bluuebunny/crossref_metadata_2025_split huggingface dataset:
3081 Four Severe Adverse Events Within One Week in a Patient With Ulcerative Colitis in the Setting of Prolonged High-Dose Steroid Use
Authors: Campos Marilia , Torrealba Mauricio , de Groen Piet 
Published: October 2019

INTRODUCTION:
Prolonged high-dose steroids are known to predispose patients to opportunistic infections and bowel perforation. Here we present a unique case with Inflammatory Bowel Disease (IBD) who within 6 weeks developed four high-dose prednisone-related complications, including clostridium difficile (C. Diff) and cytomegalovirus (CMV) colitis, herpes simplex virus esophagitis and lastly colonic perforation. This case highlights the challenges of steroid refractory ulcerative colitis and the importance of alternative medications like biologics when patients don't have an adequate response to intravenous steroids in order to prevent iatrogenic immunosuppression-related adverse events.

CASE DESCRIPTION/METHODS:
A 73-year-old male had a past medical history of pan-UC presented to his primary care provider with diarrhea; tests for infectious causes, including C. Diff and CMV, were negative and colonoscopy with biopsy specimens supported a diagnosis of severe UC. Patient was started on prednisone and mesalamine but presented to the ED 2 weeks later due to ongoing symptoms. C. Diff was again ruled out and he was discharge on same dose of prednisone and mesalamine. 2 weeks later he was hospitalized for worsening abdominal pain, diarrhea and weight loss. Stool testing for C. Diff was positive so he was switched to intravenous methylprednisolone and oral vancomycin. During this time he was also found to have biopsy proven CMV colitis and HSV esophagitis. Despite treating him with ganciclovir, the patient remained symptomatic; CT was obtained which revealed free air due to a sigmoid perforation. The patient underwent a total abdominal colectomy with ileostomy. His post-operative course was unremarkable is currently off all immunosuppressive therapy, h as an ileostomy and overall is doing well.

DISCUSSION:
UC refractory to high dose steroid treatment is evident within one week after initiation of treatment. At that time, a change in treatment needs to be made and biologics should be considered in patients not responding to steroids. Our patient initially had negative serum (CMV) and stool (C. Diff) tests which led to ongoing steroid use. CMV typically develops after four or more weeks of severe immunosuppression. Herpes can flare up in anybody who is deeply immunosuppressed and colonic perforation – if associated with high-dose steroids – typically occurs also after four or more weeks of treatment. Our case illustrates that high-dose steroids can cause many complications within a short duration in a single patient.
3086 “Knot” Your Average Nasogastric Tube
Authors: Bernica Jessica , Deng Nanfu , Cole Rhonda A. , Ketwaroo Gyanprakash Avinash , Hair Clark 
Published: October 2019

INTRODUCTION:
A nasogastric tube (NGT) is commonly used for gastric decompression or enteral nutrition. Placement is usually safely performed blindly with positioning confirmed on plain x-rays. NGT self-knotting is a rare complication that requires awareness as management may necessitate urgent endoscopy.

CASE DESCRIPTION/METHODS:
An 88-year-old man presented with nausea and vomiting, and was found to have a small bowel obstruction. He was managed conservatively with NGT placement for decompression. Due to low output, the tube required manipulation and repositioning. Upper GI series with small bowel follow was obtained for further evaluation with fluoroscopy images revealing a knotted NGT with the tip in the mid esophagus. Attempts were made at removal, but it could not be withdrawn or advanced due to patient discomfort. The patient underwent EGD which confirmed that the knotted NGT was lodged at the upper esophageal sphincter. The NGT was advanced under direct visualization to the stomach where the knotted end was snared. After cutting the proximal end exiting the nare, the knotted NGT was withdrawn endoscopically via the mouth. The patient eventually had resolution of his small bowel obstruction and was discharged.

