dependents on the site of metastasis. If metastases to liver or lung present and if they are resectable then it can have good prognosis. Nonetheless, bony metastasis is characterize as poor prognosis. Cancer type also matters in BM. Vatandoust & coworker suggested that with signet ring cell cancer, chances of getting BM is higher than other types of CRC (up to 23.7%). In our case, patient had adenocarcinoma type CRC and it is not commonly associated with BM. Our patient also had unusual type of BM that involves appendicular skeleton. To add, patient had K-RUS mutation and that is also not much common mutation type associated with BM. Thus, more molecular studies related to K-RUS and other mutations, and their association with BM need to be done. It can also help deciding appropriate treatment option at the early stage.
1650 A Case of Rectal Mucosa-Associated Lymphoid Tissue (MALT) Lymphoma Presenting as Telangiectasia: A Case Report
Authors: Shafi Amaan , Aziz Hamza , Maklad Muthena , Ohning Gordon 
Published: October 2019

INTRODUCTION:
The World Health Organization classification of lymphoid neoplasms consists of several marginal zone lymphoma subtypes, the most common of which is extranodal marginal zone lymphoma of mucosa associated lymphoid tissue (MALT lymphoma). Extranodal marginal zone lymphomas can stem from a number of epithelial tissues, including the lungs, thyroid, skin, and GI tract. Of all tissues with possible extranodal lymphoma involvement, the GI tract is the most common. However of these GI sites, colorectal lymphoma is rare, accounting for approximately 3 percent of the GI lymphomas and only 0.3 percent of all large intestinal malignancies. Symptoms including abdominal pain, occult bleeding, bowel obstruction and diarrhea are possible findings in patients with colorectal lymphoma. Findings on colonoscopy can include mucosal nodularity, ulceration and or even a mass.

CASE DESCRIPTION/METHODS:
This is a 68-year-old male with a past medical history of hemorrhoids who initially presented to clinic with complaints of hematochezia for 15 days. Patient denied any associated symptoms including fever, chills, nausea or vomiting. Physical exam revealed bright red blood per rectum. A colonoscopy was scheduled, during which the patient was found to have inflamed proximal rectal mucosa of which a biopsy was taken and sent for pathology report. Biopsy revealed diffuse infiltration of the mucosa by small lymphoid cells focally involving the epithelium which were positive for b-cell immunoperoxidase markers. These findings were consistent with malignant lymphoma (B-cell phenotype) of the extranodal marginal zone mucosa associated type. Following postoperative recovery, the patient opted for conservative management with repeat colonoscopy scheduled 6 months later.

DISCUSSION:
Extranodal marginal zone lymphomas can arise from numerous tissues. While these neoplasms often remain localized to the tissue from which the originate, diagnosis is critical because not only does recurrence frequently occur locally, but they also have the potential to transform into aggressive B cell lymphoma variants with eventual systemic spread. Although MALT lymphoma of the GI tract can present in different forms such as nodularity, ulceration or mass, this is a case of MALToma presenting in the form of telangiectasia. In this patient, correctly taking a biopsy of a telangiectatic region of mucosa resulted in diagnosis of a rare yet treatable pathology.
1651 Colon, Urothelial and Sebaceous Malignancy All in One: A Rare Presentation of Muir-Torre Syndrome
Authors: Kailas Shilpa D. , Mony Shruti , Duffoo Carla 
Published: October 2019

INTRODUCTION:
Muir-Torre syndrome (MTS) is a rare autosomal-dominant condition and phenotypic variant of Lynch syndrome caused by mutations in DNA mismatch repair genes MSH2, MSH6, and MLH1. Clinical diagnostic criteria include the presence of at least one sebaceous gland neoplasm and one visceral malignancy, often colonic or genitourinary. Compared to Lynch syndrome, the prevalence of MTS is likely underreported. We present a unique case of a patient with incidental findings of multiple visceral malignancies associated with skin cancer.