DISCUSSION:
Though generally considered safe, NGTs are associated with a variety of complications occurring at a rate of 0.3% to 8%. These include aspiration, pneumothorax, tracheal misplacement, esophageal perforation, epistaxis, mediastinitis, and sinusitis. NGT function may be compromised by kinking, malpositioning, and occlusion of the tube. With the literature limited to few case reports and series, the true incidence of NGT self-knotting is unknown. NGT knotting increases risk for further complications such as respiratory difficulty and trauma to the nasopharynx, larynx, and esophagus, including tracheoesophageal perforation or fistulization. NGT knotting may occur from faulty insertion, altered anatomy, repetitive manipulation, narrow bore design, excessive length of tubing in the stomach, prolonged duration of placement, violent peristalsis, and softening of the tube at body temperature. NGT knotting should be considered in patients with any resistance upon attempts at removal. Plain radiographs or fluoroscopy can detect knotting. Various methods for removal of knotted NGTs have been described, generally involving cutting and removing the knotted part through the mouth with the help of direct laryngoscopy or EGD, as illustrated by this case.
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3157 Sweet's Syndrome: A Rare Cutaneous Manifestation of IBD
Authors: Huda Syed A. , Alam Syed Hammad , Chandravanka Chaitanya S 
Published: October 2019

INTRODUCTION:
Sweet's syndrome (SS) is one of the rare cutaneous presentations associated with Crohn's disease. SS is characterized by a sudden onset of painful, edematous, and erythematous papules, plaques or nodules on the skin along with fever and neutrophilia. Here we present a case of SS in a patient with Crohn's disease.

CASE DESCRIPTION/METHODS:
A 29-year-old gentleman with a past medical history of Crohn's disease that was well controlled on mesalamine and infliximab infusions presented with a one week history of numerous erythematous papules on the chest and back and a few pustules around hair follicles on the upper torso. At the time of presentation, he was febrile and had elevated WBCs with a neutrophilic predominance. ESR was 63 and CRP was 11.2. Based on the presentation, he was diagnosed with Varicella infection and treated with Valacyclovir. However, he continued to be febrile with worsening new eruptions. Labs including VZV & HSV PCR, viral cultures, fungal cultures, hepatitis panel, HIV and RPR were negative so the patient underwent a skin biopsy to investigate the etiology of the rash. Biopsy showed diffuse infiltration of the epidermis and dermis by a neutrophil-rich inflammatory cell infiltrate without any signs of leukocytoclastic vasculitis. This was consistent with the histopathological findings seen in Sweet's Syndrome. His antivirals were discontinued and he was started on a high dose prednisone taper with a resultant dramatic improvement in signs and symptoms. Over the next 7 days his rash resolved with normalization of white count and inflammatory markers.

DISCUSSION:
SS can be clinically classified into malignancy associated SS, drug induced SS or classic (idiopathic) SS most commonly associated with infections, inflammatory diseases or pregnancy. Classic SS usually appears in the active phase of inflammatory bowel disease. Our patient had uncontrolled CD for two years, but he had not had any extraintestinal manifestations during this time. Moreover, Infliximab has been used to treat steroid non-responsive SS. Our patient developed the syndrome even though he was on infliximab. Sweet's Syndrome should be one of the differentials when a patient with IBD presents with painful pustular rash and fever.
3159 A Case of Takayasu's Arteritis in a Patient With Crohn's Disease
Authors: Sadiq Bitaal , Fourment Chris , Smith Jeffrey 
Published: October 2019

INTRODUCTION:
Takayasu's Arteritis is a rare, chronic inflammation of the large vessels, particularly the aorta and its primary branches. Though etiology is largely unknown, the pathogenesis is thought to be due in part to inflammation in vascular tissue. The vast majority of cases worldwide have been in females from 10-40 years of age. Cases of Takayatsu's Arteritis have been reported in patients with Inflammatory Bowel Disease.

CASE DESCRIPTION/METHODS:
We present the case of a 41 y/o Caucasian female, with long standing Crohn's Disease (2006) who reports to our clinic for evaluation in 2010. At the time of presentation, Crohn's symptoms were mild. Over the next four years the patient had multiple flares and was treated with multiple agents. In 2017 she underwent a laparoscopic hemicolectomy after colonoscopy revealed a marked stricture proximal to her terminal ileum.

DISCUSSION:
Pathology from the surgery revealed a neuroendocrine tumor. Subsequent Osteoscan was negative but a CT revealed circumferential thickening of the proximal thoracic aorta at the origin of the left subclavian artery, indicative of aortitis. The findings were consistent with a diagnosis of Takayatsu's Arteritis.
3161 A Rare Cause of Duodenal Perforation From Migrated Biliary Stent Managed Endoscopically
Authors: Barlass Usman , Amin Jaimin , Singh Ajaypal 
Published: October 2019

INTRODUCTION:
Biliary stent migration is not uncommon (6-10%). A resultant duodenal perforation is however a rare complication (<1%) often associated with significant morbidity and can require surgery. Here we present a rare case of a duodenal perforation from plastic stent migration which was successfully managed endoscopically with through-the-scope (TTS) clips.

CASE DESCRIPTION/METHODS:
A 75 years old lady with history of painless obstructive jaundice, CT imaging with a hilar soft tissue mass and intrahepatic biliary dilation underwent endoscopic ultrasound (EUS) and endoscopic retrograde cholangiography (ERCP). A 7 Fr × 15 cm plastic biliary stent was placed into the right system after sphincterotomy and stricture dilation. The left system could not be accessed. Post procedure liver chemistries improved and she was discharged on antibiotics with close follow up. Patient developed lower abdominal pain and presented to the emergency department approximately 48 hours after ERCP. CT abdomen revealed biliary stent migration with concern for duodenal perforation and extraluminal air with heterogenous free fluid. Emergent upper endoscopy (EGD) showed migration of plastic biliary stent with distal tip protruding through the lateral wall of the second portion of the duodenum. The stent was removed using rat-tooth forceps revealing a 3 mm mucosal defect which was closed with TTS clips. Hospital course was complicated by fevers and repeat imaging showed increasing size of air and fluid collection. Repeat EGD showed a visible area of leakage on one edge of the previously repaired perforation. This was closed with hemostatic clips. Small bowel follow through studies at day 3 and 7 post procedure confirmed no contrast extravasation to suggest a persistent duodenal leak. Her diet was advanced and she was discharged with clinic follow up.

DISCUSSION:
Duodenal perforation from biliary stent migration is rare and limited case reports present the use of TTS clips in endoscopic management. In our patient the plastic biliary stent was endoscopically visualized protruding through the opposite wall of the duodenum while the proximal end was still in the biliary tree, likely creating enough force to cause a perforation. Although the initial attempted closure with TTS clips revealed no leakage immediately post procedurally, there was persistent leakage requiring repeat endoscopy and further clips for closure. A high morbidity surgical procedure can be avoided by this endoscopic approach even if there is a recurrence of leakage.
3174 Carcinoid Metastasis With Unknown Primary Tumor Origin
Authors: Wieckowska Joanna , Patel Kruti , Minaudo Mark 
Published: October 2019

INTRODUCTION:
Carcinoid tumors are rare, slow-growing neuroendocrine tumors found throughout the gastrointestinal system. However, in 3% of cases, the primary tumor is never found. Because establishing the diagnosis and primary tumor location can be challenging, we present the case of an incidentally found metastatic carcinoid tumor to the liver without an identifiable primary.

CASE DESCRIPTION/METHODS:
A 60-year-old male presented to the Emergency Department with nausea, vomiting, vague abdominal pain, and profuse, cyclic diarrhea. RUQ US showed gallstones, hence he underwent cholecystectomy for presumed symptomatic cholelithiasis. During the procedure, a right focally hemorrhagic hepatic nodule lateral to the gallbladder was noted and completely resected. Pathology revealed a well-differentiated neuroendocrine tumor concerning for carcinoid metastasis. Subsequent CT Abdomen/Pelvis with Contrast was unremarkable except for ascending sigmoid colitis and diverticulosis. OctreoScan revealed two questionable foci in the right hepatic lobe and focal uptake in the proximal duodenum. This was concerning for possible origin, and the patient underwent an EGD, which did not reveal anything suspicious. Concomitant biopsies were also negative. In light of his ongoing vague abdominal pain and diarrhea, he underwent a colonoscopy that noted no obvious colonic carcinoid. Biopsies were consistent with chronic colitis. He was prescribed Lialda with improvement in diarrhea. At follow-up, his Chromogranin A was elevated at 1030 ng/mL; ESR and CRP were elevated at 37 mm and 0.8 mg/dL, respectively. Next, he underwent PET DOTATATE, which found hyperactivity in the right and left hepatic lobes and a focus in the mid-sternum compatible with osseous metastasis. Further investigation with MR Enterography revealed extensive, chronic diverticulitis with a colovesical fistula, an intramural sigmoid abscess, and two sites highly suspicious for liver metastasis. Despite these diagnostic modalities, primary tumor location has still not been found. As the patient remained asymptomatic, observation without medical intervention was recommended.