CASE DESCRIPTION/METHODS:
A 57-year-old Caucasian man presented for surveillance colonoscopy. His family history was significant for father with colon cancer at age 50, lung, and renal cancer. The patient was diagnosed with sebaceous adenocarcinoma, invasive squamous cell, and basal cell carcinomas requiring excisional surgery at age 46. Screening colonoscopy at that time was normal, with repeat after 7 years noting diminutive sigmoid tubular adenomas that were resected. Current colonoscopy revealed 14 colon polyps, multiple with high grade dysplasia, and an invasive sigmoid adenocarcinoma. Staging CT A/P was negative for metastatic disease. CEA was normal. The patient opted for left hemicolectomy instead of total proctocolectomy. Tumor pathology revealed moderately differentiated adenocarcinoma with negative margins (pT4N0M0). Colon cancer genetic testing showed lack of expression of MSH2/MSH6 and germline MSH2 mutation, confirming the diagnosis of MTS. A month later he developed hematuria and acute kidney injury that culminated in a new diagnosis of invasive high-grade urothelial carcinoma. Neoadjuvant chemotherapy was started with plan for cystectomy.

DISCUSSION:
MTS is a rare condition that warrants early recognition, regular follow-up and observation for new malignancies. Our case highlights the importance of awareness and the need for early, universal screening in high-risk individuals. MTS patients should undergo screening colonoscopy at ages 20–25 with surveillance every year thereafter to offer mortality benefit. If colon cancer is diagnosed, total rather than partial colectomy is preferred due to a high metachronous cancer rate of 25%. Patients and relatives should be counseled on increased risk of future malignancies. Reconstruction of family history may allow for the identification and selection of patients in whom to proceed with clinical, molecular, and immunohistochemical analysis. Clinicians must therefore be cognizant of this disease and its enduring effects.
1653 Large Cell Neuroendocrine Carcinoma of the Colon
Authors: Thomas Mathew J. , Chand Gaurav , Mohammed Suneel 
Published: October 2019

INTRODUCTION:
Neuroendocrine carcinomas heterogeneous group of tumors with variable clinical presentation and prognosis. Gastrointestinal neuroendocrine carcinomas are further divided into two types; small cell or large cell based on mitotic rate and or Ki-67 labeling by WHO or European Neuroendocrine Tumor Society guidelines. Large cell neuroendocrine carcinomas (LNEC) of primary colorectal origin are extremely rare and represent 0.25% of all colorectal cancers. LNEC are malignant and aggressive tumors which present in an advanced stage and median overall survival time is 4–16 months. LNEC can occur within the entire gastrointestinal tract and or biliary tract but are typically found within the colon, stomach and or rectum. Here, we report LNEC to highlight its clinical course and to expand clinician knowledge regarding this rare cancer.

CASE DESCRIPTION/METHODS:
82-year-old male who initially presented to his primary care doctors office with 4-month history of 20-pound unintentional weight loss with associated vague left lower quadrant abdominal pain. Computed Tomography of the abdomen/pelvis revealed mass-like mucosal thickening measuring approximately 5.9 cm × 6.5 cm involving the distal transverse/proximal descending colon and with innumerable hypodense lesions throughout the liver consistent with diffuse metastatic disease. Colonoscopy revealed circumferential fungating partially obstructing large mass in the within the mid-transverse colon. Histopathologic report from the endoscopic biopsy showed positive staining for pancytokeratin and synaptophysin, which was consistent with a large cell neuroendocrine carcinoma. Patient was evaluated by oncology and has started receiving carboplatin and etoposide chemotherapy for palliative purposes.

DISCUSSION:
LNEC rare subtype of neuroendocrine carcinomas, which are aggressive and often present in an advanced stage. Early detection and identification is essential as this malignancy has different treatment implications when compared to adenocarcinoma. Interestingly, extrapulmonary neuroendocrine tumors resemble small cell lung cancer where carboplatin and etoposide have established utility due to high mitotic rate. This is the treatment option chosen for our patient. Further studies will need to be done to determine optimal treatment regimens for this rare disease.