DISCUSSION:
Metastatic carcinoid tumors of unknown origin are ultimately diagnoses of exclusion after an extensive workup. Early diagnosis is imperative to survival. Therefore, familiarity with the clinical signs, symptoms, and diagnostic modalities of carcinoid syndrome may expedite early detection and diagnosis and improve overall prognosis.
3175 Gynecological Intervention Leading to Multiple Gastrointestinal Events
Authors: Sonpal Niket , Olaosebikan Kikelomo 
Published: October 2019

INTRODUCTION:
This study follows a case of a right ovarian cystectomy gone wrong. Ninety studies published between 1972-2014, representing 474,063 gynecologic laparoscopies. Six hundred and four bowel injuries were reported for an incidence of 1 in 769. The rate of bowel injuries was dependent on the type of procedure. The small bowel happens to be the most frequently injured in the gastrointestinal tract, with about 166 of 354 (45%) of the cases. The majority of these injuries were due to veres needle or trocar placement with about 201 of 366 (55%) (Llarena N.C et al 2015). This review is to evaluate the gastrointestinal complications that accompanied a trocar induced injury during a gynecological procedure.

CASE DESCRIPTION/METHODS:
A 28-year-old female presented to the ED with septic shock. History obtained from relative stated the patient had a right ovarian cystectomy performed a week before ED visit. Post-op, the patient had increasing abdominal pain which worsened until EMS was called. An abdominal ultrasound showed central vowel dilation predominantly in the small bowel in correlation with ileus. CT abdomen showed free air throughout the abdomen large amount of fluid including the edge of the liver with infarcts in the Liver and spleen. Comprehensive Metabolic Panel showed AST- 5974, ALT- 2472, LDH- 1195 Total bilirubin- 1.5, direct bilirubin- 1.91, Amylase- 155. Complete Blood Count with WBC- 20.70. Coagulation with INR- 2.39, Fibrin > 700. The above test after consultation with specialists indicated Ischemic hepatitis “shock liver” with very strong indications due to hepatic infarction as a result of hemodynamic instability (Friedman L.S et al 2018). Other complications included small bowel ileus, peritonitis due to perforation and systemic involvement as a result of shock.

DISCUSSION:
In conclusion, gastrointestinal complications are rare after a laparoscopic procedure. Irrespective of their frequency can result in mortality. The best approach lies in the surgical technique and experience. Early recognition is the best way to avoid further complications as a delay could result in sepsis and untimely death. In an event of a suspected gastrointestinal injury, general surgical consultation should be sought, and a management strategy implemented. (Karadag M.A et al 2015).
3182 Spontaneous Bacterial Peritonitis in Cardiac Ascites: A Rare but Deadly Occurrence
Authors: Canakis Justin , Canakis Andrew , Ostrander Thomas 
Published: October 2019

INTRODUCTION:
Spontaneous bacterial peritonitis (SBP) is frequently described in cirrhotic patients who develop infected ascitic fluid. The phenomenon of SBP in cardiac ascites is rare. Here we present a unique case of a patient who was admitted for advanced cardiorenal syndrome in the setting of a gastroenteritis that likely promoted a bacterial translocation resulting in SBP.

CASE DESCRIPTION/METHODS:
An 85M presented from a nursing facility with lethargy, confusion and non-bloody diarrhea. Medical history was significant for congestive heart failure (CHF) and chronic kidney disease. No history of alcohol use. Upon arrival to the hospital, he was noted to be confused with a mildly distended abdomen, asterixis and two plus lower extremity pitting edema. The patient was admitted for a CHF exacerbation and metabolic encephalopathy. Initial labs revealed a BNP 3915, WBC 11,500, BUN 89, creatinine 3.5, total bilirubin 2, AST 22, ALT 9, and INR 1.27. An abdominal CT scan showed a moderate amount of intraperitoneal fluid. A diagnostic paracentesis was performed. The aspirated fluid was dark yellow and opaque with a serum ascites albumin gradient of 1.9 g/dL, total fluid protein 3.3 g/dL, 1,115 PMNs cells/mm3, 49% polymorphonuclear leukocytes. To much surprise, these findings demonstrated cardiac ascites resulting in SBP. There was no evidence of cirrhosis. Antibiotic treatment was initiated. Unfortunately, the patient exhibited a rapid decline renal function, and expired shortly afterwards.

DISCUSSION:
Due to the liver's extensive vascular supply it is prone to hemodynamic disturbances which can result in passive hepatic congestion from right sided heart failure. Recent studies have supported the diagnostic utility of serum BNP levels to distinguish ascites from cirrhosis or heart failure. It has been generally well accepted that the low occurrence of SBP in cardiac ascites may be related to the protein rich ascitic fluid that has both opsonic and bactericidal activity. Interestingly, the “gut hypothesis” suggests that intestinal hypoperfusion and congestion can lead to altered gut morphology, permeability, and the growth of microbiota that may ultimately stimulate bacterial translocation and endotoxin release. This case tends to shed light on a few quintessential points for clinicians to be aware of, including the potential intersection between the microbiota and metabolic effects of CHF and the necessity to lower the diagnostic threshold for SBP cardiac ascites in patient's presenting for a CHF exacerbation.
3190 Gender Differences in Acute Hepatotoxicity Associated With Cocaine Use: A Case Report and Brief Literature Review
Authors: Bello Fatimah O. , Rivera Arturo Suplee , Rivas Cynthia , Tijani Aramide , Cantazaro Brandon , Rapoport Grigoriy , Herrera Henry R. 
Published: October 2019

INTRODUCTION:
A few cases of cocaine induced hepatotoxicity (CIH) have been reported in humans. Most of these cases were associated with chronic use in males, with only one case reported in females. We present a rare case of CIH associated with a binge in a female Hispanic patient with a chronic history of illicit drugs use.

CASE DESCRIPTION/METHODS:
A 32-year-old Hispanic woman with no known medical history presented to the emergency room (ER) for the evaluation of abdominal pain. Pain was said to have commenced about 10 hours prior, located in the right upper quadrant (RUQ), radiating to the back and epigastric area. Pain was described as sharp and only said to be associated with nausea. She denied the use of any illicit drugs. She was hemodynamically stable and physical examination revealed a woman in moderate painful distress and she was anicteric. Abdomen examination was significant for tenderness to palpation in the RUQ. Initial laboratory investigation was significant for elevated AST- 1236 IU/L (N: 13-39 IU/L), ALT- 955 IU/L (N: 7-52 IU/L), ALP- 127 IU/L (N: 34-104 IU/L), and normal total bilirubin. LDH was also elevated 826 IU/L (N: 140-271 IU/L). An extensive work-up was ordered. Interestingly, urine drug screen returned positive for amphetamine, barbiturates, cocaine and tetrahydrocannabinol. She later admitted using drugs on the day prior to admission. All the other results were not significant. At this point, symptoms had significantly improved with conservative management and she was discharged on the 2nd day of admission.

DISCUSSION:
The pattern of liver enzymes in our patient appears to be characteristic of what has been described in prior case reports of CIH. Worth mentioning that, in mice models, there appears to be a difference in the manifestation and pattern of injury by gender. In a study conducted by Visalli et al, both male and female mice were exposed to the same amount of cocaine, but male mice had significantly more severe disease. Lopez Patino et al also described similar gender differences in zebrafish. It is entirely unclear why these gender differences exist; however, it has been postulated that there is a possibility that males and females metabolize some of the enzymes differently. Our review showed the potential role of gender in cocaine metabolism. In patients presenting to the ER, a high index of suspicion is required to improve overall patients' outcomes and avoid unnecessary procedures. Lastly, there is a need for continued research in the area of CIH.